Our field requires the assistance of the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse in continually demonstrating through research the effectiveness and value of treatment.

On a personal level, I can say that were it not for the treatment that my own father received for alcoholism 20 years ago, there is a strong possibility I never would have known him because it is likely he would not have survived to become the warm and loving father he was as a sober man.

I have worked in nursing for a long time in alcoholism and can also testify to the thousands of people whose lives have been saved through treatment. The cutbacks that are occurring now and the barriers to treatment are affecting people on a daily basis, not only the individuals, adults and teenagers but their families as well. We would respectfully recommend the following.

First, that a commission be jointly empaneled by the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse to investigate the ramifications of and proposed solutions to the systematic denial of access to care for employed substance abusers. This commission should be composed of leaders from government, industry, and the treatment field.

Second, that a greater portion of the research resources of the Alcohol and Drug Institutes be devoted to clinical research, particularly patient placement and outcome studies, to demonstrate the value of treatment and to help improve it.

NAATP and the American Society of Addiction Medicine have worked together to devise criteria which we believe represent nationally agreed upon standards for who should be admitted to treatment, what level of care they should receive, and we urge some research and testing of those criteria so that they can be agreed upon.

PREPARED STATEMENT

Finally, we urge the committee to support the activities of the Institute of Abuse and Alcoholism at the highest possible levels. Alcohol is our Nation's No. 1 drug of addiction and abuse whose dangers and consequences are as onerous as any illegal drug. The funding of research on the causes and treatment of alcoholism should reflect the serious and widespread nature of the disease. Thank you. That concludes my statement.

[The statement follows:]

STATEMENT of Barbara DUCKETT

Good Morning, Mr. Chairman and members of the subcommittee. My name is Barbara Duckett. I am President of Beech Hill Hospital, a free-standing center for the treatment of alcoholism and drug dependency in Dublin, New Hampshire. I appear before you this morning as a member of the Board of Directors of the National Association of Addiction Treatment Providers, N.A.A.T.P., which represents more than 600 treatment centers throughout the country.

Like other members of N.A.A.T.P., Beech Hill Hospital is a private treatment center which is not funded by public monies. Treatment centers such as mine do not receive nor do they seek any funding from the National Institute on Alcohol Abuse and Alcoholism or the National Institute on Drug Abuse.

I am here today because we believe that the Federal government has a great opportunity to lead by example in its effort to reduce alcoholism and drug addiction in society. Thus far, that example has been one which has emphasized the criminal

justice side of the drug problem. Alternatively, we support a policy which regards addiction as a treatable illness.

Three presumably unintended results of our current approach to the drug problem are hampering our ability to effectively reduce addiction in this country.

First, a primary result of the Federal funding emphasis on law enforcement is that our public-funded treatment programs are vastly overloaded. We believe there is a need for a balanced approach between treatment, education and enforcement to be truly effective. In that regard, we call for a higher level of funding for public alcoholism and drug dependency treatment programs.

A second, and perhaps less obvious result of underfunding public treatment programs is that it also affects the availability of and access to treatment by blue-and white-collar workers who have health insurance-by far, the largest group of alcoholic and drug dependent persons in our society.

Though most working people have the insurance coverage, they are either afraid of the consequences of seeking treatment or they are being systematically denied care because employers believe that substance abuse benefit cutbacks will save them money.

As a further result, insured persons are now seeking care from public sector programs, which only contributes to the overloading. This demonstrates the far-reaching consequences of a public policy on addiction which is overly reliant upon law enforcement.

Treatment utilization is at an all-time low in the private sector. N.A.A.T.P. has commissioned a major study by MEDSTAT Systems, an Ann Arbor-based health care claims research organization, the results of which indicate that fewer than onethird of one percent of employed persons are receiving treatment for substance abuse, while estimates range from six percent to twenty-three percent in terms of need.

The MEDSTAT study also indicates that the costs associated with treating substance abuse can be from an eighth to half of the costs of treating its typical medical consequences.

Our field requires the assistance of the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse in continually demonstrating, through research, the effectiveness and value of treatment.

