III. Report on Programs and Initiatives

1. Initiatives To Prevent Drug Use

Understanding what determines vulnerability to substance abuse is crucial to developing prevention programming. At this point, there is no evidence for a single, unique factor that determines which individuals will abuse drugs; rather, drug abuse appears to develop because of a variety of genetic, biological, emotional, cognitive, and social risk factors that interact with features of a social context. Thus, the combination of individual and social context factors appears to make someone more or less at risk for drug abuse and influence the progression from drug use to abuse to addiction.

NIDA-supported research has already identified many risk factors associated with the development of drug problems. These factors typically have been organized into categories that represent individual, familial, and social risks. For example, we now know that individual-level risks include shy, aggressive, and impulsive personality traits and poor academic achievement; family-level risks include poor parental monitoring and exposure to substance use by parents and siblings; school-level risk factors include a pro-drug use school norm and availability of drugs on or near the school campus; and community-level risks include lack of positive academic and recreational programming for children and adolescents during after-school and weekend hours and low levels of enforcement of laws pertaining to the use of licit and illicit substances by minors. This incomplete list illustrates the breadth and complexity of the risks that can confront any one person.

For many years, our focus was discovering the factors that put people, particularly children, at risk for drug use, abuse, and addiction. We discovered that there are protective or resiliency factors — factors that protect individuals from developing drug-related problems. NIDA-supported research has already uncovered many such protective factors that operate at the individual and contextual levels through the family, peer group, school, community, workplace, and the media, among others. Examples of protective or resiliency factors can include a stable temperament, a high degree of motivation, a strong parent-child bond, consistent parental supervision and discipline, bonding to prosocial institutions, association with peers who hold conventional attitudes, and consistent, community-wide anti-drug use messages and norms. An accumulation of protective factors may counteract the negative influences of a few risk factors. The challenge for the future is to understand how the accumulation of risk and protective factors interact to make individuals more or less vulnerable to trying drugs, to abusing drugs and/or becoming addicted to drugs. This knowledge will allow prevention researchers and providers to design programs that can be more effectively tailored to individual needs.

Researchers have developed and tested a variety of efficacious prevention programs, and have analyzed these programs to identify the fundamental principles of effective drug abuse prevention. These principles were published in 1997 in NIDA's "Preventing Drug Use Among Children and Adolescents: A Research-Based Guide". As useful as these principles are, they are quite general, and must now be taken to a greater level of specificity. Prevention programs cannot simply be replicated in any setting. They must be responsive to the characteristics of different locales, and the needs of audiences that often vary in gender, ethnicity and age. We also need to determine how to best tailor programs to subpopulations that are at increased risk.

There is a need for research in several emerging areas of prevention. Strategies need to be developed that can help communities determine their needs and readiness for interventions. For example, communities require the epidemiological tools to assess their needs. Research is also needed to understanding the organization, management, financing, and delivery of prevention services. In the treatment arena there are established systems such as clinics, hospitals, out-patient centers, HMOs, clinician training and certification systems. However, there are no defined prevention provisions, financing, training, or credentialing systems. It is therefore difficult to determine how decisions are made about prevention implementation. A fuller understanding of these issues will help integrate prevention strategies and programs into existing community level service delivery systems.

The Central Role of Parents

While all parents exert a critical influence on their children, mothers and fathers of eight to fourteen year olds are especially influential. Young people in this age group normally condemn drug use. Such attitudes and attendant behavior are easily reinforced by involved parents. Adults who wait until their children are older to guide their offspring away from drugs, allow peers to have more influence on their children's decision to use drugs.

SAMHSA/CSAP's High Risk Youth program has found that protective factors and family bonding drop dramatically between ages ten and fourteen. Based on such evidence, SAMHSA/CSAP has established a new Parenting and Family Strengthening program to increase the availability of family-based prevention interventions. This two-year program funded ninety-six cooperative agreements to increase local effective parenting and family programs, document the decision-making processes for selecting and testing interventions in community settings, and determine the impact of the interventions on target families. The program works to raise awareness of the fact that good parenting and strong families are key to preventing youth substance abuse. Through CSAP's Parenting IS Prevention Initiative, significant collaborative efforts have been made with major parenting organizations such as the Child Welfare League of America, Parents Without Partners International, The National Council on Family Relations, and the Head Start Association. As a result, these organizations are offering training and other resources to their members. Finally, SAMHSA/CSAP has launched a prevention program aimed at Spanish-speaking parents and grandparents called "Hablemos En Confianza."

Children whose parents abuse alcohol or illicit drugs face heightened risks of developing substance-abuse problems themselves. An estimated eleven million such children under age eighteen live in the United States. Every day, these young people receive conflicting and confusing messages about substance abuse. Nevertheless, specially crafted prevention interventions can break through the levels of denial inherent in these families. SAMHSA/CSAP's Children of Substance-Abusing Parents program is developing community-based interventions for these youth.

Substance-Abuse Prevention in Early Childhood

Early childhood is a perfect time for prevention that targets risk factors. Intervention for substance abuse is critically important during this time because it is from infancy to the preschool period when brain development is rapid and much more vulnerable to environmental influences.¹ Children who have not developed crucial intellectual, emotional, and social abilities by age three are more likely to have problems that can limit lifelong potential. Early risk factors include parental criminality and substance abuse, low verbal ability, social disorganization and violence in the neighborhood, poor family management practices, inconsistent or harsh parenting, low socioeconomic status, and exposure to media violence. Prevention works well at this early stage when children and caregivers are susceptible to learning. SAMHSA/CSAP has initiated several programs addressing prevention in early childhood. Starting Early Starting Smart, developed and conducted collaboratively with the Health Resources and Services Administration, the Administration for Children and Families, the U.S. Department of Education, the National Institutes of Health, and The Casey Family Program, is testing the effectiveness of integrating behavioral health services with primary care and/or early childhood service settings. SAMHSA/CSAP also sponsors a Predictor Variables investigational program which is seeking to develop further the knowledge about effective prevention interventions for young children (ages 3-14) by linking them with appropriate developmental stages. Since 1992, the Robert Wood Johnson Foundation has supported Free to Grow: Head Start Partnerships to Promote Substance-Free Communities. This program provides early childhood education, health, and social services to more than 750,000 low-income children in urban, suburban, and rural communities throughout the United States. The initiative addresses the problem of substance abuse by strengthening families and neighborhoods. Free to Grow supports the design and implementation of model substance-abuse prevention projects within local Head Start programs.

