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I think we do not know the answer yet.

Dr. GOODWIN. NIDA is doing some studies on acupuncture. Do you want to comment on that?

Dr. SCHUSTER. We have two studies of acupuncture currently ongoing for the treatment of cocaine addiction. I must say that I would agree with Dr. Gordis that at least in one of them the results to date have not proven to be any better than for individuals who became engaged in other kinds of activities for a comparable amount of time. In other words, it was program involvement rather than the acupuncture which seemed to be responsible for any changes that took place.

EFFECTIVE SUBSTANCE ABUSE TREATMENT

Dr. GOODWIN. Could I perhaps make a couple of general comments about substance abuse treatment, because that often is misunderstood.

First, I will just repeat something Dr. Primm frequently says, which is that drug abuse and alcohol abuse are chronic relapsing diseases, and they should be thought of like we think of arthritis or like we think of hypertension. That is, you have episodes, you have a chronic vulnerability.

Second, the treatment varies enormously with the individual, such as whether they do or do not have a coexisting mental disorder, such as whether they are highly motivated.

It is one thing for drug abuse to be occurring in a very successful lawyer who could lose his whole practice if he does not get straight. It is quite another for drug abuse to be occurring in somebody who seems to feel that they have nothing to lose. It makes a big difference whether they have anything to be rehabilitated for, or whether, as Dr. Schuster says, they need to be habilitated in the first place. Another factor is that there might well be very little self-esteem structure there after you get rid of the drug problem. All studies indicate that the longer people stay in treatment of a variety of types, the more effective it is. However, the more arduous treatment strategies require more commitment by the patient, and, therefore, they have higher dropout rates.

We do have some evidence on what the components of a good treatment system are. We know that if you have a stable staff, if you provide educational and vocational counseling along with your drug counseling, if you have a staff-client match in terms of racial and ethnic characteristics, if you have strong leadership, these all have been shown to substantially increase the effectiveness of any given treatment, and Dr. Primm is incorporating those standards into his treatment improvement programs.

We also have data from a NIDA researcher, Chuck O'Brien, at the University of Pennsylvania, showing that a high-intensity treatment can have three times more effect in keeping people drug free than a low-intensity program, even though the cost is only double. That is, if you have a twice-as-expensive treatment which includes psychiatric care, employment counseling, and high intensity of counseling, which costs twice as much as the stripped-down version, it nevertheless provides three times more effectiveness both in terms of drug behaviors and risk of getting AIDS if you happen to inject drugs.

So that if you look across the spectrum, you have out-patient programs, you have in-patient detoxification programs, you have medication-based programs-methadone is the best established. We know that methadone works about 70 percent of the time, if it is done well. We have tricyclic antidepressants for cocaine, still experimental. We have buprenorphine, which is a very exciting new development that NIDA has data on that may well prevent some of the craving for cocaine as well as for heroin, but these are still considered experimental.

I would say the overall treatment success in drug abuse and alcohol is approximately equivalent to what it is now with some of the difficult cancers that we deal with. That is to say, we have overall an effective rate if you count good programs, poor programs, not highly motivated individuals. Overall about one-third of the clients who go into these treatment systems come out and stay clean, but two-thirds do not, and compared to some areas of medicine, that is not bad. Compared to other areas, we have a long way to go.

PSYCHOTHERAPY AND CHRONIC DISEASE

Senator HARKIN. I have a couple of questions. I will just ask one more before I turn to Senator Bumpers, and perhaps this should go to Dr. Leshner.

I asked a question again this morning about nonconventional means of treatment, investigating, and researching nonconventional means of treatment. I just mentioned one here, acupuncture, and the response was it needed more looking at, and you needed to set up better scientific analysis of it.

My question for you is, there have been some recent articles about psychotherapy being shown to help cancer patients, and I am wondering if you have any knowledge of that, and can you comment on that at all?

Dr. LESHNER. I am familiar with the study that was done. I can give you a more detailed explanation of that for the record, but a study was done recently by one of our investigators that showed that the duration of survival for breast cancer patients was enhanced following group psychotherapy treatment.

Senator HARKIN. That is interesting. The longevity, you say, the survivability, was increased?

Dr. LESHNER. That is right, yes.

