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about drugs is it is a lot easier not to start than it is to stop once you have started.

Senator BUMPERS. Is that the thrust of most of your educational programs?

Dr. GOODWIN. Yes; and I think we are catching them through OSAP programs, through the Advertising Council, through the media efforts, public and private. We are catching them young enough that they do not start, and that is why we predicted 5 years ago that the trend should continue down because we thought it was the beginning of a long-term change.

But I would emphasize that there are still significant portions of the population that are not going down that way. The school dropouts are not going down that rapidly. People in the highly impacted inner-city poverty zones are not going down that rapidly, although even there there are some encouraging early trends.

The DAWN data-that is, people who come to emergency rooms with cocaine overdoses-is down 22 percent in the last year. Th is the beginning encouragement that perhaps even in this hardcore heavy user group there are some beginnings of some reductions there, but again, the hardcore group, particularly those who inject drugs, with the AIDS epidemic is still a major challenge and we cannot afford to let up.

Dr. SCHUSTER. Well, unfortunately, one of the things the high school senior survey has shown is that attitudes toward the dangerousness of smoking one or more packs of cigarettes has not changed as significantly as it has for marijuana and for cocaine use, and we believe that changes in attitude precede behavioral changes.

What we have seen is that for the past, actually 7 years, although overall there has been a downward trend in tobacco use in high school seniors, that for the past 7 years there has not been a continuing trend. In other words, it has flattened out.

I think this is an area that we need a great deal more intervention. As you may notice my button, here, which is an antismoking button, because NIDA, as well as OSAP and others are very much involved in prevention programs for tobacco use in adolescents as well as amongst children.

Let me just point out, I am very pleased that you used the high school senior survey, which we sponsor, and this next year we will be conducting the same survey in 8th graders and 10th graders, and this is an attempt to be able to get information about children who may never reach their senior year of high school, because they drop out of school earlier. That data will also be collected on a yearly basis from here on out. Senator HARKIN. Thank you, Senator Bumpers.

I have one last question, Dr. Goodwin and Dr. Leshner. Once again the President's budget proposes to eliminate the protection and advocacy program. The program was created because States were not offering adequate protection to the institutionalized, mentally ill population. Is the number of protection and advocacy cases still increasing as it has for the past several years?

Dr. LESHNER. Yes; the number of cases has increased over the past few years, although the administration feels, as it has over the

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past few years, that this should become an increasing State responsibility to take over this program.

Senator HARKIN. Do you have evidence to show that States will continue to fund it if Federal support is eliminated as you propose?

Dr. LESHNER. We do believe that they will begin to take some responsibility for it.

Senator HARKIN. You said some responsibility, but I mean, if, for example, we do not fund it in our appropriations bill-how much is the total on that_$16 million. Do you think the States will pick that all up?

Dr. LESHNER. I do not know whether they will initially pick up the entire balance, but I suspect over time that the systems have enough momentum that they will continue to develop.

PROTECTION AND ADVOCACY PROGRAM Senator HARKIN. I want to know what evidence you have. The program was created because the States were not doing it, so we have been funding it. Now you are saying we can stop funding it because the States will do it. I do not understand what has happened all of a sudden.

Dr. LESHNER. They have become more incorporated into the normal operation of the States, and while I cannot prove to you that they will take over, we believe that it is the States' responsibility to pick this up.

Senator HARKIN. When did we start funding it, 1985?
Dr. LESHNER. In 1986.

Senator HARKIN. In 1986. Now that is a short timeframe. I wish I had some evidence that would show me that they would, in fact, pick it up, or something, because I believe that you say the cases are still going up? I read about them all the time. I get different letters or different indications from different parts of the country that we have a real problem here.

It is a small amount-well, it is not a small amount of money, but $16 million, it might be a big amount of money in some State budgets. I do not know, if I thought the States would pick it up, we might let them do it, but I am not certain that they would. And I do not see any evidence that they would.

QUESTIONS SUBMITTED BY THE SUBCOMMITTEE I have a number of other questions, but I will just have to submit those to you in writing. Is that all right, Dr. Leshner, to respond in writing?

Dr. GOODWIN. I would be happy to provide answers in writing.