National Youth Anti-Drug Media Campaign

The goal of ONDCP's bipartisan five-year National Youth Anti-Drug Media Campaign is to harness the media to educate America's youth to reject illegal drugs. Advertising, television programming, movies, music, the Internet, and print media have a powerful influence on young people's view of drugs and other dangers. The campaign focuses on primary prevention — heading off drug use before it starts — for three reasons:

1. Primary prevention targets the underlying causes of drug use and therefore has the greatest chance of success.
   
   
2. Over time, primary prevention will reduce the need for drug treatment, which is in short supply.
   
   
3. A media campaign has more potential to affirm the anti-drug attitudes of youth who are not involved with drugs than to persuade regular drug users to give up drugs.

The media campaign is based on medical and behavioral research. The campaign was developed in consultation with scores of experts in behavioral science, medicine, drug prevention, teen marketing, advertising, communications, and representatives from professional, civic, and community-based organizations.

The media can play a critical role in public-health campaigns because of its educational ability to impart information and influence behavior. A carefully planned mass media campaign can reduce substance abuse by countering false perceptions that drug use is normal. In the past, media campaigns have proved successful in changing risky behaviors, such as driving under the influence of alcohol or without seat belts. ² The media campaign needs to be integrated with anti-drug programs and other outreach initiatives based in homes, schools, places of worship and community-based organizations.

An integrated communications approach was instituted in 1999, at which time the Office of National Drug Control Policy focused on specific anti-drug themes and messages for advertising and other outreach efforts, to the entertainment industry, interactive media, and sports organizations. The advertising program is divided into four to six-week periods — a process called flighting — during which time a specific anti-drug message "platform" is communicated. Local coalitions and other partners can amplify these messages by adding their own messages and conducting related local events and activities.

Matching contributions from media outlets also multiply the impact of these messages. When advertising is purchased from a media outlet, the outlet, as mandated by Congress, must match it dollar-for-dollar with a pro bono public service activity. Most matches involve time and space for public service announcements (PSAs); media outlets match a paid PSA with a second one of equal value in a similar time slot. Magazine inserts, program content, Web site development, and community events also qualify for the pro bono match.

The Advertising Council and the American Advertising Federation lead efforts to choose eligible PSAs for both national and local media markets. Themes include underage alcohol use, parenting skills, mentoring, and structured activities for young people. In 1999 alone, the campaign shared more than 265,000 radio and television time slots with forty-five national organizations. To cite an analogy, "a rising tide floats all boats." Many related causes are served by the anti-drug media campaign.

The Partnership for a Drug-Free America (PDFA) is a private, non-profit, non-partisan coalition of professionals from the communications industry. Best known for its national, anti-drug advertising campaign, its mission is to reduce demand for illicit drugs in America through media communication. PDFA has generated more than $2.8 billion in media exposures and created more than five hundred anti-drug ads. Its long-standing national campaign is the single, largest, public service ad campaign in history. For twelve years, PDFA's process was the paradigm for a public service campaign. No other organization was as successful in generating high-quality free ads and placing them pro-bono in the media.

PDFA is a key campaign partner. The Partnership had concluded that intense competition, brought on by the splintering of the media, brought new economic realities to the media industry in the 1990s. With media donations to the Partnership down by more than $100 million since 1991, the outlook for national media giving was uncertain. The ONDCP campaign promised something unprecedented for PDFA's public-service advertising effort: precise placement of the right ads, targeting the right audience, running in the right media, consistently, over time. Presently, PDFA has developed 37 television commercials, 36 print ads, and 21 radio spots for parents and 37 TV commercials, 35 print ads, and 35 radio spots for youth.

In 1999 "branding" was introduced to unite parent message platforms, create synergy between advertising and non-advertising programs, and maximize campaign awareness and impact. The campaign's parent brand is "The Anti-Drug." It is a promise to provide America's youth and their parents with unequivocally honest and straightforward information — no hype, just honest, factual information. "The Anti-Drug" branding was launched in September 1999 in new advertising targeted at parents for television, radio, print, out of home media, and parenting brochures.

In 1999, the following organizations contributed to anti-drug efforts: the national Future Farmers of America (FFA), the YMCA of the USA and Youth Service America, National Association of State Alcohol and Drug Abuse Directors (NASADAD), Community Anti-Drug Coalitions (CADCA), the National Association of Children of Alcoholics, the National Middle School Association, the 21st Century Teachers Network, the National Elementary School Press Association, Cable in the Classroom, The New York Times, Latina, the Congress of National Black Churches, Global Mission Church, local churches and synagogues in various cities, Sun Microsystems, Media One, America Online, CSAP, NASA, and more than twenty federal agencies participating in the campaign's Federal Web site Initiative.

The campaign developed Internet sites with industry giants like America Online (AOL). The Parents' Drug Resource Center — on AOL at Keyword "Drug Help"— teaches parents about underage drug use, connects them to drug-help resources, and offers expert advice on child-rearing. In addition, content is being developed for campaign-related Web sites. One site, Freevibe.com helps youngsters make positive, well-informed, life-style decisions. Other Internet initiatives combine online banner ads with educational mini-sites, online sponsorships, promotions and interactive events.

During the past year, the campaign reached 95 percent of America's youth at 8.3 times a week through advertising, and communicated advertising messages in eleven languages to youth and adults of various ethnic groups. The campaign represents the largest multicultural advertising and communications effort ever undertaken by the federal government, with messages and delivery tailored to ethnic audiences. It combines culturally competent and relevant messages designed by African American, Hispanic, and Asian-owned companies, to ensure the credibility of the messages and to enhance their impact.

