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Answer. The Office for Treatment Improvement will begin implementation of the State Systems Development Program this year. The program will encompass:
Voluntary State Plans - 25 States participating this year.
Technical Reviews - 20 States enrolled per year, developmental phase this year; field work and assessments next fiscal year.
Developmental Technical Assistance - 20 States enrolled per year; implementation this fiscal year with field work starting in the fourth quarter.
State Epidemiology Surveys - 20 States enrolled per year; phased in this and next fiscal year.
STATE MENTAL HEALTH SYSTEMS FOR CHILDREN AND ADOLESCENTS
Question. In order to help States establish coordinated mental health systems for children and adolescents, the Committee has supported the Child and Adolescent Service System Program (CASSP). There seems to be a trend on the part of NIMH, however, to divert CASSP funds to research rather than the services they are intended for. Under your proposed budget, what funds would be available for basic State CASSP grants?
Answer. The service system improvement grants for children and adolescents have been awarded to all 50 States. NIMH'S FY 1991 estimate for these CASSP grants is $4.9 million. Based on the same proportion of available funds, the FY 1992 budget proposal includes an estimated $5.2 million for the service improvement component of CASSP.
Question. What is the difference between the research demonstrations funded through this account and other services research?
Answer. In the area of mental health services for children and adolescents, both research demonstration grants and research project grants focus on finding ways to improve the organization and financing of care, including access to appropriate care, and to improve the quality of care, including effectiveness of services being offered.
One fundamental difference is that research demonstrations offer the applicant an opportunity to receive funding for both the intervention and the research component used to study how well it works. By contrast, research project grants support only services directly related to the research component. This distinction makes research demonstrations much more expensive, on average, but it also gives them the power to study innovative programs that in many cases could never be offered and studied in any other way. The research demonstration model provides the opportunity for testing interventions in real-world situations.
Another distinction from research project grants is that CASSP research demonstrations are only available to state mental health authorities. This restriction guarantees that high-priority policy issues will be addressed, and that such areas as development of community-based services as envisioned in the State Mental Health Plan can be linked to the demonstration project.
NATIONAL PLAN FOR RESEARCH ON
Question. In the FY 1991 report, this Committee urged NIMH to increase its commitment to children's mental health research significantly, and directed NIMH to fund at least three children's mental health services research centers. Please detail the funds
dedicated to the National Plan for Research on Child and Adolescent Mental Disorders, and the specific allocation of funds for children's mental health services research.
Answer. In FY 1991, the NIMH has dedicated approximately $136.2 million to the National Plan for Research on Child and Adolescent Mental Disorders, an increase of 22.8 percent. Of this total, the NIMH has allocated $10 million for children's mental health services research?
Question. The plan for children's mental health research says that $202 million is necessary to implement the second year objectives. How much funding' is proposed in your FY 1992 budget for child mental health research.
Answer. The President's Budget proposes approximately $146.6 million for child mental health research for FY 1992.
Question. This Subcommittee directed NIMH to contract with the Institute of Medicine for a report on current prevention research, and provided $1 million for that study. What is the status of that report?
Answer. A contract with the Institute of Medicine (IOM) will be awarded for a two-year Prevention Study within the next two months. Individuals from IOM, NIMH, the National Prevention Coalition, and Senate committee staff all have agreed it would be best to broaden this study to include all aspects of prevention in the mental health arena. Therefore, discussions with key staff at the IOM and pertinent federal agencies (National Institutes of Health, Health Resources and Services Administration, Office of Human Development Services, Centers for Disease Control, Family Support Administration, and Departments of Justice and Education) with strong interests in prevention have taken place in the last few weeks. A meeting involving representatives from these agencies is planned with an expectation that they will be involved in this endeavor.
TREATMENT IN CRIMINAL JUSTICE
Question. What is the extent of substance abuse among the criminal justice population, and what is the availability of treatment?
