Page images
PDF
EPUB

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 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

problem. We are having some very promising results at the family level, at the community level, as well as at the peer level, in attempting to address the specific problems.

DRUG ABUSE PREVENTION

Dr. SCHUSTER. As Dr. Johnson commented, the National Institute on Drug Abuse has been involved in primary prevention research which has clearly demonstrated that to be effective in primary prevention—that is, to prevent drug initiation, to prevent the experimentation with drugs-it is essential that programs be comprehensive.

We have recently completed an analysis of two major city programs with all the appropriate controls and shown that those children who are part of a multifaceted program which included the family, which included the teachers, which included the family by virtue of, for example, homework assignments from school, which involved the local business community, which involved the local police not only in supply-side reduction activities but as well in demand-reduction activities, this type of total commitment, gave rise to a change in the normative values of that community.

That is what is key, because for a 24-hour-a-day period, children in this program were being given the same consistent message by all community contacts that they would have, both in the family, the school, and the media. That is what is essential.

That is for primary prevention, but in addition, we are very concerned about the issue of secondary prevention. That is, those people who experiment with drugs, who escalate and go on to abuse and dependence, and we are conducting studies to determine what are the early factors that we can identify that give rise to a vulnerability to not only experiment with drugs but to go on to addiction.

We now believe we have some factors that we can identify as early as the first grade which place individuals at greater risk for becoming drug abusers in adolescence as well as having a number of other behavioral disorders at that time. We hope, then, on the basis of being able to identify what these early risk factors are, to be able to develop appropriate interventions.

Dr. GOODWIN. I think we might say in general that some of the broader-based prevention programs are successful. If we look at our mainstream population, which are that successful core of Americans who graduate from high school, we see very encouraging longterm trends. That is, very substantial reduction from the peaks that we had in drug addiction back in the early 1980's.

We have seen a 72-percent drop in 30-day or regular cocaine use. That is a very important drop. However, that means that our prevention efforts now are shifting more and more to those high-risk populations that are not changing as much-the pockets of vulnerability, as we call them-and there, the research base is even more important to focus those programs appropriately.

TERTIARY PREVENTION

Dr. PRIMM. Dr. Johnson spoke about primary prevention, and, of course, Dr. Schuster spoke about secondary prevention, and treatment is always seen as tertiary prevention. Every time we treat

one person for substance abuse we eliminate that individual from trying to gain support for that behavior which is deleterious by transferring it to another individual, so tertiary prevention is what treatment is all about.

In treatment programs we often have family therapy since siblings are likely to also be involved in substance abuse behavior. If there is one member of the family involved in treatment then, that in itself, of course, cuts down the possibility of the spread of substance abuse, whether it be alcoholism or other substances abuse. So, again; treatment is tertiary prevention.

PREVENTION OF MENTAL ILLNESS

Dr. LESHNER. At NIMH, we basically have taken a three-pronged approach to our rather rapidly growing prevention portfolio:

One has been to support studies that are involved with direct interventions designed to prevent specific disorders.

The second category are more broad-based interventions, particularly early in life, looking at high-risk individuals that might affect a broad range of outcomes. That is, a broad range of disorders.

The third category are a variety of educational activities that we do that are involved in secondary prevention or primary prevention.

It is an area that has been growing quickly for us. We now have five major prevention intervention research centers. In addition, we have a number of prevention research demonstrations that were begun last year, and a rather extensive and diverse research portfolio.

PREVENTION OF ALCOHOL ABUSE

Senator HARKIN. Dr. Gordis.

Dr. GORDIS. Our prevention research efforts are focused both on individual grantees as well as one of our 14 research centers which is devoted solely to issues of prevention. Our work is in many spheres.

Since alcohol is a legal drug, obviously there is research to be done on issues of social policy and legislation and the impact of such, and so we have research on the economic modeling of the response of consumption to price, on elasticity-how consumption responds to price on the effect of advertising, on the question of whether drinking is initiated in the young, on server intervention programs, on drinking driver laws, and on the effect of age limitations on alcohol consumption on both the driving and the cirrhosis death rates.

As far as individual studies, we have longitudinal studies showing the mix of genetic and environmental and family relationship factors as kids move from one age of risk to another, and that is a very large area of our prevention portfolio right now.

The genetics work will pay off, I think, in identifying high-risk youth who are candidates for better-targeted intervention. We also have warning label studies now, which are studying the effect of the warning label legislation passed by Congress 2 years ago to see whether it is modifying knowledge and behavior.

We have prevention in the AIDS area, to see whether within alcohol treatment programs the kind of prevention that could be done within those programs is going to cut down on the conversion to sero-positivity.

Finally, we have a collaborative prevention announcement now with the Office for Substance Abuse Prevention-it is sponsored by both NIAAA and OSAP-to study a mixture of cities to see whether the type of community trials which have been done before in cardiovascular disease can be duplicated in the alcohol world to see which efforts within the community are best suited to reducing the hazards and the dangers of alcohol consumption.

TREATMENT OUTCOME RESEARCH

Senator HARKIN. Very good. Thank you all-good briefing.

Moving from prevention to intervention, what can you report on the progress of treatment outcome research in improving ways of matching patients to the most appropriate substance abuse treatment program?

Dr. GOODWIN. Perhaps Dr. Gordis could talk about some treatment matching in the alcohol arena, and then I will make some general comments.

Dr. GORDIS. The question is of paramount importance to the treatment world, because obviously, if we can type the treatment specifically and also describe the kinds of patients who are suited to them, we will reduce the cost of treatment, maximize its efficiency, and cut down the inconvenience to both staff and patients. We are very proud of our two big collaborative studies, one of which is on that issue. The patient-treatment matching study, which is now into its second year, is conducted in nine different centers in order to get an adequately large and diverse population. Essentially, there are three arms of treatment. In one, the conventional treatment with traditional counseling and therapy approaches and so on is a big component. Another one has to do with the cognitive behavioral modeling, and a third arm of treatment is the equivalent of minimal intervention for less dependent people, and a mix of theories are being tested as to which type of patients are suited for this.

This program is underway. The pilot studies are beginning, and we hope within several years we will have some interesting information which will affect the whole treatment community.

Senator HARKIN. It will take several years, though?

Dr. GORDIS. I believe so, yes.

ACUPUNCTURE

Senator HARKIN. What has research shown on other treatments, such as acupuncture?

Dr. GORDIS. I think the data on acupuncture must be still considered inconclusive. Most of the literature on acupuncture, I think, would not pass muster as far as the standards of rigorous analysis that we demand in all areas of health care now.

One or two of the studies have been more promising and have really satisfied some of those standards, but they have been small, and so we are welcoming applications to test this further.

« PreviousContinue »