In less than two years, the campaign's messages have become ubiquitous in the lives of America's youth and their parents. From network television advertisements to school-based educational materials, from youth basketball backboards to Internet Web sites, and from local soccer competitions to national youth organizations, the campaign's messages reach Americans wherever they are — work, play, school, worship, and home.

Safe and Drug-Free Schools and Communities

The Department of Education's reauthorization proposal for the Safe and Drug-Free Schools and Communities Act (SDFSCA) aims to insure that every school in the United States will be free of illegal drugs, violence, and the unauthorized presence of firearms, tobacco, and alcohol. Guided by extensive input from SDFSCA program participants, evaluation studies, and program reviews, the reauthorization proposal requests significant changes that would promote improvements in programs funded under the SDFSCA. Two key changes include the following:

1. Emphasize the importance of research-based programs. States would competitively award subgrants to school districts and other applicants, largely in accordance with the quality of their plans. Consistent with the Principles of Effectiveness for the program, grantees would be required to implement research-based programs to address identified needs and established goals, and to assess progress regularly. The proposal would also increase support for state activities to help applicants create and implement effective, accountable programs.

2. Strengthen accountability. State and local recipients of SDFSCA funds would be required to adopt outcome-based performance indicators and report regularly on their progress. Continuation of local grants would be conditioned upon achievement of satisfactory progress. School districts would also have to develop a comprehensive "Safe Schools Plan" to ensure that essential program components are in place and that efforts are coordinated with related community-based activities.

The reauthorization proposal reflects the direction the Department of Education's Safe and Drug-Free Schools Program is taking to ensure that SDFSCA fund recipients — including governors, state education agencies, local education agencies, institutions of higher education, and community organizations — adopt programs and practices that are based on research and evaluation. The proposal calls for a comprehensive approach that requires collaboration among agencies and organizations at the federal, state, and local level.

Key initiatives of the Safe and Drug-Free Schools Program (SDFSP) in 1999 have included Safe Schools/Healthy Students and the Middle School Drug Prevention and School Safety Program Coordinators. The former initiative, announced by the President in Spring 1999, is a grant competition jointly administered by the U.S. Departments of Education, Health, and Human Services, and Justice. The program promotes comprehensive, integrated community-wide strategies for school safety and health child development. These strategies provide students, schools, and communities enhanced educational, mental health, social service, law enforcement, and juvenile justice system services that can bolster healthy childhood development and prevent violence, alcohol, and drug abuse. Grants under this initiative have been awarded to fifty-four local educational agencies in partnership with local law enforcement and public mental health authorities. Annual awards range from three million dollars per year for urban school districts, two million dollars per year for suburban school districts, and one-and-a-half million dollars per year for rural and tribal school districts. A national evaluation of the Safe Schools/Healthy Students Initiative will be conducted to document the effectiveness of collaborative community efforts to promote safe schools and provide opportunities for healthy childhood development.

Under the Middle School Drug Prevention and School Safety Program Coordinators Initiative, ninety-seven school districts received $34.6 million in grants to recruit, train, and hire coordinators in middle schools. The three-year grants were awarded to school districts with significant drug, discipline, and violence problems in middle schools.

After-School Initiatives

Reducing the precursors of drug use — aggression, conduct disorders, shyness, and lack of school and family attachment — can be achieved through after-school activities. Mentoring programs increase the involvement of high-risk youth with caring adults. Mentors help children by modeling, teaching, and reinforcing positive behavior. In FY 1999, the Departments of Justice and Education collaborated to support twelve grants providing one-to-one mentoring programs for youth at risk of educational failure, dropping out of school, or involvement in delinquent activities including gangs and drug use. SAMHSA/CSAP'S Project Youth Connect is evaluating the comparative benefits of youth-only approaches versus programs that involve parent AND youth mentors. CSAP's public education campaign, Your Time — Their Future, encourages adults to get involved with youth to help young people build skills, self-discipline, and competence to resist alcohol, tobacco, and illicit drugs.

Drug-Free Communities

Government response is only a small part of the national effort to counter illegal drugs. Communities are significant partners for local, state and federal agencies working to reduce drug use, especially among young people and deserve continued support. Local coalitions, comprised of a broad sector of community leadership, are working to devise sound strategies based on local data and knowledge of a growing body of scientifically supported program ideas. Local leaders know that they must sustain their efforts into the foreseeable future if we are to significantly reduce demand for illegal drugs at the community level.

The Drug-Free Communities Program, created through the Drug-Free Communities Act of 1997, provides funds, knowledge, and other resources to help local leaders prevent youthful drug problems, including the underage use of alcohol, tobacco, and inhalants. This program now supports 213 communities located in forty-five states, Puerto Rico, and the U.S. Virgin Islands. Applicant communities must match their grant awards with funding from non-federal sources. Communities may re-apply for federal funds over an additional four years, but after year two become eligible for decreasing levels of federal support. The intent of Congress is to support programs that are able to support themselves in the future through non-federal resources.

CSAP carries out training and technical assistance to grantee communities through a network of private sector collaborators. The regional Centers for the Application of Prevention Technologies (CAPT) offices offer high quality, research-based knowledge and information to state and community prevention programs. Several major information clearinghouses, including the CSAP-sponsored National Clearinghouse for Alcohol and Drug Information (NCADI) provide free or low-cost material directly to all U.S. communities.³

In December 1999, SAMHSA announced the results of an extensive study of community anti-drug partnerships. Statistically significant reductions in drug and alcohol use were found among males in communities with such programs.⁴ A core set of desirable strategies that can be used by other communities were identified among model community partnerships identified in this study. These include a comprehensive vision, a wide sharing of this vision, avoidance or resolution of severe conflict in the partnership, non-disruptive partnership staff turnover, a strong core of committed partners, an inclusive and broad-based membership, decentralized management and extensive and diverse prevention activities.