Answer. Drug Use Forecasting (DUF) data and sample surveys in a number of jails and prisons around the country show, on average, a 70 percent rate of substance abuse among the criminal justice population. Cocaine use appears to be stabilizing and there appears to be a modest decline in marijuana use. Of the three million probationers and parolees, most experts agree that 70-75 percent have moderate to severe substance abuse problems. In general, drug use appears to be stabilizing among the criminal justice population, but the vast majority of criminal offenders are substance abusers. Surveys and studies over the past two years reveal the following about the availability of treatment for criminal justice populations :
Juvenile Offenders - Most juvenile justice agencies conduct substance abuse assessments and basic education and most support self-help groups (AA/NA). The majority of States make referrals to community treatment agencies. However, an American Correctional Association survey notes that only 12 States have self-contained juvenile justice treatment programs within their institutions.
Jails - The American Jail Association survey of 1988-89 showed that 28 percent (468) of responding jails had a substance abuse treatment program other than detoxification; 18 percent of jails had
funded treatment activities, and the remainder were volunteer programs (AA/NA). It is estimated that of the inmates who need treatment, 10 percent are receiving some level of treatment. Of the jails providing comprehensive treatment, average costs were $8/day per inmate.
State prisons - A recent survey shows approximately 75 percent of 800,000 inmates in State and federal institutions are in need of drug treatment services; the Association of State Correctional Administrators reports only 22 percent of the prisoner population.is currently receiving any level of treatment services (as of mid1990). The Association estimates, at an average cost of $10/day for intensive treatment, it would take nearly $1 billion per year for treatment for 500,000 inmates.
Probation/parole clients - There is no data on the number of treatment slots available, but waiting periods to community treatment agencies of 30 days up to six months are common. During the waiting periods, most offenders receive regular supervision plus urine analysis. In some States very high percentages of probationers and parolees are revoked back to prison or jail, often for substance abuse.
Question. What kind of activities are being supported by OTI's grants for model treatment programs for the criminal justice population, both in and outside correctional settings?
Answer. OTI is supporting three programs dealing with criminal justice populations.
1. Demonstration treatment programs for prison and jail populations are funded under the Treatment in Correctional Settings program. In FY 1990 six prison programs were funded, ranging from conversion of an entire prison to a treatment facility (Alabama), to a specialized female treatment program including a mother/infant unit (New York). A seventh prison program for co-morbid populations (mental illness and drug addiction) will be funded in the near future. In addition, three model metropolitan jail treatment projects were funded in Seattle, Chicago, and Montgomery County, Maryland.
2. In FY 1990, demonstration treatment programs for NonIncarcerated Criminal Justice Populations were funded in 10 jurisdictions. Four projects involved diversion from the court to mandatory treatment, and six projects involved intensive treatment for high risk probationers and parolees. An additional eight projects will be funded in the near future.
3. A new Adolescent/Juvenile Justice Treatment Program will be announced shortly. This program will fund drug treatment for two juvenile populations: (a) juveniles held in State institutions, based on a comprehensive treatment plan prepared by the State Juvenile Services Agency; and (b) adolescents and juvenile justice populations that will receive treatment as part of a community treatment network. OTI expects to fund 12 adolescent/juvenile justice demonstrations this fiscal year.
In summary, OTI expects to fund about 40 demonstration projects ranging from diversion to treatment models through institutional and community-based treatment services over two fiscal years. The projects cover both adult and juvenile justice populations. Treatment modalities range from outpatient drug free through intensive day treatment and methadone maintenance for nonincarcerated persons, through a range of residential and modified therapeutic communities for incarcerated persons.
Question. How many States are using Block Grant and related funds for services focused on this population?
Answer. There is currently no systematic data collection on use of ADMS Block Grant funds for criminal justice populations. The National Association of State Alcohol and Drug Abuse Directors is now collecting this data for the annual State Alcohol and Drug Abuse Programs Report (NIDA-funded).
We do know that significant percentages of clients in publicly · funded community-based treatment programs are directly or indirectly referred from criminal justice agencies, or are under some form of correctional supervision (individual agencies report percentages ranging from 20 to 60 percent). The major portion of institutional (prison/jail) treatment resources are derived from the operating budgets of corrections agencies. The Criminal Justice Block Grant is also a significant source of funding in some States.