The third, presumably unintended result of our focus on illegal drugs is our virtual exclusion of alcoholism from the anti-drug effort, despite the fact that, for example, some eighty percent of patients seeking treatment for cocaine addiction also suffer alcohol addiction. Again, as a matter of public policy, the Federal government needs to lead by example in righting this wrong.

We respectfully recommend the following:

(1) A commission should be jointly impaneled by the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse to investigate the ramifications of and to propose solutions to the systematic denial of access to care for employed substance abusers. This commission should be composed of leaders from government, industry and the treatment field.

(2) A greater portion of the research resources of the Alcohol and Drug Institutes should be devoted to clinical research, particularly patient placement and outcome studies, to demonstrate the value of treatment and to help improve it.

For example, N.A.A.T.P. and the American Society of Addiction Medicine have worked together to devise clinical guidelines on patient placement; that is, to determine which substance abusers need inpatient treatment and which need outpatient treatment. These criteria, as they are known, should be validated through controlled research, which the Institutes should be in a position to fund. We also recommend more and more rigorous outcome studies; that is, we must be in a position to demonstrate, through unbiased research, that treatment works.

(3) We urge the Committee to support the activities of the National Institute on Alcohol Abuse and Alcoholism at the highest possible levels. Alcohol is our nation's number one drug of addiction and abuse, whose dangers and consequences are as onerous as any illegal drug. The funding of research on the causes and treatment of alcoholism should reflect the serious and widespread nature of the disease.

Senator ADAMS. Thank you very much. I am also a member of the Senate Labor Committee, the authorizing committee, as well as the Appropriations Committee which we are holding hearings with this morning. In your testimony you have talked about the need to put more resources from NIDA and NIAAA into applied research, clinical studies, and so on.

Do you think that we should be addressing this in the ADAMHA reauthorization legislation this year? It is a real shift in legislative system rather than just a money shift that you are talking about. Ms. DUCKETT. Well, I feel that in the research money that is allocated, more research focusing on the efficacy of treatment might be the direction. I think that we have lost sight. Yes; I guess that is the answer, that we have lost sight of the fact that treatment does work, but we seem to need to continue to demonstrate that, to prove that to people and to also look at the various criteria for what works for what people.

As you were speaking earlier about crack and the fact that what we are doing does not always seem to be the best, and we have a continuing problem, I think we need more research into what does work for crack. Some facilities are having more success than others, and if we could look more at who needs what and helping those people to get that through research studies.

Senator ADAMS. Thank you very much. We appreciate your testimony this morning, Ms. Duckett.

Ms. DUCKETT. You are welcome.

STATEMENT OF DR. MELVIN SABSHIN, MEDICAL DIRECTOR, AMERICAN PSYCHIATRIC ASSOCIATION

Senator ADAMS. Our next witness is Dr. Melvin Sabshin from the American Psychiatric Association.

Doctor, welcome to the committee.

Dr. SABSHIN. Thank you, Senator Adams.

I am the Medical Director of the American Psychiatric Association, and I am testifying for that group and a constellation of other psychiatric groups, Senator.

Senator ADAMS. Thank you.

Dr. SABSHIN. Senator Adams, it is a particular pleasure for me to testify before you because I am very close to developments in the State of Washington. Prof. Gary Tucker and the group at the University of Washington are close colleagues.

May I add another reason for my pleasure? Previously I was the dean of the medical school at the University of Illinois and head of the department of psychiatry. One of the trainees 25 years ago was James McDermott. He was a resident of psychiatry at that point, and he has become the only psychiatrist in the Congress of the United States at this point.

Senator ADAMS. We enjoy having him over there, I want you to know.

Dr. SABSHIN. I am glad you do, sir. I am testifying for the fiscal year 1992 appropriations for ADAMHA. I do want you to know that the funding recommendations that are in my written testimony have been approved by the ad hoc group for medical research funding. That is a group of 139 medical organizations, and you will see their brochure later. They have endorsed our recommendations as being reflective of research needs and research capabilities at the present time.

