IV. Agency Budget Summaries

SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION

1. RESOURCE SUMMARY

   

2. METHODOLOGY
   • Funding for Substance Abuse Prevention and Treatment Knowledge Development and Application (KDA) activities and funding for OAS Data Collection Activities are considered 100 percent drug-related. Funding for the Substance Abuse Performance Partnership Block Grant (SAPPBG) is considered drug-related to the extent that these funds are used by the States/Territories for treatment and prevention of the use of illegal drugs and used by the Agency for technical assistance, data collection, and program evaluation.

   • Five percent of the block grant is required to be used for SAMHSA set-aside activities which support data collection, technical assistance, the National Data Center, and program evaluation. The remaining 95 percent is distributed to the States and Territories where at least: 35 percent must be used for alcohol prevention and treatment activities; 35 percent must be used for other drug prevention and treatment activities; and, the remaining 30 percent is to be used at the State's discretion, either for alcohol alone, for drugs alone, or shared by both alcohol and drug programs. For budget formulation purposes, SAMHSA and ONDCP agreed to score the discretionary amount equally for alcohol and drugs, with 15 percent assigned to alcohol programs and 15 percent assigned to drug programs.

   • In 1997 and 1998, SAMHSA received a $50 million supplement to the SAPPBG, funded as part of P.L. 104-121, Social Security Earnings Limitation Amendments, Contract with America Advancement Act. The mandate for use of these funds was to provide "treatment of the abuse of alcohol and other drugs," and excluded use of any part for SAMHSA set-aside activities. Scoring of the $50 million distribution to the States parallels scoring of the basic SAPPBG, providing treatment support for the abuse of pure alcohol, co-morbid use, under age twenty-one use, and the abuse of other drugs.

   • Funding for Program Management activities is considered drug-related to the extent that funds are used to support the operations of the Center for Substance Abuse Treatment (CSAT), the Center for Substance Abuse Prevention (CSAP), and the activities of the Office of Applied Studies (OAS) that are supported by Set-aside funds from the SAPPBG.

3. PROGRAM SUMMARY

   Goal 1: Educate and enable America's youth to reject illegal drugs as well as the use of alcohol and tobacco.

   • Financial support for this Goal includes funding for the Prevention Knowledge Development and Application program (KDA), Data Collection Activities (administered by OAS), 20% of the Substance Abuse Performance Partnership Block Grant, as well as program support for these activities.
     • Funding for Prevention KDA programs includes continuation of pre-1996 demonstration awards including funding for the Community Prevention Program (Systems Partnerships and Service Partnerships, High Risk Youth Program (Public Housing, School Based, Violence, Adolescent Women), Public Education Activities (Communications, Conferences) and Training Programs. A key activity funded with the KDA for changing systems and practices is the new Youth Prevention Initiative which includes funding for State Incentive Grants, Regional Centers for the Application of Prevention Technologies, and a Media/Public Education Campaign in response to the increase in drug use among youth.

     • These activities are augmented by funding for Data Collection Activities to expand the National Household Drug Abuse Survey to provide State-level estimates as part of the Secretary's Youth Prevention Initiative.

     • SAPPBG activities include State expenditures of a minimum of 20% of their block grant allotment for primary prevention as well as CSAP expenditures of 20% of the Block Grant Set-Aside for the development of State data systems (including the development and maintenance of baseline data on incidence and prevalence as well as the development and implementation of outcome measures on the effectiveness of prevention programs), provision of technical assistance, and program evaluations.

   Goal 3: Reduce health and social costs to the public of illegal drug use.
   • Financial support for this Goal includes funding for the Treatment Knowledge Development and Application program (KDA), Workplace programs (administered by CSAP), 80% of the Substance Abuse Performance Partnership Block Grant, as well as program support for these activities.
     • Funding for Treatment KDA programs includes continuation of pre-1996 demonstration awards, including funding for the Target Cities program, Women and Children programs (Pregnant and Postpartum Women, Residential Treatment for Women and Children), Criminal Justice programs (adult, juvenile, institutional, community based), Critical Population programs, AIDS program (Linkage, Outreach), and training programs. The remainder of the Treatment KDA portfolio includes knowledge development and application activities in the areas of: Clinical Interventions; Systems Development and Integration; organization of Services and Financing; Exemplary Program Replication; Community/Family/Consumer Networks; organizational and Professional Development; Targeted Treatment Capacity; and, Pharmacologic Treatment.

