oversight

Drug Control: Observations on Elements of the Federal Drug Control Strategy

Published by the Government Accountability Office on 1997-03-14.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                United States General Accounting Office

GAO             Report to Congressional Requesters




March 1997
                DRUG CONTROL
                Observations on
                Elements of the
                Federal Drug Control
                Strategy




GAO/GGD-97-42
             United States
GAO          General Accounting Office
             Washington, D.C. 20548

             General Government Division

             B-275944

             March 14, 1997

             The Honorable Frank R. Wolf
             Chairman, Subcommittee on
               Transportation and Related Agencies
             Committee on Appropriations
             House of Representatives

             The Honorable John Edward Porter
             Chairman, Subcommittee on Labor, Health
               and Human Services, and Education
             Committee on Appropriations
             House of Representatives

             The federal government’s investment in the war on drugs has grown to
             over $15 billion in fiscal year 1997. Yet the availability of drugs on U.S.
             streets and the number of persons using illegal drugs continue to be
             serious problems. We have reported many times over the past decade on
             federal antidrug efforts. This report responds to your October 30, 1996,
             request that we provide information to help Congress examine and
             improve the federal government’s drug control1 strategy.

             Specifically, this report (1) identifies findings of current research on
             promising approaches in drug abuse prevention targeted at school-age
             youth; (2) describes promising drug treatment strategies for cocaine
             addiction; (3) summarizes our recent work assessing the effectiveness of
             international efforts to reduce illegal drug availability, including
             interdiction; (4) assesses whether the U.S. Coast Guard’s performance
             measures for its antidrug activities conform to the principles of the
             Government Performance and Results Act of 1993 (GPRA); and
             (5) summarizes several of our recent products on federal drug prevention-
             and treatment-related efforts.


             In 1995, an estimated 22.7 million Americans had used at least one illicit
Background   drug in the past year—17.8 million had used marijuana, 3.7 million had
             used cocaine; and 428,000 had used heroin.2 From 1992 to 1995, there was

             1
              As defined in the Anti-Drug Abuse Act of 1988, P.L. 100-690, “drug control” is any activity conducted
             by a national drug control program agency involving supply reduction and demand reduction. Supply
             reduction includes international drug control; foreign and domestic drug enforcement intelligence;
             interdiction; and domestic drug law enforcement, including law enforcement directed at drug users.
             Demand reduction includes drug abuse education, prevention, treatment, research, and rehabilitation.
             2
               National Household Survey on Drug Abuse: Population Estimates 1995, Substance Abuse and Mental
             Health Services Administration, 1996.



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a pronounced rise in the estimated drug use rates among school-age
youths—the estimated rate of marijuana use by 8th grade students
increased from 7.2 percent to 15.8 percent; the estimated rate of marijuana
use by 10th graders rose from 15.2 percent to 28.7 percent; and for 12th
graders, the estimated rate of marijuana use increased from 21.9 percent
to 34.7 percent. According to the Office of National Drug Control Policy
(ONDCP) social costs of illegal drug use were estimated at $67 billion
annually. In addition, ONDCP reported that in the 1990s there were 100,000
drug-related deaths, approximately 20,000 deaths per year.3

In 1988, Congress created ONDCP to lead the nation’s war on drugs. The
federal budget for drug abuse control climbed from $1.5 billion in fiscal
year 1981 to about $15.1 billion in fiscal year 1997.4 Approximately
$1.8 billion of the over $15 billion authorized by Congress to implement
the 1996 national drug control strategy is devoted to international
programs with the goals of shielding U.S. air, land, and sea frontiers from
the drug threat; breaking foreign drug sources of supply; and destroying
international drug-trafficking organizations. (A more complete discussion
of the national drug control strategy goals is in app. I.)

In 1988, we provided Congress with an overview of the drug problem and
the federal response.5 The report described the drug problem in the 1980s
nationally and in six major cities where drug problems were among the
worst in the nation. In 1993, in conjunction with our report on the
reauthorization of ONDCP,6 we summarized the results of our work to date
on U.S. antidrug efforts and the participation of federal, state, and local
agencies in the national drug control strategy. These two reports identified
the immensity of the challenges facing the antidrug effort, challenges that
range from helping foreign governments break their dependence on
drug-related revenues to helping drug users in this country turn away from
what they may see as the allure of drugs.

We recommended in our 1993 report that ONDCP,7 as the coordinator of the
federal drug control effort, (1) develop additional measures to assess

3
 The National Drug Control Strategy, 1996. Office of National Drug Control Policy, Washington, D.C.
4
  In constant 1987 dollars. National Drug Control Strategy: 1996. Office of National Drug Control Policy,
Washington, D.C.
5
 Controlling Drug Abuse: A Status Report (GAO/GGD-88-39, Mar. 1, 1988).
6
 Drug Control: Reauthorization of the Office of National Drug Control Policy (GAO/GGD-93-144, Sept.
29, 1993).
7
 GAO/GGD-93-144.



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                   progress in reducing drug use, (2) develop performance measures to
                   evaluate the contributions made by major components of current antidrug
                   efforts and significant new initiatives, and (3) incorporate these measures
                   into annual drug control strategies.

                   GPRA was enacted in 1993 to, among other things, improve performance
                   measurement by federal agencies. It provides a useful framework for
                   assessing the effectiveness of federal drug control efforts. It requires
                   agencies to set goals, measure performance, and report on their
                   accomplishments. Under GPRA, it is envisioned that federal agencies will
                   move away from their concentration on traditional workload measures,
                   such as staffing and activity levels, and move toward a focused assessment
                   of their results.


                   Recent research points to two types of promising drug prevention
Results in Brief   approaches for school-age youth. The first approach emphasizes drug
                   resistance skills, generic problem-solving/decisionmaking training, and
                   modification of attitudes and norms that encourage drug use (the
                   psychosocial approach). The second approach involves the coordinated
                   use of multiple societal institutions, such as family, community, and
                   schools, for delivering prevention programs (the comprehensive
                   approach.) Both approaches have reduced student drug use as well as
                   strengthened the individual’s ability to resist drugs in both short- and
                   longer-term programs.

