a/ Includes $31 Million in obligational Authority for funds transferred from the Office of National Drug Control Policy Special Forfeiture Fund

NATIONAL DRUG STRATEGY

Senator HARKIN. Dr. Goodwin, thank you very much for your opening statement

Senator COCHRAN. I do not have any questions, Mr. Chairman. Senator HARKIN. Dr. Goodwin, your Department released a report last November on the economic costs of alcohol and drug abuse which estimates that alcohol abuse cost this Nation $86 billion in 1988 and drug abuse cost $58 billion.

In 1985, the most recent year for which we have data, alcohol abuse caused 94,768 deaths. Drug abuse caused 6,118 deaths. In terms of lost productivity, alcohol abuse cost $24 billion, drug abuse $2.6 billion.

Alcohol is our Nation's No. 1 drug of abuse and top public health problem, yet the budget proposes not a single penny more for the ADMS block grant than we provided in fiscal year 1991.

Given that alcohol abuse is the most prevalent and costliest drug to society, how should the national drug strategy address this issue?

And I guess I want to say also, is the $99 million proposed for capacity expansion to be directed to alcohol, drugs, or both?

Dr. GOODWIN. Well, it will be directed to drugs, but because of the co-morbidity of drugs and alcohol, it is more the rule than the exception that a very large portion of those people will also be alcohol abusers.

I can also point out that we have recent data that the early onset of drug abuse substantially increases by a factor of fourfold to fivefold your risk of becoming an alcoholic later on.

So, in effect, the drug abuse problem is helping to fuel the alcohol problem and make it worse and more intractable.

Senator HARKIN. So it is really going for drugs, but you say there is some coincidental

Dr. GOODWIN. Particularly among the young.

Senator HARKIN. Use of that money for alcohol.

Dr. GOODWIN. It is virtually unheard of to see a pure alcohol abuser or alcohol addicted young person. Among young people today, the coexistence of these disorders is much more the rule than it is the exception, and we know that the early onset of drug abuse can substantially worsen the later expression of the alcohol disorder.

Senator HARKIN. The other part of my question was, how should the national drug strategy address the issue of alcohol?

Dr. GOODWIN. To the extent that the national drug strategy was in response to the drug problem as having special relationships to crime, special relationships to AIDS through HIV intravenous transmission, special relationships to crack babies, a variety of social problems that are serious halo effects of the drug problem which are not halo effects of the alcohol problem to the same extent that we understand the social and public health implications behind the emphasis on drugs. From a public health point of view, we certainly agree that alcohol is a very serious problem, even by itself, without the co-morbidity. Alcohol has an enormous impact on health.

For example, of the $15 billion in direct costs associated with alcohol, only about 20 percent of that goes to the treatment of the addiction itself. The rest goes to the medical consequences of alcoholism.

In the general health arena, alcohol has a major consequence. We do think that many of the treatment dollars in the block grant do end up benefiting those with alcohol along with drugs because of the co-morbidity.

SUBSTANCE ABUSE MORTALITY

Senator HARKIN. It says here you have 94,000 deaths attributable to alcohol and 6,000 attributed to other drug abuse.

Dr. GOODWIN. Yes.

Senator HARKIN. Is it fair to say that alcohol is, you use the word, major? It is beyond that. I mean, it dwarfs the problems caused by other drug abuse.

I am wondering if we are really putting everything we need into alcohol abuse. I have been told time and time again that the-what is the word that is used, gateway drug or the gateway to drugs, is alcohol. It starts with alcohol among young people.

If they do not start on drugs first, they start with alcohol. Maybe that is what you mean by co-morbidity.

Dr. GOODWIN. Well, the problem is that alcohol consumption by the young, at least experimental drinking is so ubiquitous that it is virtually everybody so that, of course, everybody who ends up on drugs will have used alcohol.

But since that is such a common-that is, the use of alcohol among the young is so common from our high school surveys that it is difficult to really call that a gateway drug.

If you look at a more careful longitudinal analysis, actually what we find is that drugs can be gateways to more serious problems with alcohol just as alcohol can be a gateway to drugs. In fact, they

sort of wash out.

But let me speak to the issue of 90,000 versus 6,000. I agree that there are certainly more deaths due to alcohol than there are due to drugs. On the other hand, the deaths due to drugs usually occur to young people.

So that the years of life-it is the same argument that we have about AIDS and why AIDS is to important-the years of productive life lost are substantially greater with a young cocaine overdose in a high school or college kid, compared to cirrhosis of the liver that may tragically shave off several years at the terminal end of life. And that is not to trivialize the alcohol problem at all, it is just that the comparison of the numbers dead need to take into account the age at which these people are dying.

Senator HARKIN. I think that makes sense. I understand that.