     • SAPPBG activities include State expenditures of 80% of their drug-related block grant allotment for treatment services as well as CSAT and OAS expenditures of 80% of the Block Grant Set-Aside for the collection and analysis of national data, the development of state data systems (including the development and maintenance of baseline data on the incidence and prevalence as well as the development of outcome measures on the effectiveness of treatment programs), provision of technical assistance, and program evaluations.

4. BUDGET SUMMARY

   1998 Program

   • The total drug control budget supported by the 1998 Appropriation is $1.319 billion, including $375.5 million for Goal 1 and $944.1 million for Goal 3.

   Goal 1: Educate and enable American's youth to reject illegal drugs as well as the use of alcohol and tobacco.

   • Goal 1 activities through the Block Grant/PPG include:
     • State expenditures of a minimum of 20% of their block grant/PPG allotment for primary prevention, as well as CSAP expenditures of 20% of the block grant/PPG set-aside for the development of State data systems (including the development and maintenance of baseline data on incidence and prevalence as well as the development and implementation of outcome measures on the effectiveness of prevention programs), provision of technical assistance (including the administration of the regulations implementing the Synar amendment on the use of tobacco by youth), and program evaluations.

     • The 1998, State distribution has been frozen at 1997 levels by the Congress. This action was taken to minimize disruption in State activities funded by the block grant while allowing additional time for review of the distribution formula. A proposal has been made to update demographic statistics that reflect the use of a non-manufacturing wage proxy in the calculation of the cost of services index, but the Congress has directed further study of this issue. SAMHSA anticipates legislation to phase in the impact of changing the wage proxy effective in 1999. Legislation will also be submitted that will increase State flexibility by waiving certain requirements in exchange for performance, and strengthen State performance data infrastructure by working with States to identify and test performance and outcome indicators.

     • In 1998, the Agency will be expanding the data collection efforts begun in 1997, to all other States, the effort will be funded from a separate budget line outside of the block grant program. A total of $18 million in direct budget authority (BA) is available to develop baseline data to monitor marijuana use on a State basis, as well as the trends in substance abuse identified for the Nation as a whole. Such information will be used to measure the effectiveness of prevention programs designed to reduce the use of marijuana, as well as the effectiveness of prevention programs funded through the Substance Abuse Performance Partnership Block Grant (SAPPBG). Additional funding for this activity will be made available from the SAPPBG Set-aside.

   • A total of $157.0 million is available for Goal 1 Knowledge Development and Application activities including funding for the following:
     • Prevention Services, which will continue to focus on very young children, children of substance abusing parents, and welfare reform and its impacts on youth at risk for substance abuse;

     • Evaluation and Outcomes, which addresses the systematic process by which effective prevention knowledge, technologies, and innovations are exchanged among researchers, evaluators, and practitioners for successful adoption and utilization at national, State, and local levels;

     • Systems Services and Financing, which focuses on Prevention and Workplace Managed Care initiatives, and continuation of Federal Drug-Free Workplace efforts that provide oversight of over 120 Federal agency drug-free workplace programs;

     • Knowledge Synthesis and Technology Transfer, which comprise a systematic process by which effective prevention knowledge, technologies, and innovations are exchanged among researchers, evaluators, and practitioners for successful adoption and utilization at national, State, and local levels;

     • Targeted Capacity Expansion, which focuses on the expansion of substance abuse prevention services in communities across the States, including three major programs: the State Incentive Grant program, the Drug Free Communities Program, the U.S. Mexico Border Initiative, and a new program to be initiated in 1998 targeting high risk youth, in particular, those youth who are at high risk for becoming substance abusers and/or involved in the criminal justice system; and,

     • Changing Practices and Norms, which involves CSAP's partnership with the Office of National Drug Control Policy (ONDCP) to conduct national media and public education campaigns to draw attention to emerging substance abuse trends, including successful initiatives such as the highly successful marijuana use prevention initiative, Reality Check, and Girl Power! The latter has been identified by the Secretary, HHS, as one of her initiatives since the concepts and messages of the campaign encompass all the health issues facing girls age 9-14. Both campaigns have strong support and endorsement from a large number of public and private intermediary organizations to promote and implement the campaigns which includes placement of campaign materials and joint production of other materials.