                   Three approaches have been found to be potentially promising in the
                   treatment of cocaine use. These approaches include (1) avoidance or
                   better management of drug-triggering situations (relapse prevention
                   therapy); (2) exposure to community support programs, drug sanctions,
                   and necessary employment counseling (community
                   reinforcement/contingency management); and (3) use of a coordinated
                   behavioral, emotional, and cognitive treatment approach (neurobehavioral
                   therapy). Drug abuse clients using these approaches have maintained
                   extended periods of cocaine abstinence and greater retention in treatment
                   programs.

                   While these prevention and treatment approaches have shown promising
                   outcomes in some programs, sufficient evaluative research has not been
                   done to test their effectiveness and their applicability among different
                   populations in varied settings. This research should help policymakers
                   better focus efforts and resources in an overall drug control strategy.



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Despite some successes, United States and host countries’ efforts have not
materially reduced the availability of drugs in the United States for several
reasons. First, international drug-trafficking organizations have become
sophisticated, multibillion dollar industries that quickly adapt to new U.S.
drug control efforts. Second, the United States faces other significant and
long-standing obstacles, such as inconsistent funding for U.S. international
drug control efforts, competing foreign policy objectives, organizational
and operational limitations, and a lack of ways to tell whether or how well
counternarcotics efforts are contributing to the goals and objectives of the
national drug control strategy, which results in an inability to prioritize the
use of limited resources. Third, in drug-producing and transit countries,
counternarcotics efforts are constrained by competing economic and
political policies, inadequate laws, limited resources and institutional
capabilities, and internal problems such as terrorism, corruption, and civil
unrest.

Although there is no panacea for resolving all of the problems associated
with illegal drug trafficking, in our February 1997 report,8 we
recommended that the Director of ONDCP: (1) complete the development of
a long-term plan with meaningful performance measures and multiyear
funding needs that are linked to the goals and objectives of the
international drug control strategy; (2) at least annually, review the
progress made and adjust the plan, as appropriate; (3) enhance support for
the increased use of intelligence and technology to improve U.S. and other
nations’ efforts to reduce supplies of and interdict illegal drugs; and
(4) lead in developing a centralized lessons-learned data system to aid
agency planners and operators in developing more effective counterdrug
efforts.

Measuring the effectiveness of U.S. antidrug activities has been a
continuing problem in assessing the results of the national drug control
strategy. In reauthorizing ONDCP in 1993, Congress specified that ONDCP’s
performance measurement system should assess changes in drug use, drug
availability, the consequences of drug use, drug treatment capacity, and
the adequacy of drug treatment systems. To implement the statutory
requirements, which are consistent with recommendations in our 1993
report,9 ONDCP is developing national-level measures of drug control
performance.


8
 Drug Control: Long-Standing Problems Hinder U.S. International Efforts (GAO/NSIAD-97-75, Feb. 27,
1997).
9
 GAO/GGD-93-144.



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                      Similarly, the Coast Guard is developing performance measures to assess
                      the results of its antidrug activities. It appears from our review of the
                      Coast Guard’s strategic and performance plans that it has taken steps
                      toward conforming with certain GPRA principles. However, it is too soon to
                      tell whether performance measurement systems being developed by ONDCP
                      and the Coast Guard will be fully consistent with the results-oriented
                      principles of GPRA.


                      In responding to your request, we adopted the following approach in
Objectives, Scope,    meeting the objectives agreed upon with the Subcommittees.
and Methodology
                      We identified and summarized findings and conclusions from our recent,
                      relevant reports and testimonies that examined U.S. antidrug programs
                      and activities, including international initiatives and domestic measures,
                      aimed at interdicting illegal drugs and reducing drug use through
                      prevention or treatment. We identified and reviewed selected literature on
                      drug prevention and drug treatment research and evaluated syntheses of
                      research literature, including data on program outcomes, to identify
                      promising approaches in drug abuse prevention that focus on school-age
                      youth. (See app. II for additional information on the methodology we
                      used.)

                      To obtain information on the U.S. Coast Guard’s performance measures
                      for its antidrug activities, we interviewed officials responsible for
                      managing the Coast Guard’s drug interdiction program and reviewed key
                      agency documents such as the Coast Guard’s preliminary performance
                      plans (for implementing the GPRA). We compared the Coast Guard’s
                      performance measurement plans with GPRA to determine whether they
                      conform to the principles of the act.

                      We did our review from November 1996 to January 1997 in accordance
                      with generally accepted government auditing standards. We obtained
                      comments on a draft of this report from ONDCP. These comments are
                      discussed at the end of this letter.


                      Recent research demonstrates basically two types of prevention
Two Drug Prevention   approaches that show promise when used in programs with school-age
Approaches Show       youths. The first approach emphasizes individual drug resistance skills,
Promise Among         generic problem-solving/decisionmaking training, and modification of
                      attitudes and norms that encourage drug use (the psychosocial approach).
School-Age Youth

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The second approach involves the use of multiple societal institutions
(e.g., schools, families, media, and community), working together in
collaborative fashion, to achieve a multicomponent approach to
prevention (the comprehensive approach).10 These approaches have been
used in several notable programs. However, the extent to which these
promising approaches yield results in a wide range of community settings
remains an open question.

The major aim of drug abuse prevention programs is to prevent the initial
use of both illicit and nonprescribed legal drugs and avert subsequent
drug-related problems (like AIDS and other sexually transmitted diseases.)
For youths already experimenting with drugs, or using them on a
recreational basis, prevention programs may be aimed at early screening
and intervention activities, with the end goal of eliminating drug use, or at
least long-term cessation.

