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 majority 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 Development of improved technologies and standards to detect Discovery of the brain mechanisms involved in drug seeking 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 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 post-treatment outcomes were significantly better for those in methadone maintenance, therapeutic community, or drug-free outpatient treatment than for those in detoxification-only. NIDA research has shown that outreach programs to people not in treatment can reduce intravenous use of drugs, reduce the number of people who share needles, reduce unsafe sexual practices, and increase the number of people seeking treatment. Methadone maintenance can reduce intravenous drug use thereby reducing a high-risk behavior and the spread of HIV infection. Scientists at the ARC recently completed a survey of six programs in New York, Philadelphia, and Baltimore. They found marked variation in the effectiveness of the various programs; however, overall, 71 percent of patients who remained in treatment for two or more years stopped intravenous drug use. The Methadone Level Study found that methadone abuse treatment without counseling has a poor efficacy, but adding family therapy makes methadone therapy highly effective. Buprenorphine appears to have significant advantages over methadone in terms of its ability to block the effects of other opiates, in the ease with which patients may be withdrawn, and the ability to safely put this medication in long-acting formulation. Over the 17 weeks of the maintenance phase of the study, 8mg of buprenorphine was both clinically and statistically better than methadone 20mg, while methadone 60mg and buprenorphine were not significantly different. Naltrexone, a medication developed by NIDA in cooperation with the private sector, blocks the effects of heroin. Patient compliance with Naltrexone has not been very successful. NIDA has developed a depot preparation; a single administration of this dosage form will provide "protection" against heroin for up to thirty days. Euphoria is thought to be a major contributing factor leading to the initiation and maintenance of drug abuse. Investigators at the ARC used positron emission tomography (PET) to determine which brain areas are affected by morphine and cocaine. Morphine and cocaine, at doses that produced euphoria, reduced glucose utilization, an index of brain function. The findings indicate that a reduction in cortical activity may be part of the mechanism by which abused drugs produce euphoria. Scientists at the ARC recently identified the brain sites responsible for the seizure producing and lethal effects of cocaine. The primary action of cocaine in producing seizures appears to be that it increases the effects of serotonin, a naturally occurring brain neurotransmitter. The actions of cocaine which result in death are more complex and involve multiple brain sites. Researchers have identified drugs which, by blocking activity at these same sites, effectively prevent these toxic effects of cocaine. The site of action of cocaine in the brain, has recently been identified and specified. It will now be possible to clone this protein, specifically determine the sequence of its cocaine binding site and compare the structure of the binding site to other substances that bind to the dopamine transporter protein and block uptake of dopamine. Such information could lead to a more rapid development of a drug that can interfere with cocaine. Using PET scanning, the chronic effects of cocaine administration have been identified in animals. The D-1 dopamine receptor site, where cocaine acts, is " down-regulated" by chronic cocaine administration. A D-1 blocker could reverse this effect and bring the dopamine system back towards normal. This could possibly alleviate craving for cocaine. Over a dozen medications that are thought to reverse some of the effects of cocaine are being pursued in clinical trials. Desipramine was shown to be effective in reducing cocaine abuse in two studies, amantadine reduced cocaine abuse in methadone maintained cocaine abusers, and buprenorphine reduced both cocaine and opiate use compared to methadone. Random assignment of cocaine dependent patients to intensive outpatient programs or inpatient treatment has shown an outcome equally effective for both treatments. At followup, two-thirds of treated patients are cocaine-free. Outpatient treatment is less expensive than inpatient psychiatric care and this research should result in significant reduction of treatment costs. The experimental evaluation of aversion therapy treatment for cocaine abuse is producing promising preliminary findings. Some subjects are showing clear signs of developing conditioned aversions to placebo cocaine products, and these conditioned aversions appear to be exerting some therapeutic real-life benefits following discharge. A link between cocaine self-administration and internal opiate mechanisms has been suggested. Researchers gave buprenorphine, to a group of cocaine trained monkeys, and the monkeys stopped self-administering cocaine. These results are being followed up with both human and animal studies. After many years of research a receptor for THC, the active ingredient in marijuana, has been isolated and cloned. This has important implications for treatment: knowing the structure of the receptor is the first step in designing a THC antagonist to block the effects of marijuana. Recent studies show that when male rats were exposed to morphine and then bred with drug-naive females, both male and female offspring had abnormal levels of various hormones in adolescence. This is a troubling finding and suggests, at a minimum, that programs addressing the needs of female drug abusers, whether pregnant or not, must consider the drug use patterns of sex partners in terms of any potential pregnancy outcome. Recent studies show that when male rats were exposed to morphine and then bred with drug-naive females, both male and female offspring had abnormal levels of various hormones in adolescence. This finding suggests that programs addressing the needs of female drug abusers, whether pregnant or not, must consider the 38-711 0-91-19 drug use patterns of sex partners in terms of any potential pregnancy outcome. A four-year follow-up from the Midwestern Prevention Program indicates that a comprehensive, multiple component prevention strategy incorporating the individual, family, peers, schools, communities, and the workplace is reducing the use of marijuana and cocaine among adolescents. Family interventions for high risk youth have shown significant success rates. Effective strategies including but are not limited to educating and training parents to address drug abuse issues with children beginning as early as the elementary school level, teaching parenting skills, and structuring family processes to foster healthy development and family interactions. One of the most consistent factors correlated with the initiation of drug use is the influence of peers. Prevention intervention specialists have used this finding to develop programs that utilize the positive aspects of peer relationships to reduce the initiation of drug use. High sensation/novelty seeking behavior has consistently been linked to drug use onset and progression. Current research is focused upon design and testing of prevention interventions targeted to high sensation seeking youth. Further research is examining the heritability of personality traits and alcohol and other drug abuse associated with drug use risk. The demonstration programs of the Office for Treatment Improvement (OTI) were authorized beginning in FY 1990, and awards have been made and new programs are already operational. We have had an external assessment of the impact of our Waiting List Reduction Grant Program; and, while the report of this assessment is not in final form, it does seem fair to conclude that it is possible by expanding capacity to substantially reduce or eliminate the delays in entry that discourage many addicts from seeking treatment. It also seems to be true that when addicts find such delay they do not seek treatment elsewhere and, quite typically, when contacted weeks later about entering treatment, a substantial proportion of the majority have lost the motivation to accept treatment. The bulk of OTI's other demonstration and service projects (e.g.; Target Cities, Critical Populations) will also be subjected to depth study, and this is currently being launched. Although we expect to get some information within the first two years, it will be at least three years before any in depth assessment of these programs can be made. REDUCTION OF DRUG DEMAND Question. In your professional judgement, should we be spending more on the "demand" side of the drug war? Is the current 1/3 demand reduction, 2/3 supply reduction strategy appropriate? Answer. In the early 1970s, when the Federal Government first initiated its "balanced approach" with attention to both demand side and supply side reduction, the proportion spent on demand reduction |