   Goal 3: Reduce health and social costs to the public of illegal drug use.
   • A total of $1.360 billion is available for the SAPPBG in 1998, this includes $50 million from the Social Security Supplemental (SSI) to the SAPPBG for FY 1998. Approximately 71 percent of this total, or $966 million, is drug-related. This includes $36 million from the SSI supplemental. Among the activities funded through the SAPPBG are:
     • Block Grant/PPG activities include State expenditures of 80% of the drug-related block grant/PPG allotment for treatment services as well as CSAT and OAS expenditures of 80% of the block grant/PPG set-aside for the collection and analysis of national data, the development of State data systems (including the development and maintenance of baseline data on the incidence and prevalence as well as the development of outcome measures on the effectiveness of treatment programs), provision of technical assistance, and program evaluations.

     • Resources from the SAPPBG 5% set-aside ($52.4 million) will be used for State data systems as well as for national data collection, technical assistance, and program evaluation activities. Set-aside activities include State Needs Assessments, State Treatment Outcome Pilots, National Household Survey on Drug Abuse (NHSDA), Drug Abuse Warning Network (DAWN) survey, and development of Treatment Improvement Protocols, as well as to supplement funding available to expand the NHSDA.

   • A total of $155.9 million is available for Goal 3 KDA drug-related activities in 1998, including funding for the following activities:
     • Clinical Interventions, including: the Residential Treatment Programs for Women and Their Children (RWC) and Pregnant and Postpartum Women (PPW), targeting services for women and their children; the SAMHSA-wide Starting Early/Starting Smart Programs, targeting services for children of alcoholics, children of HIV-infected adults, and foster care children; the Homelessness Prevention Program, a collaboration with the Center for Mental Health Services, examining models for preventing homelessness, focusing specifically on areas such as contributors to loss of housing, the effects of representative payee functions, and family support; the Marijuana Interventions for Adults, examining the efficacy of brief treatment interventions for marijuana dependence; and a follow-up study on the Effectiveness of Treatment for Marijuana Dependent Youth, evaluating the effectiveness of a variety of interventions and treatment for adolescents meeting the criteria for marijuana dependence;

     • Systems Development and Integration, including: the Target Cities Program, designed to assist major metropolitan areas with increasing the effectiveness of substance abuse treatment delivery; a study to analyze the Effects of the Potential Loss of SSI Payments for individuals whose receipt of benefits was determined to be material to alcohol and other drug abuse; the Criminal Justice Treatment Networks Program, which supports planning, implementation, and evaluation of sophisticated criminal justice treatment networks in seven metropolitan jurisdictions; the National GAINS Center for People with Co-Occurring Disorders, established in 1995 as a locus for collection and dissemination of information about effective mental health and substance abuse treatment services for dually diagnosed clients; and the Criminal Justice Diversion study, a collaboration with the Center for Mental Health Services designed to identify methods for diverting individuals with substance abuse disorders from the criminal justice system to community treatment alternatives;

     • Organization of Services and Financing, including: the Managed Care and Vulnerable Populations cross-site study, a SAMHSA-wide initiative describing how managed care in the public sector affects the provision of substance abuse and mental health services to adult chronic substance abusers, adults with severe and persistent mental illness, and seriously emotionally disturbed children and adolescents; the Managed Care for Adolescents examining the effects on cost, utilization, and outcomes of different models of managed care on adolescents with substance abuse problems; and the Rural, Remote and Culturally Distinct Populations Program designed to deliver treatment services in innovative ways to hard-to-reach populations, and to serve as models of programs to be replicated for Native Americans, Native Hawaiians, Alaska Native Villagers, or migrant farm workers;

     • Exemplary Program Replication, including: the Replicating Effective Treatment for Methamphetamine Dependence study, which will contribute to the development of knowledge of psychosocial treatment of methamphetamine dependence as well as providing an opportunity to determine the problems involved in technology transfer; and the Identification of Exemplary Treatment Models creating a partnership between States and the Federal government to explore the development of knowledge and its application in the development of effective treatment approaches;

     • Community/Family/Consumer Networks, including: Statewide and Regional Networks and Partnerships that will be comprised of consumers and families in order to ensure that they are vital participants in the planning, policy development and programming process; in collaboration with NIDA, a program evaluating Substance Abuse Treatment as HIV/AIDS Prevention to study treatment efficacy, outcomes, recidivism and HIV risk behaviors (needle use and sex) among injecting drug users (IDUs); and, in collaboration with NIAAA, a program focusing on Treatment for Adolescent Alcohol Abuse and Alcoholism;