In addition, drug prevention programs have focused on strengthening the
individual’s ability to resist drugs. This has taken the form of helping
individuals to minimize the drug “risk factors” in their lives as well as
building up their psychological “protective factors.” Risk factors that have
been related to an individual’s subsequent drug use activity include a
variety of personal, social, and community factors, including societal
norms favorable to drug use, easy access to drugs, and favorable parental
attitudes toward drug use. Enhancing one’s coping skills, problem-solving
ability, and self-esteem, however, provides some alternative means of
strengthening the individual’s protection or resilience to drug use in
high-risk situations.

The strategies used in prevention programs can be classified by three
interventions (universal, selective, and indicated) that target different
audiences: (1) universal interventions are directed at the general
population, (2) selective intervention strategies target individuals or
subgroups at risk for drug abuse, and (3) indicated interventions are
directed at individuals who already are using drugs but have not yet met
the criteria for a diagnostic disorder. Prevention activities can be
conducted in school settings, in peer groups, within the family context, or
within the larger community.

Drug prevention activities can encompass a wide array of functions. They
include the provision of information and education classes or training


10
   Institute of Medicine, Pathways of Addiction: Opportunities in Drug Abuse Research (Washington,
D.C.: National Academy Press), 1996, pp. 141-145.



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programs to enhance one’s knowledge of drug abuse and alternative
lifestyles, teaching skills to cope with or manage potential high-risk drug
situations, enhancing generic skills for the solution of general life
problems and decisionmaking, as well as encouraging communities to
implement societalwide institutional approaches to drug problems.

The following features are associated with positive outcomes in many
studies of prevention programs: (1) increasing awareness of the social
influences that promote drug use (for example, peer pressure);
(2) modifying societal norms or expectations concerning drug use; and
(3) targeting multiple aspects of youths’ lives through use of school,
family, peer, and community factors.

Drug prevention programs that use the psychosocial and comprehensive
approaches have shown promising results among school-age youth in
reducing drug use and strengthening the individual’s ability to resist drugs.
Although information dissemination, effective education, and alternatives
to drug use are approaches that have been used in prevention programs,
they have not been shown to be consistently effective when utilized
individually. However, they have been included in promising
comprehensive approaches to drug prevention.

Our review of the research on drug prevention programs that have
outcome data revealed several programs that show promise when using
the psychosocial or comprehensive approach. Some of the most notable
psychosocial and comprehensive drug programs include (1) the
Adolescent Alcohol Prevention Trial (psychosocial), which demonstrated
that the increase in initial use of marijuana for intervention participants
was 65-percent less than that of a comparison control group at 1 year
follow-up and 23-percent less than control group participants for alcohol;
(2) the Life Skills Training Program (psychosocial) showed 44 percent
fewer intervention participants reported use of three drugs over a
specified period of time, as compared to control group participants; and
(3) the Midwestern Prevention Project—also known as Project Star or
I-Star (comprehensive), showed a 20- to 40-percent net reduction in the
use of two drugs by school-age youth over a 3-year period.




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                           Three approaches have been found to be potentially promising in the
Three Approaches           treatment of cocaine abuse and dependency:
Show Promise in the
Treatment of Cocaine   •   “Relapse prevention” provides users with the ability to better recognize
                           drug “triggering” events, places, people and situations, and helps
Abuse and                  individuals develop better coping strategies to resist their specific triggers.
Dependency             •   “Community reinforcement/contingency management” consists of several
                           community-oriented components, including the participation of the
                           client’s family member or significant other in the treatment process;
                           management incentives or rewards for drug abstinence; employment
                           counseling when needed; and encouragement of participation in
                           recreational activities as health alternatives to a drug-free lifestyle.
                       •   “Neurobehavioral therapy” consists of a comprehensive behavioral,
                           emotional, and cognitive treatment approach, utilizing individual therapy,
                           drug education, and self-help group involvement. According to research
                           results, each approach has demonstrated positive outcome results with
                           regard to extended periods of cocaine abstinence and greater client
                           retention in treatment.

                           The National Institute on Drug Abuse (NIDA) has also supported the testing
                           of 20 major drugs in the treatment of cocaine. However, no medication has
                           been shown to be consistently effective in the treatment of cocaine, and
                           no medication has been submitted to the Food and Drug Administration
                           for approval for this purpose.

                           Attaining abstinence is a major goal of drug treatment. Once initial
                           abstinence is attained, efforts are directed toward maintaining continued
                           abstinence over more extended periods of time. Individual objectives of
                           treatment can include the social and personal rehabilitation of the
                           individual (including improved health and reduced psychological
                           problems), enhancement of familial relationships, reduction of criminal
                           behavior and resolution of legal problems, improved coping skills, and
                           attainment of educational and occupational aspirations.

                           The range of treatment services can include diagnostic assessment,
                           detoxification (when necessary), medication, counseling, drug education,
                           psychotherapy, case management, and self-help group participation. The
                           Institute of Medicine (IOM) and others have identified four types of
                           treatment modalities in which these services are delivered: (1) outpatient
                           methadone maintenance facilities (primarily for opiate users),
                           (2) outpatient nonmethadone or drug-free facilities, (3) chemical




                           Page 8                                               GAO/GGD-97-42 Drug Control
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                       dependency programs, and (4) long-term residential therapeutic
                       communities.

                       Our review of recent cocaine treatment research identifies several
                       programs that have shown positive outcome results using
                       cognitive/behavioral therapies. For example, one relapse prevention
                       program11 showed cocaine dependent clients were able to remain
                       abstinent at least 70 percent of the time while in treatment. A community
                       reinforcement/contingency management program12 showed that
                       42 percent (or almost half) of the participating cocaine-dependent clients
                       were able to achieve nearly 4 months of continuous abstinence. And a
                       neurobehavioral program13 showed that more than a third (38 percent) of
                       the clients were abstinent from the drug at the 6-month follow-up.