Dr. GOODWIN. It is a function of how early the intervention is done, because the apparent mechanism of this relates to the control by the brain of the immune system, but the so-called psychoimmunological control mechanisms work better-the immune system's control of cancer works better early in the development of some cancers. If you study them very late when they are in the hospital, there is very little effect.

Senator HARKIN. There is still a lot we have got to learn about that interaction between the brain and

Dr. LESHNER. That is That is right. right. We have an extensive psychoneuroimmunology research program going, looking at that interface between brain, immune, and endocrine systems.

[The information follows:]

PSYCHOTHERAPY AND CHRONIC DISEASE

In NIMH supported research, Dr. David Spiegel and colleagues at Stanford University have shown that participation of metastic breast cancer patients in weekly group support treatment increases survival time to an average of thirty-six months. Women who participated in the one year intervention survived twice as long as women who received only medical treatment. The intervention was the only variable found to affect survival time. This effect was not apparent until 8 months after the intervention ended.

Dr. Spiegel is continuing to examine the effects of psychosocial treatment for patients with metastatic carcinoma. One hypothesis to be tested is that as a result of decreased anxiety, depression, and pain, patients who are in the support group improve survival by added attention to exercise, diet, and medical treatment. Dr. Spiegel has proposed this group support intervention as a model system for other terminal illnesses that may be valuable not only to cancer patients but also to those with HIV/AIDS.

For cancer patients receiving repeated chemotherapy or other immune suppressive therapies, the suppression of the immune system may in some cases prove to be drastic enough to increase the risk of infectious disease. Psychological means may be useful to block this immunosuppression. Conversely, when immunosuppression is necessary, such as in transplants or lupus erythematosus, physicians may use psychological means to decrease the number of treatments with immunosuppressive drugs, thus reducing both drug side effects and costs. An NIMH-funded project at the Memorial Sloan-Kettering Cancer Center, under the direction of Dr. William Redd, has as its long-term objective understanding how psychological factors influence immune functioning in humans. Researchers have been attempting to relate changes in immune function with physical and mental illnesses. Initial results with 20 breast cancer patients found that the repeated experience of the immune suppressing effects of chemotherapy in the distinctive hospital environment can affect patients so that merely returning to the clinic triggers immune suppression. These findings may help to elucidate the biological links between psychological factors and immune function; such changes in immune function may allow rigorous investigation of the mechanisms by which mind influences the body. At UCLA, Professor Shelley Taylor is examining the psychosocial aspects of cancer and other illnesses. NIMH is providing career support to Dr. Taylor who is studying social support needs and use of social support groups among cancer patients with funding from the National Cancer Institute. The project seeks to generate guidelines for social support groups in order to increase their appeal to target populations, such as male, working class, minority cancer patients.

ADMS BLOCK GRANT

Senator HARKIN. Interesting. I am prepared to yield to Senator Bumpers, if you would like at this time.

Senator BUMPERS. Mr. Chairman, thank you very much. I will be very brief.

Dr. Goodwin, I am greatly concerned about the block grant-drug abuse block grant. Are you familiar with the GAO report that Senator Pryor and some of us had done last year?

Apparently, the report does indeed indicate that the drug problems of the larger metropolitan areas in the country are more acute than they are in rural areas, though I think the studies show they are much greater in rural areas than the ordinary layman_might think, and while I might be willing to take some abuse for the rural areas, including Arkansas, in order to accommodate that slight disparity, according to the report, the fact is that here is what they say:

The studies we reviewed suggest that urban incidence rates are somewhat less than three times higher than nonurban rates. By comparison, the use of total urban population and current law produces a pattern of funding differences appropriate for an incidence-rate differential of over 15 to 1 between urban and nonurban residents. Now, do you think a Senator from Arkansas ought to sit still for that?

Dr. GOODWIN. By no means. Actually, what we have seen, of course, is a shift from the older formula which was purely population based to this cruder way of getting at need through a new formula which is weighted toward the urban and the young. I emphasize crude because that was based on assumptions that you were just questioning, and I think we should be questioning the assumptions.

One of the reasons we are putting the new capacity expansion program in place, and it really represents our only expansion in the budget for drug treatment, is that this allows for more targeting of need. That is to say, we can look at areas that States submit evidence that they have, for example, a high rural problem that does not show up in the urban weighting in the existing block grant, and that will allow us to fill those gaps in the block grant.