     • Organizational and Professional Development, including: CSAT's network of Addiction Technology Transfer Centers (ATTCs) which now disseminate clinically relevant, research-based addiction knowledge in 24 States and Puerto Rico; a series of Persistent Effects of Treatment Studies (PETS), the purpose of which is to provide follow-up studies evaluating the long-term effectiveness (up to 36 months) of CSAT-sponsored substance abuse treatment grants and cooperative agreements, and to conduct a number of special studies and policy analyses that address specific drugs of abuse, methods of treatment, populations or policy issues; and,

     • Pharmacologic Treatment, which will include: an expansion of the Accreditation of Opioid Treatment Programs project, awarded in 1997, an Evaluation of the Accreditation for Opioid Pharmacotherapy programs, and a Technical Assistance Program for OTPs to States to ensure a smooth transition to the accreditation project.

   1999 Request
   • A total of $1.510 billion is requested for the SAPPBG in 1999, (a total of $1.36 billion is requested for the drug budget), representing an increase of $200 million to the Substance Abuse Block Grant, of which, $143 million is drug-related.
     • The total increase to the SAMHSA drug budget is $40.5 million over FY 1998. This total reflects major reductions in funding of $70 million for the Substance Abuse KD&A discretionary grant and contract activities, and supplemental funding to the States for the treatment of former SSI beneficiaries ($35.5 million drug-related) offset by a major increase in funding for the Substance Abuse Performance Partnership Block Grant ($143 million drug-related of the total $200 million increase). Also included is additional funding for the expanded National Household Survey on Drug Abuse, $4.0 million, and High Risk Youth, $4.0 million.

     • The 1998 and 1999 budget estimates include funding for the transfer of the Methadone Regulatory program from FDA, $900,000, and the establishment of the Opiate Treatment Program (OTP) in CSAT. The functional transfer will take place over a two year period.

   Goal 1: Educate and enable America's youth to reject illegal drugs as well as the use of alcohol and tobacco.
   • The total drug control request for Goal 1 activities for FY 1999 is $375.990 million for SAMHSA. This represents a net increase of $454,000 over FY 1998. The 1999 request includes the following enhancements:
     • CSAP will have available a total of $127.4 million (including $10 million for high-risk youth) for the KD&A program in drug-related funding, which is 12 percent below the amount necessary to continue all current awards. Of this amount, $5 million will be used to fund new starts in 1999 to expand the State Incentive Grant (SIG) program to 2 additional States. This program was initiated in FY 1997 and constitutes the focal point of the Secretary's Youth Substance Abuse Prevention Initiative. The State Incentive Grant (SIG) program is the vital link between the KDA program and the Substance Abuse Block Grant program. SIG funds will continue to be used to encourage States to adopt effective service strategies and to leverage block grant and other resources to "grow" statewide systems in conjunction with increased funding proposed for the block grant program. Between 19 and 25 States will be participating in the program in FY 1999.

   Goal 3: Reduce health and social costs to the public of illegal drug use.
   • The total drug control request for Goal 3 activities for FY 1999 is $984.144 million, a net increase of $40.1 million over FY 1998. The 1999 request includes the following enhancements:
     • A total of $1.510 billion is requested for the Substance Abuse Performance Partnership Block Grant (SAPPBG), representing an increase of $200 million. Of this amount, $143 million is drug- related.

     • In 1997 and 1998, SAMHSA received a $50 million Supplement to the Substance Abuse Performance Partnership Block Grant (SAPPBG), funded as part of the P.L. 104- 121. This Supplement has expired, resulting in a drug-related reduction of $35 million to the SAPPBG.

     • Additional funding of $4 million is requested for the National Household Survey (NHSDA) to generate state level estimates for drug use for the year 2000 survey. This survey will provide the means for identifying States with relatively serious levels of substance abuse. It will clearly show which States have overall higher rates of youth substance abuse, and the data, when used with sub-State and program information, will help States target their prevention efforts accordingly. The expanded NHSDA will also help to identify areas where we need to understand and explain substance abuse problems, develop innovative solutions for those problems, and provide immediate assistance to help States adopt such solutions.