                       Regardless of early positive results in certain drug abuse prevention and
Experts Say            treatment approaches, research experts suggest that additional research is
Additional Research    needed to better identify and understand elements of effective prevention
Is Needed for Drug     and treatment. They say substantiating early program results through
                       further research and evaluation is an important step in advancing
Abuse Prevention and   promising drug prevention and treatment approaches. It is also important
Treatment              in helping policymakers to better direct the nation’s efforts and resources
                       toward reducing or eliminating drug abuse or dependency.

                       Prevention initiatives for future research that NIDA, IOM, and others have
                       mentioned include (1) the utility of booster sessions in extending positive
                       program outcomes, (2) determining the mix of approaches that yield the
                       most significant outcome results, and (3) how best to disseminate positive
                       findings to the larger community, and (4) assessing those types of
                       approaches that work best for different population groups. Future cocaine
                       treatment initiatives mentioned include (1) identifying improved or
                       additional cognitive/behavioral strategies to reduce relapse, (2) testing the
                       effectiveness and safety of new medications to prevent or reduce drug
                       intake, and (3) identifying the necessary components of
                       cognitive/behavioral strategies and medications that lead to successful
                       outcomes.

                       11
                        Kathleen Carroll and others, “Psychotherapy and Pharmacotherapy for Ambulatory Cocaine
                       Abusers,” Archives of General Psychiatry, 51 (1994), 177-187.
                       12
                        Stephen Higgins and others, “Achieving Cocaine Abstinence With a Behavioral Approach,” American
                       Journal of Psychiatry, 150:5 (1993), 763-69.
                       13
                        Stephen Shoptaw and others, “The Matrix Model of Outpatient Stimulant Abuse Treatment: Evidence
                       of Efficacy,” Journal of Addictive Diseases, 13:4 (1994), 129-41.



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                      See appendix II for a detailed description of the results of our review of
                      selected literature on drug prevention for school-age youth and cocaine
                      treatment approaches.


                      Recognizing the link between drugs and crime, Congress authorized
Summary of Selected   federal grants-in-aid to states and localities to assist them in addressing
GAO Products on       drug-related crime in their communities. We have reported on three such
Federal Prevention-   programs during the past few years—drug courts, Operation Weed and
                      Seed, and Treatment Alternatives to Street Crime (TASC).
and
Treatment-Related     Title V of the Violent Crime Control and Law Enforcement Act of 1994
                      authorized the award of federal grants to states and localities to establish
Efforts               drug courts. In 1995, we reported that (1) in exchange for dismissed
                      charges or reduced sentences, drug-using, primarily nonviolent defendants
                      were being diverted to drug courts where judges monitor their progress
                      through frequent status hearings; (2) drug court programs varied in length,
                      participant eligibility, funding, and other practices; (3) as of March 1995,
                      there were at least 37 drug courts operating nationwide; (4) 33 of these
                      drug courts had accepted over 20,000 defendants; (5) most drug courts did
                      not accept offenders with prior violent convictions, and none accepted
                      those currently charged with a violent offense; and (6) drug courts had not
                      been operating long enough to determine their overall effectiveness.14

                      Operation Weed and Seed is a Department of Justice grant program. Its
                      strategy is to support community-based, multiagency efforts to weed out
                      crime from targeted neighborhoods, then seed the site with a variety of
                      programs and resources to prevent crime from recurring. In 1994, we
                      reported that (1) community involvement was important to the program’s
                      effectiveness and long-term success; (2) community residents at local sites
                      needed to be involved in/control steering committees and help design and
                      implement activities; (3) the emphasis on activities varied at local levels
                      and community policing was a strong component of many programs;
                      (4) weeding efforts had removed criminals from communities and
                      increased interagency cooperation; (5) program officials believed that
                      Justice should increase its funding for seeding activities so that seeding
                      and weeding activities would have equal funding; (6) Justice had
                      established guidelines to monitor program funds and compliance with its
                      policies and also an interagency work group to coordinate social services
                      agencies’ recommendations on seeding programs and exchange

                      14
                       Drug Courts: Information on a New Approach to Address Drug-Related Crime (GAO/GGD-95-159BR,
                      May 22, 1995).



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                     information; and (7) the program’s management structure provided for
                     federal, state, local, private agency, and citizen participation.15

                     The TASC program is an offender case management program designed to
                     link drug-using offenders within the criminal justice system to
                     community-based drug abuse treatment as an alternative or supplement to
                     criminal penalties. In a 1993 report, we concluded that TASC appeared
                     promising as a way to help reduce offender drug use. The TASC program
                     model incorporated many elements that had been found to contribute to
                     effective drug abuse treatment, including (1) coordinating criminal justice
                     and treatment efforts, (2) providing incentives to enter treatment,
                     (3) matching offenders with the most appropriate treatment, and
                     (4) monitoring with drug testing.16 (See Related GAO Products at the end of
                     this report for a list of other products on treatment and prevention.)


                     Over the past 10 years, U.S. agencies involved in counternarcotics efforts
Obstacles to U.S.    have attempted to reduce the supply and availability of illegal drugs in the
International Drug   United States by implementing the U.S. international drug control strategy.
Control Efforts      Although these efforts have achieved some successes, we found that the
                     flow of cocaine, heroin, and other illegal drugs into the United States
                     continues, and the availability of drugs and the cultivation of drug crops
                     have not been reduced.17

                     Between 1988 and 1995, illegal drug cultivation and drug-related activities
                     increased throughout South America, Mexico, the Caribbean, Southeast
                     Asia, and other countries. The total net area of cultivation for coca leaf
                     and opium poppy increased. Between 1988 and 1995, about 56,000
                     hectares18 of coca plants were eradicated. However, while the areas under
                     cultivation have fluctuated from year to year, farmers planted new coca
                     faster than existing crops were eradicated. Thus, the net area under
                     cultivation increased from 186,000 hectares to 214,800 hectares, or by
                     about 15 percent.19 Also during this period, the amount of opium poppy
                     under cultivation increased by over 46,000 hectares, or by about

                     15
                       Weed and Seed: Program Objectives (GAO/GGD-94-128R, May 10, 1994).
                     16
                      Drug Control: Treatment Alternatives Program for Drug Offenders Needs Stronger Emphasis
                     (GAO/GGD-93-61, Feb. 11, 1993).
                     17
                       GAO/NSIAD-97-75.
                     18
                       One hectare equals 2.47 acres.
                     19
                       According to officials at the Department of State, initial information indicates that, during 1996,
                     significant reductions occurred in the amount of coca under cultivation in Peru.