Senator HARKIN. OK, thank you all very much. Again, thanks for your answers on your prevention activities. I will review the record on that, and I may get back to you, Dr. Goodwin, and in turn to all of you, about the prevention programs in different areas, and try to highlight this a little bit more as we go through the year.

Dr. GOODWIN, OK. Thank you.

[The following questions were not asked at the hearing, but were submitted to the Department for response subsequent to the hearing:]

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Question. I have received disturbing reports that your Agency's delay in determining the States' ADMS Block Grant allocations and in sending out Block Grant applications for several months into the fiscal year caused States to have serious cash-flow problems in their treatment programs. States couldn't even apply for funds. Some ran out of money to pay for substance abuse treatment. When did States learn their FY 1991 Block Grant allocations, and when were applications for the funds sent to States?

Answer. The States are free to apply for the ADMS Block Grant without waiting for us to formally invite their applications. Nevertheless, we do typically invite States to apply. When the FY 1991 letter of invitation was sent on January 22, 25 States and 2 Territories had already applied. That letter of invitation included a schedule showing the official State allotments; however, within two weeks of receiving our appropriation, we had shared tentative allotment information with state associations which, in turn, quickly provided the information to the States.

Question. What was the reason for the delay?

Answer. The application invitation letter is usually sent out shortly after our appropriation is enacted. However, this year the letter was delayed due to our desire to provide an alternative voluntary application format for the States to use. This optional format would have provided us and the Congress with additional information regarding State treatment services and would also have served as a "dry run" for development of State Substance Abuse Treatment Plans. We published the alternative format (and the existing format) in the Federal Register for State comment on November 29, and OMB granted approval on January 19. As a practical matter, ADAMHA staff had since September 1990 been reminding States of their right to apply using the older format without invitation. In fact as of March 25, we have awarded 43 grants, which is more than the 38 awarded by the same time last year.


Question. Once again, the President's budget proposes to eliminate the Protection and Advocacy program. This program was created because States were not offering adequate protection to the institutionalized mentally ill population. Is the number of P&A cases still increasing, as it has for the past several years?

Answer. The number of cases has increased over the past few years.

Question. What evidence do you have that States will continue to fund the P&As if federal support is eliminated as you propose ?

Answer. P&As have become more incorporated into the normal operation of the States and while we have no direct evidence that the States will take over, we believe that it is the States' responsibility to pick this up.


Question. 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 number one drug of abuse and a top public health problem, yet the budget proposes not a single penny more for the ADMS Block Grant than we provided in FY 1991. Would increasing excise taxes combat alcohol abuse?

Answer. Yes, research evidence indicates that increases in excise taxes on alcoholic beverages can reduce alcohol consumption and its adverse consequences. Specifically, increases in excise tax rates have been causally linked with decreased fatality rates for liver cirrhosis, reductions in traffic fatalities among young people, and reduced quantity, frequency, and prevalence of consumption among. youth. The public health benefits of a specific tax increase will depend in part on the degree to which prices rise as a result. The recent increases in federal excise taxes are small in comparison to the prices charged for these beverages. It is not yet clear whether tax increases of this size will have a significant impact on alcoholrelated problems.

Question. Given that alcohol abuse is the most prevalent and costliest drug to society, should the National Drug Strategy address the issue?

Answer. The National Drug Strategy provides a cohesive strategy for attacking illegal drug usage including the use of alcohol for those under the age of 21. While the National Drug Strategy does not address alcohol, the Department is committed to tackling this public health problem. All of the prevention programs operated by the Office of Substance Abuse Prevention within ADAMHÀ incorporate alcohol as well as drug prevention. Most drug abusers are poly-drug a busers and in many cases alcohol is one of the many drugs they are abusing. Through the office of Treatment Improvement we are working toward providing comprehensive drug treatment which includes addressing alcohol abuse.