I am testifying in the context of a revolution in psychiatric diagnosis and treatment. This is a new and exciting period, and part of that excitement and part of that development has come from

what your subcommittee has recommended. I am delighted with that.

I am also delighted that there is increased public understanding of the problems. A new constellation and coalition development has occurred with citizens groups supporting mental illness development, addition development, et cetera, and I am delighted with the hundreds of thousands of people involved.

Senator Adams, stigma still exists, and it exists broadly in this society in which literally thousands of people do not seek treatment because of the stigma, hundreds of thousands. Stigma also occurs in a variety of other contexts and work sites.

I do want to make the special point that in this subcommittee there is a remarkable example. A former chair of this subcommittee who then became engaged in a political campaign to become Governor of Florida experienced the stigma very, very directly in that political campaign. Senator Chiles acknowledged the benefit from prozac and new medication that helped him in overcoming depression, but in the aftermath of that he experienced what millions of other people have experienced in this country, and that should be noted very carefully.

I want to emphasize that the problems with mental illness and addiction are indeed massive. You in this committee have been remarkable in what you have done to try to overcome the problem. I am delighted also that there has been congressional initiative through Senator Domenici in regard to schizophrenia and that the late Congressman Silvio Conte's activities on the Decade of the Brain were indeed marvelous.

We have started with good momentum in dealing with all of these problems. It will be tragic if after our downpayment, our initial investment to develop new approaches the momentum was lost. It will be tragic. One medication developed 15 years ago, lithium, has been estimated to have saved $39 billion in terms of direct costs and increased productivity in this cou..try, remarkable developments that can occur with new research.

The President's budget unfortunately will not maintain this momentum, and we have depended on you, this subcommittee, to help in achieving those issues.

PREPARED STATEMENT

There are many, many things, many objectives that could be accomplished through new imaging studies, new kinds of medications to replace the clozapine which is effective, but we need drugs with less toxicity. We need to develop new markers for mental illness that we can help in diagnosing patients. We need new research for treatment and drug abuse. We need to implement a variety of national plans for children for severe mental disorders, et cetera.

We know that this subcommittee has been enormously helpful in the past. We ask you to keep the momentum going.

I would like to submit my written testimony for the record. [The statement follows:]

STATEMENT OF MELVIN SABSHIN

Mr. Chairman and members of the Subcommittee. I am Dr. Melvin Sabshin, M.D.. Medical Director of the American Psychiatric Association, a medical specialty society representing more than 37,000 psychiatrists nationwide. I testify this year on behalf of not only the American Psychiatric Association, but the American Association of Chairmen of Departments of Psychiatry, the American Association of Directors of Psychiatry Residency Training and the American Society of Adolescent Psychiatry. I also wish to associate the APA with the testimony of the Ad Hoc Group for Medical Research Funding, the Coalition for Health Funding and the Mental Health Liaison Group.

The nation has been witnessing a dramatic scientific revolution in the understanding and treatment of mental disorders and the interrelated illnesses of alcoholism and drug abuse. We have seen the introductions of tricyclics and MAO inhibitors for the treatment of depression; of neuroleptics for those suffering from psychoses; of clozapine for those unresponsive to other neuroleptics; and chlomipramine for obsessive-compulsive disorders. We have also seen the increasing use of dynamically oriented but time-limited psychotherapy, as well as new techniques of crisis intervention, multiple-family group treatment for families with schizophrenic relatives, new behavioral treatments, and documented proof of the effectiveness of psychotherapy in the treatment of depression. Our field can now offer a variety of treatments.

Simultaneously, public understanding of the complex nature of the mental and addictive disorders; their underlying co-morbidities and interrelationships; and the challenges of tailoring appropriate treatment to the affected individual has evolved and heightened, slowly serving to eradicate the dangerous social stigma -- rooted in fear and ignorance attached to these disorders which prevent individuals from seeking necessary and appropriate treatment. Research

continues to be the most potent tool we have for generating valid bases for hope that mental and addictive disorders are amendable to treatment and for destigmatizing these disorders. The urgent need for this research investment is seen in the chilling data. For example, the aggregated rate of psychiatric