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25 percent. Moreover, Drug Enforcement Administration (DEA) and
National Narcotics Intelligence Consumers Committee data on the
availability of illegal drugs, as measured by the average price and purity of
the drugs, showed that the price and purity of cocaine have remained
relatively constant since 1988. According to a DEA official, all other factors
being equal, had the United States achieved substantial success in
reducing supply, and demand remained constant, the prices of these drugs
would have increased, and the purity would have decreased.

The amount of cocaine and heroin seized between 1990 and 1995 had little
impact on the availability of illegal drugs in the United States in satisfying
estimated U.S. demand. In 1996, the National Narcotics Intelligence
Consumers Committee estimated the potential cocaine production for
1995 at about 780 metric tons, of which about 230 metric tons were seized
worldwide. The remaining amount was more than enough to meet U.S.
demand, which was estimated at about 300 metric tons per year. Heroin
production in 1995 was estimated to be over 300 metric tons, while
seizures were about 32 metric tons, and U.S. demand was between 10 and
15 metric tons.

When confronted with threats to their activities, drug-trafficking
organizations use a variety of techniques to quickly change their modes of
operation, thus avoiding capture of their personnel and seizure of their
illegal drugs. For example, when air interdiction efforts have proven
successful, traffickers have increased their use of maritime and overland
transportation routes. According to recent U.S. government reports, even
after the capturing or killing of several drug cartel leaders in Colombia and
Mexico, other leaders or organizations soon filled the void, and adjusted
their areas of operations.

In carrying out its foreign policy, the United States seeks to promote U.S.
business and trade, improve human rights, and support democracy as well
as reduce the flow of illegal drugs into the United States. These objectives
compete for attention and resources, and U.S. officials must make tough
choices about which to pursue more vigorously. As a result of U.S. foreign
policy decisions, counternarcotics issues have often received less
attention than other objectives. Our work has shown the difficulties in
balancing counternarcotics and other U.S. foreign policy objectives.
Sometimes, resources are shifted to satisfy other policy objectives. For
example, as we reported in 1995, $45 million originally intended for
counternarcotics assistance for cocaine source countries was
reprogrammed by the Department of State to assist Haiti’s democratic



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transition.20 A similar diversion occurred in the early 1990s, when U.S.
Coast Guard assets in the Caribbean were reallocated from
counternarcotics missions to the humanitarian mission of aiding emigrants
in their mass departures from Cuba and Haiti.

We have reported that in some cases the United States has not adequately
controlled the use of U.S. counternarcotics assistance and it was unable to
ensure that the assistance was used as intended. Despite legislative
requirements mandating controls over U.S.-provided assistance, we found
instances of inadequate oversight of counternarcotics funds. For example,
between 1991 and 1994, we issued three products in which we concluded
that U.S. officials lacked sufficient oversight of aid to ensure that it was
being used effectively and as intended in Peru and Colombia.21 In 1996, we
reported that the government of Mexico had misused U.S.-provided
counternarcotics helicopters when it used them to transport Mexican
military personnel during the 1994 uprising in the Mexican state of
Chiapas.22

During this period, we reported on other significant long-standing
obstacles faced by the United States in its international drug control
efforts, including the inconsistency in the amount of funds applied to
international drug control programs, difficulty in obtaining bilateral and
multilateral donor support for U.S. drug control efforts, and organizational
and operational limitations. For example, several of our products have
identified problems involving competing priorities and interagency
rivalries, lack of operational coordination, and inadequate staffing of joint
interagency task forces.

Regarding obstacles confronting foreign governments’ antidrug efforts, we
have repeatedly reported that narcotics-related corruption is a
long-standing problem in U.S. and foreign governments’ efforts to reduce
drug-trafficking activities. For example, we reported in 1991 and 1993 that
corruption in Colombia and Peru—two of the countries most significantly
involved in producing and shipping cocaine—had spread throughout the
civilian governments, the military force, and the police force and that even
though the governments were attempting to reduce corruption, its

20
 Drug War: Observations on U.S. International Drug Control Efforts (GAO/T-NSIAD-95-194, Aug. 1,
1995).
21
 Drug War: Observations on Counternarcotics Aid to Colombia (GAO/NSIAD-91-296, Sept. 30, 1991);
The Drug War: U.S. Programs in Peru Face Serious Obstacles (GAO/NSIAD-92-36, Oct. 21, 1991); and
The Drug War: Colombia Is Implementing Antidrug Efforts, but Impact Is Uncertain
(GAO/T-NSIAD-94-53, Oct. 5, 1993).
22
  Drug Control: Counternarcotics Efforts in Mexico (GAO/NSIAD-96-163, June 12, 1996).



Page 13                                                            GAO/GGD-97-42 Drug Control
B-275944




pervasiveness made such action difficult.23 We also reported that
corruption remained a serious, widespread problem in Colombia and
Mexico, the two countries most significantly involved in producing and
shipping cocaine.24 In March 1996, the State Department reported that
persistent corruption within Mexico continued to undermine both police
and law enforcement operations. Drug-related corruption also remained
widespread, although to a lesser extent, throughout several island nations
in the Caribbean25 and in Bolivia and Peru.