The Drug-Free Communities Program is complemented by a number of private sector organizations and other public agencies, including the National Association of State Alcohol and Drug Abuse Directors (NASADAD), National Prevention Network, National Guard, Mothers Against Drunk Driving (M.A.D.D.), AmeriCorps and National Inhalant Prevention Coalition, that provide useful tools, occasional funding and frequent communications among the communities and other useful resources. The program is ably guided by the Advisory Commission on Drug-Free Communities, an eleven member, presidentially-appointed expert group representing many sectors and organizations across the United States. The Community Anti-Drug Coalitions of America (CADCA) is a coalition membership organization that provides a wide array of technical support, program ideas, and advocacy to community coalitions around the U.S. CADCA (www.cadca.org) actively assists the Drug-Free Community grantees on a regular basis. Join Together, a Boston University based organization, (www.jointogether.org) examines and reports on critical issues of interest to communities around the issues of drugs, guns, and violence.

At the national level, future initiatives will involve creating new training capabilities, detailed descriptions of successful local innovations that can be replicated through public/private coalitions, and better dissemination and utilization of scientific knowledge about the application of prevention strategies in the natural environments of neighborhoods and communities. In addition, efforts on the local level should be focused on improved data collection and analysis which can inform coalition leadership, so that they may make educated financial and personnel decisions in the best interest of the coalitions.

Housing Initiatives

Housing and Urban Development's (HUD) Public and Indian Housing Drug Elimination Program provides funds to public housing agencies, Indian tribes and their tribally designated housing entities, and owners of federally assisted low-income housing to support their anti-drug and anti-crime efforts. Since 1989 HUD awarded approximately 6,500 grants totaling more than $2 billion to public housing agencies and tribally designated housing entities. Grantees have used these resources to fight crime by increasing police coverage and security and by providing residents with alternatives to crime and violence. In particular, they have used their PHDEP funding to employ security personnel and investigators; to contract with private security services; to reimburse local law enforcement agencies for above-baseline services; to establish volunteer resident patrols; to implement physical improvements to enhance security; and to establish and operate drug prevention, intervention, and treatment programs, as well as youth violence prevention initiatives.

Prevention through Service Alliance

Volunteer-based organizations continue to make major contributions to the national counter-drug effort. Since November 1997, an alliance of civic, fraternal, service, veterans, sports, and women's groups has been helping young people pursue healthy, drug-free lifestyles. Currently, national service organizations representing more than a hundred million volunteers are members of a "Prevention Through Service Alliance."^* Through a resolution agreement, member organizations have pledged to increase substance-abuse prevention messages to their members and the youth they serve, establish a communication link to share programs and resources, collaborate on community prevention efforts, promote service opportunities for youth, and publicly recognize young people involved in community service. Alliance organizations offer mentoring programs, school-based curricula dealing with drug prevention, and educational brochures for youth. Other Alliance-supported activities that promote a drug-free lifestyle include youth groups, sports teams, scholarships, and specific drug-free events. Many Alliance groups have assisted in the ONDCP National Youth Anti-Drug Media Campaign. During this coming year, a significant number of Alliance partner organizations will provide pro-bono contributions to the media campaign through their national publications and Web sites.

Workplace Prevention Initiatives

The workplace is an effective venue for influencing drug-use behavior and shaping community norms for drug-free living. In 1998, more than 73 percent of all current drug users were employed full or part-time — more than 8.3 million workers.⁶ About 1.6 million full-time workers, aged 18-49, both abuse illicit drugs and are heavy alcohol users.⁷ Alcoholism alone accounts for 500 million lost workdays each year.⁸ Casual drinkers, in aggregate, account for far more incidents of absenteeism, tardiness, and poor quality of work than those regarded as alcohol dependent.⁹ Among 18–49 year-olds, the highest rate of illicit drug abuse and heavy alcohol use is among those 18–25 years old, males, whites, and those with less than a high school education.¹⁰ About one half of young adults ages 16–17, work during the year. Those working more than 20 hours per week are at high risk for substance abuse and injury.¹¹

Since 1986, Executive Order 12564,the Drug-Free Federal Workplace, has mandated a comprehensive drug-free workplace program for all Executive Branch federal agencies. Elements include a clear policy of no use; employee education about the dangers of illicit drug use and the workplace consequences of drug use; supervisor training about their responsibilities under the policy; access to employee assistance programs (EAPs) and treatment referral; and accurate and reliable drug testing, consistent with the policy. These programs have been implemented in 120 federal agencies, with 1.8 million employees, and the Mandatory Guidelines for Federal Workplace Drug-Testing Programs have also been adopted by the Department of Transportation and the Nuclear Regulatory Commission for their regulated industries. As the nation's largest employer, the federal government has continued to provide leadership by example. For federal job applicants and employees, the positive rate is one-tenth of the national average, or only 0.5 percent, compared to 5.0 percent for other workplaces nationally.¹²

The available data suggest that comprehensive drug-free workplace programs also work for non-federal public and private sector employers. Periodic surveys of employees in large workplaces (500 or more employees) say such organizations are more likely to incorporate drug-free workplace policies, information, access to EAPs, and drug testing, than smaller employers (1–24).¹³ Perhaps even more important for all employers to consider is that current illicit drug users say they would be less likely to work for an employer that conducted pre-employment or random drug-testing.¹⁴ Prevention in the workplace helps non-users from starting and users from increasing their dependence on illegal drugs and alcohol.¹⁵ Workplaces provide an ideal opportunity to influence individual behavior and community norms. Clear and consistent messages of no use and the consequences of use are crucial. Referrals to treatment and support for employees who want to change their behavior are key. EAPs offer a wide range of services and are increasingly being used by employers.