We also know that there is a growing number of State Alcohol and Drug Abuse Agencies which are funding or negotiating Block Grant projects with criminal justice agencies. Examples from a range of States include:
Wisconsin - $1.5 million is earmarked for juvenile justice treatment and $1.9 million is earmarked for adult institutional treatment services this fiscal year; treatment programs include institutions, residential facilities, and TASC case management.
Illinois - $2.7 million is earmarked for criminal justice activities; the largest element represents TASC ($2.4 million), with other treatment for work release and other institutional treatment.
Colorado - $1.7 million of ADMS Block Grant funds is earmarked for 6,700 criminal justice clients per year --$530,000 for support services to adult institutions (Department of Corrections) and TASC case management; $ 534,000 for DUI treatment; and $618,000 for community based outpatient and residential treatment (probationers and parolees).
Pennsylvania - $1.6 million is earmarked for adult institutions (Department of Corrections); $1.8 million for treatment of high risk probationers, including TASC case management; and $2.7 million for juvenile justice populations, including residential treatment, intensive supervision, and identification, assessment and consultation for high risk youths.
Washington State - $50,000 of ADMS Block Grant funds support juvenile justice treatment; negotiations are currently under way for a jointly funded project to convert an adult institution into a treatment center; about 25 percent of community treatment slots are filled by offenders (equivalent to $4 million of Block Grant activities).
QUESTIONS SUBMITTTED BY SENATOR ARLEN SPECTER
SUCCESSFUL DRUG TREATMENT AND PREVENTION
Question. Dr. Goodwin, since fiscal year 1989 the Congress has appropriated over $5,000,000,000 to your agency for drug abuse research, demonstrations and services. What have we learned from this investment concerning successful drug treatment and prevention strategies?
Answer. The vast majority of these studies represent incremental advances in our attempt to more fully understand, treat, and prevent drug abuse. The value of a drug abuse research program is not whether there is a "breakthrough" every year but whether, over a
period of time, the gradual development of a base of knowledge allows for improvement in preventing and treating the disease.
The investment in research over the past twenty years is producing returns in terms of new, more effective treatments and our ability to respond to the problems presented by new drugs of abuse. This is especially true when we consider the significant possibilities now before us to develop medications to prevent and treat drug addiction and to integrate these techniques into comprehensive therapeutic programs. When these new medications are approved it will be the culmination of the efforts of hundreds of researchers extending back in time and concept to the Addiction Research Center (ARC) in the 1930s.
While you asked about recent accomplishments, these should be put into the context of NIDA's long term research program. Since NIDA has traditionally supported the vast ma jority of drug abuse research in the U.S., and relatively little research into drug abuse goes on elsewhere in the world, it is a fair statement that almost all that is known about drug abuse and addiction has been derived from NIDA-funded research. The following deserve special mention:
Discovery of opiate receptors and endogenous opiate-like peptides that revolutionized the field of neuroscience and that are leading to new medications to treat heroin addiction. .
Development of improved technologies and standards to detect illicit drug use that has made possible the Federal drug-free workplace initiative.
Discovery of the brain mechanisms involved in drug seeking behavior and addiction that provide the scientific basis for developing treatments for cocaine addiction.
Demonstration of the addictive nature of nicotine that has played a key role in the development of smoking prevention programs.
Development of naltrexone, a medication designed to block the effects of narcotics such as heroin, and development of procedures involving clonidine and clonidine combined with naltrexone for rapid and effective detoxification from opiates. Demonstration of the value of treating the depression suffered by many drug abusers as a means to improving treatment outcome.
Development and evaluation of pharmacologic treatment for newborns withdrawing from exposure to narcotics. These medical regimens have been published and are available to pediatricians and neonatologists.
Among NIDA's recent most significant accomplishments are the following:
The Treatment Outcome Prospective Study demonstrated: (1) no differences in outcomes between methadone maintenance, therapeutic community, drug-free outpatient, and detoxification only, for those who stayed in treatment for less than 90 days; (2) a significant, linear relationship between positive posttreatment outcomes and retention in treatment, between 90 days and 2 years; and (3) among those in treatment at least 90 days,