The governments involved in drug eradication and control have other
problems that cause competition for limited resources. As we reported in
1988, six drug-producing countries’ efforts to curtail drug cultivation were
constrained by political, economic, and/or cultural problems that far
exceeded counternarcotics program managers’ abilities to resolve.26 Many
of the source countries lacked the political will necessary to reduce coca
and opium poppy cultivation partly because drug trafficking contributes to
their economies. Also, as we reported in 1992, severe economic problems
in Brazil, Ecuador, and Venezuela limited these governments’ ability to
devote the resources needed to develop effective drug control efforts.27
Internal strife in the source countries is yet another problem that
competes for resources. For example, two primary source
countries—Peru and Colombia—must allocate scarce funds to support
military and other internal defense operations to combat guerilla groups,
which negatively affect counternarcotics operations. In Peru, for example,
we reported that terrorist activities had hampered antidrug efforts.28

Inadequate resources and institutional capabilities of these and other
foreign countries have limited arrests and convictions of drug traffickers.
For example, in 1991 we reported that the lack of resources and
adequately trained police personnel hindered Panama’s ability to address
drug-trafficking and money-laundering activities.29 Also, in 1994 we


23
 The Drug War: Observations on Counternarcotics Programs in Colombia and Peru
(GAO/T-NSIAD-92-2, Oct. 23, 1991) and The Drug War: Colombia Is Undertaking Antidrug Programs,
but Impact Is Uncertain (GAO/NSIAD-93-158, Aug. 10, 1993).
24
 Drug War: Observations on the U.S. International Drug Control Strategy (GAO/T-NSIAD-95-182, June
27, 1995) and Drug Control: Counternarcotics Efforts in Mexico (GAO/NSIAD-96-163, June 12, 1996).
25
  Drug Control: U.S.Interdiction Efforts in the Caribbean Decline (GAO/NSIAD-96-119, Apr. 17, 1996).
26
  Controlling Drug Abuse: A Status Report (GAO/GGD-88-39, Mar. 1, 1988).
27
   The Drug War: Extent of Problems in Brazil, Ecuador, and Venezuela (GAO/NSIAD-92-226, June 5,
1992).
28
  The Drug War: U.S. Programs in Peru Face Serious Obstacles (GAO/NSIAD-92-36, Oct. 21, 1991).
29
  The War on Drugs: Narcotics Control Efforts in Panama (GAO/NSIAD-91-233, June 16, 1991).
Page 14                                                              GAO/GGD-97-42 Drug Control
                      B-275944




                      reported that Central American countries did not have the resources or
                      institutional capability to combat drug trafficking and depended heavily on
                      U.S. counternarcotics assistance.30 Our more recent work indicates that
                      these problems have persisted over time. For example, we reported in
                      1995 that the Colombian national police had only 10 helicopters available
                      for interdiction and eradication operations in the entire country.31

                      There is no easy remedy for overcoming all of the obstacles posed by
                      drug-trafficking activities. International drug control efforts aimed at
                      stopping the production of illegal drugs and drug-related activities in the
                      source and transit countries are only one element of an overall balanced
                      national drug control strategy. Alone, these efforts will not likely solve the
                      U.S. drug problem. Overcoming many of the long-standing obstacles to
                      reducing the supply and smuggling of illegal drugs requires a long-term
                      commitment. As stated in our February 1997 report,32 we believe the
                      United States can improve the effectiveness of planning and implementing
                      its current international drug control efforts by (1) developing a multiyear
                      plan with measurable goals and objectives and a multiyear funding plan;
                      (2) at least annually, review the progress made and adjust the plan, as
                      appropriate; (3) enhance support for the increased use of available
                      intelligence and technologies and increasing intelligence and technology,
                      and (4) lead in developing a centralized “lessons-learned” data system to
                      aid agency planners and operators in developing more effective
                      counterdrug efforts.


                      We have reported over the past few years on various aspects of domestic
Summary of Our Work   drug interdiction. For example, criminal activities such as illegal drug
on Federal Domestic   sales produce a tremendous amount of currency that would be regarded as
Drug Interdiction     suspicious unless it was disguised as legitimate through various money
                      laundering schemes. Consequently, U.S. efforts to combat money
Programs              laundering rely heavily upon the reporting of transactions involving large
                      amounts of cash. In March 1994, we reported that the Customs Service
                      was aware of the impact of currency smuggling on drug control efforts and
                      at that time had increased national oversight of and emphasis given to
                      outbound inspection programs to interdict unreported currency.33

                      30
                       Drug Control: Interdiction Efforts in Central America Have Had Little Impact on the Flow of Drugs
                      (GAO/NSIAD-94-233, Aug. 2, 1994).
                      31
                       Drug War: Observations on U.S. International Drug Control Efforts (GAO/T-NSIAD-95-194, Aug. 1,
                      1995).
                      32
                        GAO/NSIAD-97-75.
                      33
                         Money Laundering: U.S. Efforts to Fight It Are Threatened by Currency Smuggling (GAO/GGD-94-73,
                      Mar. 9, 1994).


                      Page 15                                                             GAO/GGD-97-42 Drug Control
                       B-275944




                       Experts estimate that most of the cocaine entering the United States
                       enters from Mexico across the southwest border. For example, it has been
                       estimated that between 50 and 70 percent of the cocaine smuggled into the
                       United States transits through Mexico, entering primarily by land across
                       the southwest border. We concluded that the Immigration and
                       Naturalization Service’s (INS) 1994 national strategy for gaining control of
                       the nation’s borders had affected drug smuggling in that smugglers began
                       rerouting drugs from San Diego and El Paso to other southwest border
                       areas.34

                       We also examined INS’ role in the Organized Crime Drug Enforcement Task
                       Force program, which is designed to be a comprehensive, multiagency
                       attack on drug-related and money laundering enterprises. Nine federal
                       agencies, including INS, and various state and local organizations
                       comprised individual task forces. The task forces were to use the special
                       skills and expertise of all participating agencies and rely on the
                       jurisdictional authority of those agencies. We reported in July 199435 that
                       when carrying out task force investigations, INS contributed its
                       alien-related expertise and its jurisdictional authority to apprehend and
                       remove criminal alien drug traffickers from the country.