Implemented in the interest of public safety and expanded under the Omnibus Transportation Employee Testing Act of 1991, the Department of Transportation's (DOT) mandatory drug-free workforce initiative has helped reduce drug abuse in the transportation industry. This program has become the industry model for non-regulated employers throughout the United States and other countries around the world. DOT's program, covering eight million individuals, encompasses more than just drug testing; it is built around employee education, supervisory training, and rehabilitation for workers in regulated businesses within the aviation, motor carrier (including drivers from Canada and Mexico), rail, transit, pipeline, and maritime industries. DOT requires workers in safety-sensitive positions who test positive for drugs to be referred to substance-abuse professionals before returning to work. If substance abuse is diagnosed, the employee must receive treatment before resuming duties. The level of positive drug test results in transportation has dropped approximately fifty percent since the program's onset.

Adoption of anti-drug programs in the private sector, most notably by employers with worksites of more than five hundred employees, has produced a two-thirds reduction in the rate of positive drug test results in the last decade — from 13.6 percent in 1988 to 4.7 percent in 1999.¹⁶ Within a comprehensive approach, drug testing has proven to be an effective tool not only to identify drug use before serious harm or accidents develop but as a way to cut through the denial of many drug users, which frequently impedes their ability to seek treatment. According to a study by the American Management Association of its membership's (typically larger employers) corporate practices, workplace drug testing increased from 1987 to 1996 by 1200 percent. Likewise, the perceived effectiveness of drug testing increased from 50 percent to 90 percent in 1996. Companies combining testing with other anti-drug initiatives report test positive rates 33 percent to 50 percent lower than companies that conduct drug tests only.¹⁷

However, 80 percent of private-sector U.S. workers are employed in small or medium-sized organizations which have a significantly lower percentage of drug-free workplace programs. Considerable challenges remain for these businesses to emulate the reduction in work-related accidents, absenteeism, health-care expenses, and worker compensation costs reported by larger employers implementing drug-free programs. To help address this need among smaller employers, Congress passed the Drug-Free Workplace Act of 1998, funding thirty new grants and contracts through the Small Business Administration's new Drug-Free Workplace Demonstration Program. SAMHSA/CSAP also assists businesses implement drug-free workplace programs through its Web site (www.health.org/workplace/),Workplace Helpline,¹⁸ and by providing supplemental materials and training programs on request.¹⁹ Additionally, businesses and other employers can access the Department of Labor's (DOL) Working Partners for an Alcohol- and Drug-Free Workplace initiative and Web site (www.dol.gov/dol/workingpartners.htm).²⁰

Athletic Initiative

Each year approximately 2.5 million students play football and basketball in high school and junior high. Millions of children are involved in soccer and softball leagues, among other sports. Studies show that a young person involved in sports is 40 percent less likely to get involved with drugs than an uninvolved peer.²¹ Scores of children admire professional athletes, but some stars often convey mixed messages pertaining to drugs.

In 1998, ONDCP began an Athletic Initiative Against Drugs.²² During 1999, ONDCP provided coaches across the nation with the Coach's Playbook Against Drugs, which contains information to help prevent drug abuse among their students and teams.²³ ONDCP/CTAC is sponsoring a comprehensive analysis of the use of banned substances and drugs of abuse among Olympic, professional, collegiate, and high school athletes in America to identify more effective substance-abuse testing, sanctions, and treatment. ONDCP joined a wide-range of athletes and teams from the victorious U.S. Women's World Cup soccer team to the New York Rangers and Knicks — to convey anti-drug messages to America's youth. In 2000, we will conduct regional soccer tournaments.

The use of drugs in sports has become a serious threat — not just to elite athletes but also in colleges and high schools across America. To help address this problem, ONDCP, the Department of Health and Human Services, and the White House Olympic Task Force have been working together on behalf of young athletes. As part of this effort, ONDCP is assisting the U.S. Olympic Committee form an independent agency to oversee amateur athletic drug-testing in the United States. Internationally, the United States joined the twenty-six nations assembled at the Sydney, Australia Summit on Drug Use in Sport to develop an international agreement on combating this threat.

Faith Initiative

The faith community plays a vital role in building social values, informing the actions of individuals and inculcating life skills that are critical to resisting illegal drugs. The clergy of faith-based organizations serve as civic leaders. Many run programs that provide much-needed counseling and drug treatment for members of their communities. Consequently, ONDCP encourages religious communities to speak out against drugs and further develop faith-based initiatives to prevent and treat drug use.

Drug Prevention through Law Enforcement

Many federal agencies form government partnerships to prevent drug abuse. DEA's Demand-Reduction Program supports youth-oriented drug prevention through educational activities like the Boys Scouts of America's Law Enforcement Explorer Program. The FBI's Community Outreach disseminates prevention material and sponsors youth programs like Adopt-A-School and Junior Special Agent Classrooms. The Bureau of Justice Assistance (BJA) helped revise the Drug Abuse Resistance Education (D.A.R.E.) curriculum. D.A.R.E. is an extremely popular program for school-based drug abuse and violence prevention. It is being implemented by more than 8,600 law-enforcement agencies. The ATF's Gang Reduction Education and Training (GREAT) program helps teach seventh graders to reject gangs and the drugs often associated with them. The United States Customs Service actively supports the Explorer program, maintaining 37 posts that provide young adults with drug abuse prevention training for dissemination to the community. The Office of Juvenile Justice and Delinquency Prevention (OJJDP) runs a life-skills training program that provides curriculum, training, and technical assistance at seventy demonstration sites. The National Citizens' Crime Prevention Campaign focuses on reducing juvenile crime and drug use. The Office of Justice Programs supports projects related to juvenile substance abuse, like Combating Underage Drinking and the Juvenile Mentoring program. All Weed and Seed sites are required to have "Safe Havens" — after-school programs where anti-drug education joins a range of constructive activities. The DOJ- Drug Education for Youth (DEFY) program promotes positive life choices, including drug resistance, in nine-to-twelve year-olds. DEFY's two-phased curriculum covers summer leadership camp coupled with a school-year mentoring program.