Second, I would point out that one of the important efforts that Dr. Primm has launched in his Office for Treatment Improvement is a mainstreaming initiative which is particularly important in rural areas, because as you well know, health care delivery in rural areas is heavily dependent upon the primary care specialists. Senator BUMPERS. That is right.

Dr. GOODWIN. They are the ones there for the mental illness services and for the substance abuse services, and until we can get substance abuse and mental illness treatment integrated into the general health stream, we are going to always have a problem about these illnesses in the rural areas.

Also, by the way, I have just been reminded that many of our prevention programs indirectly benefit rural areas. We estimate that about 23 percent of our OSAP programs in substance abuse prevention apply to rural areas, even though the percent of the population living in rural areas, of course, is substantially lower than that.

Senator BUMPERS. How much money is in that program?

Dr. GOODWIN. In the total, $281 million, and it is 23 percent of that $281 million. We could also point out in our critical populations grants from the categorical part of OTI, 17 percent went to rural areas, which again is still above the population distribution. Senator BUMPERS. Well, my State is a big loser in fiscal year 1992 under the current ADMS formula. We lose about 12 percent in 1992 over what we are going to get in 1991.

Dr. GOODWIN. I am sorry to say that it is, I think, the biggest loser, and that is because of the shift-although it was designed to be a gradual 4-year shift, the shift from that old formula that took into account only population and median income, so that the lower median income States got more.

The shift to the urban and young person weight, which was a crude attempt to target to drug addiction, has put States like Arkansas at a disadvantage, but we hope that the other programs that are targeted—that is, the capacity expansion program and the other programs of OTI, as well as the prevention programs-can fill that gap.

Senator BUMPERS. Well, I must say this-I do not know whether somebody crafted it very carefully to make sure that there were going to be 51 votes against changing this formula in the Senate, but as I look it over, it looks that way. I do have Senator Dole on

my side, because Kansas is a State that takes almost as big a hit as Arkansas does.

Dr. GOODWIN. Well, I am glad you reminded all of us that these formulas were in both cases were, of course, congressional formulas.

Senator BUMPERS. I know you did not do it, and I know who did. [Laughter.]

It was not in the Senate, I might also say. These things have a tendency to originate in the House.

HIGH SCHOOL DRINKING

Dr. Gordis, just one question do you do the high school senior survey every year?

Dr. GOODWIN. Yes; now it is every year. Yes.

Senator BUMPERS. That is an extremely helpful and informative survey. I am pleased you do that. I get a chance to look that over, and I get a chance to make a lot of barn-burning speeches about some of the information in it.

Dr. Gordis, can you remind me of the percentage of high school seniors-it seemed to me like it was over one-third-who said they had had five successive drinks or more on one occasion in the preceding 2 weeks? What was that statistic? Was it 37 percent?

Dr. GORDIS. The 1990 numbers, Senator, are that episodes of heavy drinking—that is, five or more drinks at a time during the 2 weeks preceding the survey-were reported by 32 percent. Senator BUMPERS. Thirty-two percent?

Dr. GORDIS. Down a little bit from the 34.7 percent in 1988, so there is a slight improvement in that, but it is still, obviously, a figure which we are all concerned about.

Senator BUMPERS. Well, it is encouraging that that figure has gone down ever so slightly, but that still is a shocking figure to me. I am still really appalled that that many seniors have and are willing to say on that survey that they have had five drinks or more in the preceding 2 weeks.

Dr. GOODWIN. It is a little more encouraging when you look at the long-term trends. The peak for binge drinking was back in 1979. It is down 22 percent, so one of the disadvantages of doing the survey every year is that looking at it year by year it may be hard to see some of these long-term trends, but as you said, we are much more encouraged about the drug trends in this mainstream population.

Dr. Primm just reminded me that an interesting aspect of that high school survey is that the reduction in drug use by our black population actually exceeded the reduction by the white population in that particular sample of kids, the 76 percent of kids who stay in school-that is, the mainstream population.

Senator BUMPERS. That is all very encouraging. What do you attribute that to, Dr. Goodwin?

Dr. GOODWIN. In terms of the overall trend downward, I think that the overall efforts of prevention, the efforts of the private sector, some of the highly publicized deaths of very important actors and athletes have caught the attention of kids, and most of the change is kids refusing to start using drugs. One thing we know

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