                       In a 1990 report,36 we pointed out the difficulties in measuring the
Difficulties in        effectiveness of drug interdiction activities. For example, we noted that
Measuring Agencies’    while agencies generally view the number or amounts of seizures as an
Antidrug Performance   indicator of program success, a decrease in seizures does not necessarily
                       mean that a program was less effective than it was previously or less
                       effective than other programs making more seizures.

                       We took this concern one step further in our 1993 report on the
                       reauthorization of ONDCP.37 We found that national strategies contained
                       inadequate measures for assessing the contributions of component
                       programs for reducing the nation’s drug problems and recommended that,
                       as part of its reauthorization of ONDCP, Congress direct the agency to
                       develop better performance measures. In reauthorizing ONDCP in 1993,


                       34
                         Border Control: Revised Strategy Is Showing Some Positive Results (GAO/GGD-95-30, Dec. 29, 1994).
                       35
                         INS Drug Task Force: Federal Agencies Supportive of INS Efforts (GAO/GGD-94-143, July 7, 1994).
                       36
                        Drug Interdiction: Funding Continues to Increase but Program Effectiveness Is Unknown
                       (GAO/GGD-91-10, Dec. 11, 1990).
                       37
                          Drug Control: Reauthorization of the Office of National Drug Control Policy (GAO/GGD-93-144, Sept.
                       29, 1993).



                       Page 16                                                              GAO/GGD-97-42 Drug Control
B-275944




Congress specified that ONDCP’s performance measurement system should
assess changes in drug use, drug availability, the consequences of drug
use, drug treatment capacity, and the adequacy of drug treatment systems.

ONDCP   has been working toward this end since our 1993 report. In 1994,
ONDCP   began efforts to measure the international supply reduction
components of the national drug control strategy. In early 1996, ONDCP
decided to expand this effort to all drug control programs and activities.
As of January 1997, ONDCP had convened working groups composed of
representatives from all federal drug control agencies as well as from
state, local, and private entities to develop national level measures of drug
control performance. ONDCP plans to submit proposed national
performance measures to federal agencies involved in national drug
control efforts for comment by the summer of 1997.

We reported in September 1996 that the Customs Service was developing
some nontraditional measures to use in assessing the effectiveness of its
drug interdiction activities.38 In addition to the traditional measures of
seizures, arrests, indictments, and convictions, Customs began measuring
the reduction in the number of drug smugglers who attempt to race a
drug-laden vehicle through a port of entry, and the ratio of seizures to
examinations conducted for cargo and passengers. In addition, Customs is
estimating the number of persons violating U.S. laws at major air and land
ports.

The Coast Guard has taken steps toward conforming with certain GPRA
principles. It has defined its performance goal as “reducing the amount of
illegal drugs entering the country through maritime routes by 25 percent
over 5 years.” It plans to gather data to compare the amount of drugs it
seizes with estimates of the amount of drugs produced in source countries
and shipped to the United States via maritime routes.

However, agency officials recognize that challenges remain. The Coast
Guard has developed preliminary performance plans that reflect a need for
additional work in three areas: (1) developing goals and ways of achieving
them, (2) developing data to measure the results of its actions, and
(3) identifying wide variety of constraints that could influence the
effectiveness of its antidrug activities. (See app. III for more details on the
Coast Guard’s performance measures.)



38
  Customs Service: Drug Interdiction Efforts (GAO/GGD-96-189BR, Sept. 26, 1996).



Page 17                                                             GAO/GGD-97-42 Drug Control
                  B-275944




                  ONDCP and several other agencies are developing measures of the results of
Conclusions       their antidrug activities. Used together, these measures could provide
                  information congressional and executive branch decisionmakers need to
                  assess program performance and make judgments about future funding
                  levels. It is important to consider both ONDCP and operational agency data
                  together because results achieved by one agency in reducing the use of
                  drugs may be offset by less favorable results by another agency. For
                  example, increased Customs Service inspections and use of technology to
                  detect drugs being smuggled through ports of entry may cause smugglers
                  to seek other routes; this would put more pressure on drug interdiction
                  activities of other agencies, such as the Coast Guard. Experts say
                  substantiating outcome results through further research and evaluation is
                  an important step in advancing promising drug prevention and treatment
                  approaches. It is also important in helping policymakers to better focus
                  efforts and resources on proven effective drug abuse prevention and
                  treatment programs.

                  It is too soon to tell whether the measures being developed by ONDCP and
                  each agency participating in implementing the U.S. drug control strategy
                  will be adequate for assessing results. Congressional and agency officials
                  will need to review several years of data before they can assess whether
                  changes in funding or allocation of resources would improve the results
                  being achieved.


                  On January 31, 1997, we provided a draft of this report for comment to the
Agency Comments   Director, Office of National Drug Control Policy; the Secretary of
                  Transportation; and the Commandant of the U.S. Coast Guard. Between
                  February 7 and 14, 1997, officials from ONDCP and the U.S. Coast Guard
                  provided comments on this draft by teleconference. On February 7, 1997,
                  Department of Transportation officials provided their comments by
                  electronic mail. Officials from all three organizations generally agreed with
                  the information presented in the report and provided technical comments
                  that we incorporated where appropriate.


                  We are sending copies of this report to the Ranking Minority Members of
                  your Subcommittees, the Director of ONDCP, the Secretary of
                  Transportation, and the Commandant of the U.S. Coast Guard. We will
                  also make copies available to others upon request.