Countering Attempts to Legalize Drugs

Given the negative impact of drugs on society, the overwhelming majority of Americans reject illegal drug use. Indeed, millions of citizens who once used drugs have turned their backs on such self-destructive behavior. While most people remain steadfast in condemning drugs, small elements at either end of the political spectrum argue that prohibition — not drug abuse — creates problems. These groups offer solutions in various guises, but one of the most troublesome is the notion that eliminating the prohibition against dangerous drugs would reduce the harm drugs cause. Such legalization proposals are often presented under the euphemism of "harm reduction."

All drug policies claim to reduce harm. No reasonable person advocates a position consciously designed to be harmful. The real challenge is to determine which policies actually decrease harm and increase good. The approach chosen by some people who say they favor "harm reduction" — when they are really supporting drug legalization — would in fact hurt Americans.

The theory behind what legalization advocates call "harm reduction" is that illegal drugs cannot be controlled by law enforcement, education, public-health interventions, and other methods. Therefore, proponents say, harm should be reduced by the decriminalization of drugs, heroin maintenance, and other intermediate measures. The real intent of many harm-reduction supporters is the legalization of drugs, which would be a mistake.

Some people maintain that they are not calling for the legalization of all drugs but only "soft" drugs. Since many users enter treatment every year to help recover from chronic abuse of marijuana and other "soft" drugs, this idea overlooks the danger posed by such substances. Groups that support decriminalization of drugs, so that drug use would remain against the law but penalties would be minimal, want use of illegal drugs to resemble minor indiscretions like jay-walking. Other defenders emphasize the therapeutic value of specific drugs or economic viability of drug-related products. By making drug use more acceptable, these people argue, society would reduce the harm associated with drug abuse.

The truth is that drug abuse wrecks lives. It is shameful that more money is spent on illegal drugs than on art or higher education, that drug-exposed babies are born addicted and in pain, that thousands of adolescents lose their health and future to drugs. Addictive drugs were criminalized because they are harmful; they are not harmful because they were criminalized. If drugs were legalized in the U.S., the cost to the individual and society would grow astronomically.

The Use of Marijuana as Medicine

Because of its high potential for abuse and lack of accepted medical use, the manufacture, acquisition, distribution, and possession or marijuana is subject to regulation under Schedule I of the Controlled Substances Act, the most restrictive of the five federal classes of controlled substances. The medical use of Schedule II, drugs such as cocaine and methamphetamine, is also strictly controlled. Marijuana is regulated internationally by the Single Convention on Narcotic Drugs, to which the United States is a party. In the past decade, data has been gathered relative to the negative impact of marijuana on young people. As described in Chapter II, marijuana use by adolescents correlates with delinquent and antisocial behavior.

The Administration is adamantly opposed to the use of marijuana outside of authorized research.²⁴ However, legitimate medications containing marijuana components have proven effective in relieving the symptoms of some medical conditions. Dronabinol, a synthetic form of the major psychoactive component in marijuana — tetrahydrocannabinol (THC) — has been approved by the Food and Drug Administration (FDA) to stimulate appetite in AIDS patients and to control nausea in cancer patients receiving chemotherapy. The pill form of THC has been available for fifteen years and sold under the trade name Marinol.® Dronabinol was rescheduled in 1999 to Schedule III of the Controlled Substances Act, making it easier for patients to obtain.

The Administration has provided information to states considering ballot initiatives on "medical marijuana" so that citizens will be informed about the ways such measures undermine the scientific process for establishing safe and effective medicines. These initiatives also contradict federal law and are potential vehicles for the legalization of recreational marijuana use. Ballot initiatives to date generally have not limited use of marijuana to a small number of terminally-ill patients, as most voters envisioned. Rather, they commonly allow marijuana to be obtained without prescription and used indefinitely without evaluation by a physician.

The U.S. medical and scientific communities have not closed the door on marijuana or any other substance that may offer therapeutic benefits. However, both law and common sense dictate that the process for establishing substances as medicine be thorough and science-based. Persons who intend to study or seek approval of marijuana for use in the cure, mitigation, treatment, or prevention of disease are subject to the "drug" and "new drug" provisions of the Federal Food, Drug, and Cosmetic Act (FDC Act) (21 USC 321 et seq.). The FDC Act requires an applicant to submit data from well-controlled clinical trials to the FDA for evaluation of the safety and efficacy of a proposed product. A New Drug Application (NDA) must contain sufficient information to satisfy the statutory standards for marketing approval. This rigorous process is in the interest of public health. Allowing marijuana, or any other drug, to bypass this process would be unwise and unlawful.

In light of the need for research-based evidence, ONDCP asked the Institute of Medicine (IOM) in January 1997 to review all scientific evidence concerning the medical use of marijuana and its constituent cannabinoids. ONDCP felt that an objective, independent evaluation of such research was appropriate given the ongoing debate about the health effects of cannabis. The IOM published Marijuana and Medicine: Assessing the Science Base in March 1999.²⁵ This study is the most comprehensive summary of what is known about marijuana. It emphasizes evidence-based medicine (derived from knowledge and experience informed by rigorous analysis) as opposed to belief-based opinion (derived from judgment or intuition untested by science).

The IOM study concluded that there is little future in smoked marijuana as medication. Although marijuana smoke delivers THC and other cannabinoids to the body, it also contains harmful substances, including most of those found in tobacco smoke. The long-term harms from smoking make it a poor drug delivery system, particularly for pregnant women and patients with chronic diseases. In addition, cannabis contains a variable mixture of biologically active compounds. Even in cases where marijuana can provide symptomatic relief, the crude plant does not meet the modern expectation that medicines be of known quality and composition. Nor can smoked marijuana guarantee precise dosage. If there is any future for cannabinoid medications, it lies with agents of certain composition and delivery systems that permit controlled doses. Medical marijuana must conform to classical pharmacological practices that characterize clinical research.