     • CSAT will have available a total of $115.4 million for the KD&A program. Of this amount, $7.5 million will be used to fund new starts in 1999 to expand the number of Incentive Grants to States and communities, and to initiate several new projects which focus on alcohol prevention and treatment and pharmacologic therapies as well as to expand targeted treatment capacity. Funding will be used to test demonstrated models of prevention, education, intervention, assessment, referral, treatment and continuing care on college campuses and within sorority, fraternity and house plan environments. Funding will also be used to foster greater use of pharmacotherapies including LAAM and Naltrexone as well the use of state of the art techniques in the treatment of opioid withdrawal syndrome (including the use of alpha 2 adrenergic blockers, antagonists, combinations of antagonists and heavy sedation or anesthesia, and partial opioid antagonists.)

5. PROGRAM ACCOMPLISHMENTS
   • Starting Early Starting Smart (SESS), a child-centered, family-focused, and community-based cross center initiative that represents a collaboration with DHHS agencies, the Department of Education, and The Casey Family Program, awarded $6.1 million to support five grants to primary care service settings (public and private health care programs) and seven grants to early childhood service settings (early learning programs, child care programs, pre-schools, etc.). An additional grant supports a Data Coordinating Center to work with SAMHSA and the individual programs in gathering and analyzing information across all sites. The Casey Family Program, a private foundation, has dedicated almost $4 million over the next four years to this collaborative effort.

   • In FY 1997, SAMHSA awarded five State Incentive Grants for a total of $15 million, to initiate the Secretary's Youth Substance Abuse Prevention Initiative (YSAPI). These grants call upon State Governors to develop comprehensive strategies for youth substance abuse prevention in their State. These strategies include the identification of program and funding gaps, the coordination and/or combining of resources and funding streams and the development of cooperative efforts with other state and local agencies. A second component of the Secretary's YSAPI initiative involves establishment of Regional Centers for the Application of Prevention Technology. Five awards for a total of $5 million, will help support the States and communities by ensuring that they implement promising research based prevention programs, practices and policies at the state and local level.

   • CSAP's Girl Power! media campaign has grown into a national, HHS-sponsored campaign that empowers girls to focus on such issues as physical activity, nutrition, and mental health. The campaign has been endorsed by over 300 organizations and agencies, spreading the word through posters, TV and radio announcements delivered by Olympic Gold medal winner Dominique Dawes, and other vehicles. CSAP continues to respond to an average of over 3,000 requests per month.

   • CSAP's Reality Check campaign raises awareness of the dangers of marijuana use. Copies of its community kit have been distributed to over 5,000 community, State, and national groups, including Just Say No International and Big Brothers/Big Sisters. Outreach includes public service announcements and a magazine for youth aged 12 to 17 that helps them see through and think critically about our society's many pro-marijuana messages.

   • Currently all states are in compliance with the Synar Amendment. Every State has in place a law prohibiting the sale or distribution of tobacco products to minors. Also, forty three States have finalized baseline and interim target rates. Since some State legislatures did not meet in 1993 and 1994, Congress provided seven States (Arkansas, Kentucky, Texas, Oregon, North Dakota, Montana, Nevada) an additional year to meet the compliance requirements of the statute.

   • In March, 1997, CSAT published results of the National Treatment Improvement Evaluation Study (NTIES), the most robust database to date showing the degree to which treatment is cost effective. The NTIES study examined whether specific patient characteristics, or the characteristics of the treatment units, could explain variations in pre/post treatment outcomes. It found that drug and alcohol use was significantly reduced, criminal activity declined dramatically (as much as 80%), and employment outcomes were measurably better among individuals who completed their treatment plans, received more intensive treatment and were treated longer.

   • CSAT conducted 4 regional work sessions on the implementation of welfare reform in 1997. All 50 States sent teams composed of SSA Directors and State Welfare, Child Welfare, Medicaid, legislative and labor leaders. Approximately 15 States indicated that these working sessions represented the first time that the SSA and the welfare representatives had met and discussed collaboration. The Department of Labor participated in one of the work sessions and collaborated with CSAT in the development of a Welfare to Work grant program. The relevance of this work is the potential benefit to be gained by millions of welfare recipients to be favorably impacted by the establishment of substance abuse treatment services as part of the welfare reform initiative.

   • CSAT successfully planned for and negotiated the transfer of the Federal monitoring and oversight functions for pharmacotherapy in opioid addiction treatment from the Food and Drug Administration. While the transfer will occur incrementally over the next two to three years, this accreditation/regulatory model will benefit the treatment field by shifting from a purely regulatory program to one which provides for accreditation from licensed independent bodies. The program also provides technical assistance for treatment programs as well as an impact evaluation on the transition process.

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