The Secretary, DHHS, and the Surgeon General are launching highly visible initiatives to increase public awareness on the dangers and costs of alcohol abuse and dependence; to reduce the number of associated deaths, injuries, and suffering; and to foster support for biomedical research on the causes and effects of alcohol abuse and alcoholism, and clinical research on the treatment and prevention of alcohol-related problems. The Secretary's initiative to reduce alcohol abuse is centered on a strong anti-drunk driving campaign, continuing communication with the Department of Treasury concerning the effectiveness of warning labels on alcoholic beverages, and the reduction of alcohol abuse among special populations such as high risk youth, pregnant and postpartum women, and Native Americans.

The Surgeon General is leading the PHS Five-Year Strategic Plan to Reduce Alcohol Abuse. The critical goals are to overcome public complacency about the toll of alcohol abuse and alcoholism; reduce the associated morbidity and mortality, especially the incidence of Fetal Alcohol Syndrome ; and increase public and scientific knowledge about the adverse consequences of alcohol abuse through biomedical and behavioral research on alcohol-related problems.

Question. Is the $99 million proposed for "capacity expansion" to be directed to alcohol, drugs, or both?

Answer. Although the Capacity Expansion Program focuses on effective and comprehensive drug abuse treatment, the extensive overlap of alcohol and other drug abuse problems in the same individuals dictates that almost all service providers address the treatment of the dually diagnosed. The 1989 National Drug Abuse Treatment Utilization Survey reported that the percent of drug patients who have secondary alcohol problems ranged from 12 percent in Maine to 100 percent in Nebraska and Pennsylvania. Eighteen States reported in excess of 45 percent of drug patients with secondary alcohol problems.

Question. What would it cost to provide treatment on demand for alcohol and other drug problems?

Answer. Significant inroads to treatment of drug and alcohol abuse can only be achieved through a partnership between federal and State governments, communities and the private sector. Since 1989, , the Department's budget for drug treatment has nearly doubled, and' i believe that the new $99 million Capacity Expansion Program in the FY 1992 budget is a significant effort in this direction.

The FY 1992 President's Budget would provide support for 106,474 ADAMHA drug treatment slots, which together with expected other federal and non-federal support would provide treatment services for 2.2 million persons. The Administration has not made similar projections for the number and cost of treating persons with alcohol problems.

ALCOHOL AND DRUG ABUSE PREVENTION Question. Dr. Goodwin, I recently introduced a prevention package of seven bills designed to encourage wellness in both children and adults. It seems to me that, be using our dollars wisely today to provide prevention and screening programs to at-risk individuals, we will save billions of treatment dollars tomarrow.

ADAMHA recently released a study of the costs to society of alcohol, drug abuse, and mental illness. This report illustrates again the old adage the "an ounce of prevention is worth a pound of cure. The study estimates the total economic costs at over $273 billion in 1988, including $129 billion of mental illness, $86 billion for alcohol abuse, and $58 billion for drug abuse.

These really are alarming figures, especially when you take into account that mental and addictive disorders are chronically underreported; and this study doesn't even include costs associated with crack cocaine abuse or drug-exposed babies.

In light of this, Dr. Goodwin, how can you justify that your budget for research, treatment and prevention programs provides the smallest increase--a mere 3.7 percent, not enough to cover inflation- to prevention?

Answer. Since the Office of Substance Abuse Prevention was created, it has been the fastest growing component of ADAMHA. OSAP has gone from a grant program of just over $20 million to nearly $300 million. In addition, there is a $20 million prevention setaside in the Block Grant; and also, prevention research is an extremely important component of the research inistitutes.

PREVENTION DEMONSTRATION AND YOUTH SUICIDE Question. Dr. Leshner, we know that prevention is a major component of the NIMH mission. And the Institute supports research and programs that anticipate and intervene when an individual's behavior starts to deviate from the norm.

One of the Subcommittee's key concerns is the issue of preventing teenage suicide--a problem that has become increasingly significant in recent years. In fact, the Centers for Disease Control reports that the suicide rate among 15-24-year-olds has almost tripled since 1950. Surely this steep increase in the teenage suicide rate is not simply due to increased rates of serious mental disorders such as schizophrenia. What is the Institute doing to identify other factors--what we often call "life stressors"--that place young people at risk of attempting suicide?

Answer. The NIMH is doing a great deal to identify risk factors for suicide and suicidal behavior. Research projects addressing this complex issue cut across a wide range of NIMH programs. One thing we

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