The United Nations' International Narcotics Control Board (INCB), which ensures an adequate world supply of drugs for medical purposes, has stressed that research must not become a pretext for legalizing cannabis. If the drug is determined to have medicinal value, the INCB maintains that its use needs to be subjected to the same stringent controls applied to cocaine and morphine. "Should the medical usefulness of cannabis be established," the 1998 INCB annual report states, "it will be a drug no different from most narcotic drugs and psychotropic substances. Those drugs, however, must continue to be used for medical purposes only, in line with the requirements of the international drug control treaties."²⁶ The INCB report concluded: "Political initiatives and public votes can easily be misused by groups promoting the legalization of all use of cannabis for recreational use under the guise of medical dispensation."²⁷

"Industrial" Hemp

Under the Controlled Substances Act, the definition of marijuana includes all parts of the Cannabis sativa plant except for the sterilized seeds, fiber from stalks, and oil or cake made from the seeds.²⁸ However, all hemp products that contain any quantity of THC are considered Schedule I controlled substances and cannot be imported into the United States or cultivated domestically without DEA registration and permits.

Hemp products — fiber for use in the manufacture of cloth, paper, and other products as well as seed for birdseed — were authorized for importation during the last decade. Over the past two years, the Drug Enforcement Administration (DEA) received information that sterilized cannabis seed, not solely birdseed, has been imported for the manufacture of products intended for human consumption. DEA also learned from the armed forces and other federal agencies that individuals who tested positive for marijuana use subsequently raised their consumption of these products as a defense against positive drug tests. Consequently, the Administration is reviewing the importation of cannabis seeds and oil because of their THC content. NIDA is studying the effect of ingesting hemp products on urinalyses and other drug tests.

The government is concerned that hemp cultivation may be a stalking horse for the legalization of marijuana. According to a recent report by the Department of Agriculture, U.S. markets for hemp fiber (specialty textiles, paper, and composites) and seed (in food or crushed for oil) are, and will likely remain, small and thin.²⁹ U.S. imports of hemp fiber, yarn, and fabric and seed in 1999 could have been produced on less than 5,000 acres of land. Also, the potential exists for these markets to quickly become oversupplied. Uncertainty about long-run demand for hemp products and the potential for oversupply discounts the prospects for hemp as an economically viable alternative crop for American farmers.

Child Welfare Initiatives

The safety of children and families is jeopardized by the strong correlation between chemical dependency and child abuse. Several studies recently demonstrated that approximately two-thirds of more than 500,000 children in foster care have parents with substance-abuse problems.³⁰ A new federal law regarding adoption and child welfare, the Adoption and Safe Families Act (P.L. 105-89), requires that substance-abuse services be provided promptly for parents so that families are given realistic opportunities to recover from drug problems before children in foster care are placed for adoption.

In addition to compromising parental ability to raise children, substance abuse interferes with the acquisition and maintenance of employment. An estimated 15 to 20 percent of adults receiving welfare have substance-abuse problems that prevent them from working.³¹ If drug prevention and treatment are not provided for this high-risk population, these families will remain extensively involved in the welfare and criminal-justice systems at great cost to society and with devastating consequences for children. Historically, welfare agencies have not played a direct role in addressing substance abuse and therefore may need assistance in identifying addiction and making appropriate referrals.

To address these issues, SAMHSA/CSAP's Parenting Adolescents and Welfare Reform Program focuses on the parenting adolescent (who often must rely on welfare) to prevent or reduce alcohol, tobacco, and drug use; improve academic performance; reduce subsequent pregnancies; and foster improvement in parenting, life skills, and general well-being. The Administration for Children and Families (ACF) has taken several steps to improve the delivery of substance abuse services to clients involved with child protection and welfare programs. Five states are implementing child welfare waiver demonstrations that test strategies to engage and retain clients in substance abuse treatment. Conferences and technical assistance workshops have been held around the nation, in cooperation with SAMHSA, to encourage improved partnerships between human services and substance abuse agencies and to highlight model programs. In addition, grants have been made to several schools of social work to develop cross-training curricula in these fields. Finally, research is being conducted on how to screen and assess substance abuse and other barriers to work and to evaluate a model of addressing clients' substance abuse problems.

Welfare-to-Work Initiatives

Although states have experienced remarkable success in decreasing welfare rolls, many of those who remain on welfare suffer from alcohol or drug addiction, which impedes their ability to succeed in the workplace. The federal government is looking for ways to help welfare and workforce agencies identify and refer welfare recipients and other underemployed individuals — whose employability is hindered by substance abuse problems — to treatment. To help these individuals make a successful transition to meaningful employment, DOL, through the Workforce Investment Act of 1998, supplies funds to states and communities to help deliver substance abuse services to the unemployed. Through Welfare-to-Work grants, a total of 138 million dollars has been awarded to provide workforce preparation and job retention services that include substance abuse programs and are available to eligible long-term welfare recipients and non-custodial parents. Of these grants, thirteen, totaling fifty million dollars, specifically target substance abuse services.

In FY 1999, Congress authorized $24 billion for states to spend on children's health services, to provide a safety net for children with substance abuse problems, whose parents are off welfare either because they have found jobs or have been taken off welfare. Subsequently at least nine have developed plans that specifically include substance-abuse services. Alabama, for instance, will provide specialty care to uninsured children and those with special needs. Delaware's Children's Health Insurance Program (CHIP) includes 31 days of substance abuse and mental health treatment services annually, plus outpatient mental-health care. Florida's health-care and children's agencies will provide Medicaid and state-funded addiction and mental-health services, while the state mental-health agency will work with at-risk youth in the criminal justice system.

The Partners Project in Pittsburgh, Pennsylvania, funded by a one million dollar grant from the Department of Housing and Urban Development, provides comprehensive services to welfare recipients, and their children, in recovery from substance abuse problems. This project offers specialized addiction treatment and other services to families living in 22 subsidized apartments. In addition to the Housing Authority of the City of Pittsburgh, a treatment program, child development center at the University of Pittsburgh Medical Center, and a local women's center for victims of domestic violence are part of the project.