Dr. GOODWIN. And of course, the HIV connection is a very important one that Dr. Primm could speak to. Drug abuse is now the fastest growing reason for AIDS; that is, the AIDS population that is increasing most rapidly and is causing the spread into the heterosexual population and into women and children is principally related to injection drug abuse or the sexual partners of injection drug users, so we almost have to consider the AIDS epidemic as part of a burden on us in relation to the drug war.

SUBSTANCE ABUSE FUNDING

Senator HARKIN. I guess I just do not know why we do not just focus both on alcohol and drugs.

Dr. GOODWIN. Well, we do, and I think that the block grant in most of the State treatment systems are jointly administered. That is, drug and alcohol are jointly administered by the same authority at the State level, and indeed in 40 percent of the States the mental health and substance abuse programs are administered together as well.

Perhaps we also should point out that all of Dr. Johnson's prevention programs are focused on substance abuse, not just on drug abuse, even though that was money from the war on drugs, and the same is true for many of the OTI programs. Dr. Primm insisted that alcohol treatment be part of any drug abuse center. Perhaps, Dr. Johnson, do you want to make a comment on alcohol-how much work you are doing in the alcohol arena in prevention?

Dr. JOHNSON. I should point out that alcohol issues are fully integrated in all of OSAP's programs. In addition to that, we have special initiatives and special concerns in the alcohol area.

For example, there is our concern about driving impairment due to alcohol use, underage drinking related to the young, and of course, drinking during pregnancy, so all of our programs, be they the high-risk youth program, the community partnership programs, and the pregnant postpartum women and infants programs, and our communications and media strategies, all of them cover alcohol issues as well.

Dr. PRIMM. Mr. Chairman, the Office for Treatment Improvement has come up with a comprehensive approach on the way one should treat people who are addicted to substances. Dr. Goodwin has already indicated that those substances are generally alcohol and other substances of abuse.

All of the grants that will be awarded under the new capacity expansion program unquestionably will focus on all drugs of abuse that the individual may be using and that bring them to the treatment arena. Those persons diagnosed with an alcohol problem will be either treated in that program or referred to a freestanding alcoholism program.

PREVENTION

Senator HARKIN. Dr. Goodwin, this morning, the last few hearings that we have had I keep stressing the importance of prevention, and Dr. Roper this morning referred to it as an idea whose time has come. Of course, the Centers for Disease Control has always led the way in prevention efforts and we hope it will continue to do so.

You had a report that came out recently that said the total economic costs of alcohol, drug abuse, and mental illness hit about $273 billion in 1988-$129 billion for mental illness, $86 billion for alcohol abuse, $58 billion for drug abuse.

These are alarming figures, especially when you take into account that mental and addictive disorders disorders are chronically underrecorded. In light of this, how can you justify that your budget for research, treatment, and prevention programs provides the

smallest increase-3.7 percent, not even enough to cover inflation— that goes to prevention?

Dr. GOODWIN. Well, I will have Dr. Johnson comment on that in a second, but I should point out that if we look at our prevention programs over a 3-year period, nearly 4 years since OSAP was created, it has been the fastest-growing component of ADAMHA through all those years and it has gone from a grant program of just over $20 million to over $300 million. In addition, there is a $20 million prevention set-aside in the block grant; and also, the prevention research is an extremely important component of the research institutes.

One of the problems about the overall prevention efforts is that the knowledge base about prevention is not as well-developed as it is about some other areas. For example, we know more about some aspects of treatment than we know about prevention. It is one of the things that is very important for us to do, and, in fact, I am just noting that 27 percent of our total budget is prevention. It is important to keep the research on prevention moving along so that we can tailor prevention programs to those prevention strategies that work.

I think Dr. Johnson would say that the community-based prevention program was largely modeled after a national institute drug abuse study that showed prevention working more effectively when it was comprehensive rather than just school-focused. Do you want to comment any further on prevention?

Senator HARKIN. Actually, what I would like to have is each of you-and we will just begin at this end with Dr. Johnson-in each of your areas just briefly, I do not need a long discourse, but briefly tell me what you are doing in the area of prevention.

SUBSTANCE ABUSE PREVENTION

Dr. JOHNSON. As we approach prevention, we understand that the factors contributing to alcohol and other drug use are very complex and they cover a number of different factors. Our program is geared to be very comprehensive.

We have three different types of programs. First, we have our client-oriented programs, and those are the programs for high-risk use and for pregnant and postpartum women and their infants.

Then we have a program that looks at the community as a whole, and it is more systems-oriented, and that is our comprehensive community prevention program. What we are learning through research both at NIAAA as well as the drug institute is the fact that you have to approach these problems in a very comprehensive fashion, and we are attempting to do that, whether they are client-oriented or whether they are a systems-oriented program.

So in terms of, for example, the high-risk youth programs, we are looking at the family, we are looking at the school, we are looking at the community, and, of course, we are looking at peer factors and we are developing a number of innovative approaches to this problem in those various settings.

In the comprehensive program, what we are attempting to do is involve the entire community, all segments of the community, in developing a very comprehensive strategy to their alcohol and drug