Youth Tobacco Initiative

The Youth Tobacco Initiative is a multifaceted HHS campaign coordinated by the Centers for Disease Control and Prevention (CDC). Its purpose is to reduce availability and access to tobacco and the appeal tobacco products have for youth. The initiative includes funding for tobacco prevention and cessation programs, research, legislative projects, regulation, and enforcement. It is supported by the FDA, NIH, and SAMHSA. The FDA — under the Food, Drug and Cosmetics Act — regulates and enforces federal age and identification requirements regarding the sale of tobacco products. The FDA also conducts an extensive advertising campaign to deter retailers from selling tobacco products to minors. The NIH — through the National Cancer Institute, NIDA, and others — supports biomedical and clinical research on tobacco. SAMHSA, through its Substance Abuse Prevention and Treatment (SAPT) Block Grant, administers the Synar Amendment, which requires state legislative and enforcement efforts to reduce the sale of tobacco products to minors. Since the enactment of Synar in 1994, states increased retailer compliance rates from approximately 30 percent to 79 percent in 1998, reported in 1999.

States are at the forefront of efforts to prevent tobacco use by youth. Arizona, California, Florida, and Massachusetts are conducting paid anti-tobacco media campaigns restricting minors' access to tobacco, limiting smoking in public places, and supporting school-based prevention. CDC provides funding for state health departments and national organizations to conduct tobacco-use prevention and reduction programs, including media and educational campaigns, training, and surveys. The CDC's Office on Smoking and Health has developed a four-point prevention and control strategy to support state campaigns. CDC's Media Campaign Resource Center provides states with television and radio advertisements as well as printed materials. The federal government is responsible for the diffusion of science-based models and strategies in support of state and community efforts. Accordingly, the CDC funds evaluations of specific programs and disseminates information to the public. The CDC's Guidelines for School Health Programs to Prevent Tobacco Use and Addiction, for example, includes recommendations for tobacco-use policies, tobacco prevention education, teacher training, family involvement, tobacco-use cessation programs, and evaluation.

Youth Alcohol Use Prevention

SAMHSA and NIAAA have a variety of programs and projects to help curb underage alcohol use. Within SAMHSA's prevention and treatment budget, it is estimated that $88.6 million is designated to fight underage alcohol use and NIAAA targeted $36.3 million to curb youth alcohol abuse. HHS' existing projects include a collaboration between SAMHSA, NIAAA, and the Department of Education to fund five new grants, totaling approximately $2.9 million, to test a variety of interventions that have the potential to reduce alcohol abuse on college campuses, and a 5-year SAMHSA/NIAAA partnership, totaling $3.9 million annually, to fund research programs related to treatment among adolescents. NIAAA recently published "Make a Difference: Talk to Your Child About Alcohol," a guide for parents of kids, aged ten to fourteen years old. In addition, The National Youth Anti-Drug Media Campaign's pro-bono match requirement has generated more than twelve million dollars in public service advertising time and space for organizations like Mothers Against Drunk Driving and NCADD.

Comprehensive Prevention Systems

It has been well established that prevention works best when a comprehensive approach is used — including youth, family, school, and community activities. Results from SAMHSA/CSAP's Community partnership and coalition programs reflect the positive nature of such an approach.

SAMHSA/CSAP's State Incentive Grant (SIG) program is designed to coordinate all substance-abuse prevention funding within a state and to implement prevention programs in selected communities. This competitive grant program serves as an incentive for synchronizing state-wide prevention with private and community-based organizations. Eighty-five percent of SIG funds must be devoted to actual prevention programming, and 50 percent or more of the activities must involve science-based programs. To date, twenty-one grants have been awarded to states and the District of Columbia. Some governors report having leveraged as much as ten dollars for every one dollar invested. For example,

• In Vermont, funds from United Way agencies, Safe and Drug-Free Schools, and other grants from state and local agencies and private businesses have been merged to support local prevention activities.
  
  
• The SIG program in Oregon calls upon the state to work with every county to develop a comprehensive plan incorporating substance-abuse prevention in schools, the juvenile justice system, and teen pregnancy programs. The state is also working for the first time with nine tribal governments to implement substance-abuse prevention.
  
  
• In Kansas the SIG prompted the governor to issue an executive order establishing a Governor's Substance-Abuse Prevention Council. This Cabinet-level group has already conducted a county-level resource assessment and developed a science-based prevention publication that integrates guidelines and strategies across multiple federal and state funding sources.

To address the technical assistance and training needs of SIG states and community subrecipients, as well as non-SIG states, and facilitate the selection of science-based prevention models that meet community needs, SAMHSA/CSAP's Centers for the Application of Prevention Technologies (CAPTs) will be expanded.

---

^* Current Alliance member organizations are 100 Black Men of America, Inc., AMBUCS, AMVETS, Benevolent and Protective Order of Elks, Big Brothers Big Sisters, Boys and Girls Clubs of America, Boy Scouts of America, B'nai B'rith Youth Organization, Camp Fire Boys and Girls, Campus Outreach Opportunity League, Civitan International, Fraternal Order of Eagles, General Federation of Women's Clubs, Girls, Inc., Girl Scouts of the USA, Improved Benevolent and Protective Order of Elks of the World, Independent Order of Odd Fellows, Jack and Jill of America, Inc., Junior Chamber International, Knights of Columbus, Lions Clubs International, Moose International, Masonic National Foundation for Children, Mothers Against Drunk Driving, National Beta Club, National Council of Negro Women, National Council of Youth Sports, National Exchange Club, National Family Partnership, National 4-H Council, National FFA Organization, National Panhellenic Conference, National Retired Teacher's Association, Optimist International, Pilot International, Quota International, United Native Tribal Youth, Ruritan National, Sertoma International, The Links, Inc., Veteran's of Foreign Wars, YMCA of the USA, Youth Power, Youth to Youth International, YWCA of the USA, and Zeta Phi Beta Sorority, Inc.

Previous

Contents

Next