                  Page 18                                             GAO/GGD-97-42 Drug Control
B-275944




The major contributors to this report are listed in appendix IV. If you or
your staffs have any questions on this report, please call me on
(202) 512-8777.




Norman J. Rabkin
Director, Administration
  of Justice Issues




Page 19                                             GAO/GGD-97-42 Drug Control
Contents



Letter                                                                                              1


Appendix I                                                                                         22

Background
Appendix II                                                                                        27
                        Introduction                                                               27
Drug Abuse              Scope and Methodology                                                      28
Prevention and          The Nature and Objectives of Drug Prevention and Treatment                 30
                        The Types of Prevention Approaches Currently Being Used for                34
Treatment                  School-Age Youths
                        The Types of Approaches Currently Being Used to Treat Cocaine              42
                           Addiction
                        Additional Research Initiatives Identified for Prevention and              52
                           Treatment Effectiveness

Appendix III                                                                                       55
                        Coast Guard Has Made Progress Toward Implementing GPRA                     56
Coast Guard Has           Principles
Made Progress, but      Measuring Results of Drug Interdiction Presents Challenges                 56
Challenges Remain in
Developing Antidrug
Strategic and
Performance Plans
Appendix IV                                                                                        61

Major Contributors to
This Report
Related GAO Products                                                                               64


Tables                  Table I.1: Federal Drug Control Spending by Function, FYs                  22
                          1995-1997
                        Table I.2: U.S. Retail Price Range for 1 Kilogram of Cocaine,              25
                          1988-1995
                        Table II.1: Types of Prevention Approaches                                 34




                        Page 20                                             GAO/GGD-97-42 Drug Control
          Contents




          Table II. 2: Methodology and Results of Illustrative School-Age           36
            Prevention Programs
          Table II.3: Methodology and Results of Illustrative                       44
            Cognitive-Behavioral Studies

Figures   Figure I.1: Percentage of Drug Control Funds by Agency, 1997              24
          Figure I.2: Average U.S. Rate of Purity of Cocaine, 1988-1995             25
          Figure I.3: Adolescent Illicit Drug Use, 1991-1996                        26




          Abbreviations

          ATP        Adolescent Transitions Program
          CSAP       Center for Substance Abuse Prevention
          CSAT       Center for Substance Abuse Treatment
          DEA        Drug Enforcement Administration
          DOJ        Department of Justice
          FBI        Federal Bureau of Investigation
          GPRA       Government Performance and Results Act
          HHS        Department of Health and Human Services
          HIV        Human Immunodeficiency Virus
          INS        Immigration and Naturalization Service
          IPR        interpersonal relations
          IOM        Institute of Medicine
          NIDA       National Institute on Drug Abuse
          NIJ        National Institute of Justice
          ONDCP      Office of National Drug Control Policy
          SAMHSA     Substance Abuse and Mental Health Services Administration
          SFP        Strengthening Families Program
          SSDP       Seattle Social Development Project
          TASC       Treatment Alternatives to Street Crime
          VA         Department of Veterans Affairs


          Page 21                                            GAO/GGD-97-42 Drug Control
Appendix I

Background


                                          The United States has developed a multifaceted drug control strategy
                                          intended to reduce the supply and demand for illegal drugs. The 1996 U.S.
                                          drug control strategy includes five goals: (1) motivate America’s youth to
                                          reject illegal drugs and substance abuse; (2) increase the safety of U.S.
                                          citizens by substantially reducing drug-related crime and violence;
                                          (3) reduce health, welfare, and crime costs resulting from illegal drug use;
                                          (4) shield America’s air, land, and sea frontiers from the drug threat; and
                                          (5) break foreign and domestic drug sources of supply. For fiscal year
                                          1997, the President requested $15.1 billion for programs designed to attain
                                          the strategy’s goals. Table I.1 lists federal drug control spending by
                                          function for fiscal years 1995 to 1997.


Table I.1: Federal Drug Control Spending by Function, FYs 1995-1997
Dollars in millions

                                                          FY 1995      FY 1996    President’s FY   FY 1996-1997 change
                                                           actual     estimatea    1997 request     Amount        Percent
Drug function
Criminal justice system                                   $6,545.4     $7,105.1         $7,790.5      $685.4           9.6%
Drug treatment                                             2,692.0      2,679.4          2,908.7       229.3           8.6%
Drug prevention                                            1,559.1      1,430.1          1,591.6       161.5         11.3%
International                                                295.8       319.5             400.5        81.0         25.4%
Interdiction                                               1,280.1      1,339.4          1,437.2        97.8           7.3%
Research                                                     542.2       569.6             559.2       –10.4         –1.8%
Intelligence                                                 336.6       340.4             375.9        35.4         10.4%
Total                                                    $13,251.2    $13,783.5        $15,063.5    $1,280.0           9.3%


Function areas
Demand reductionb                                         $4,691.9     $4,571.9         $4,970.6      $398.7           8.7%
Percentage                                                      35%         33%              33%
Domestic law enforcement                                  $6,983.3     $7,552.8         $8,255.3      $702.5           9.3%
Percentage                                                      53%         55%              55%
International                                               $295.8      $319.5           $400.5        $81.0         25.4%
Percentage                                                       2%          2%               3%
Interdiction                                              $1,280.1     $1,339.4         $1,437.2       $97.8           7.3%
Percentage                                                      10%         10%              10%
Total                                                    $13,251.2    $13,783.5        $15,063.5    $1,280.0           9.3%


Supply/demand split
Supply                                                    $8,559.2      9,211.6        $10,093.0      $881.4           9.6%
Percentage                                                      65%         67%              67%
                                                                                                               (continued)


                                          Page 22                                             GAO/GGD-97-42 Drug Control
                          Appendix I
                          Background




Dollars in millions

                                              FY 1995        FY 1996            President’s FY      FY 1996-1997 change
                                               actual       estimatea            1997 request          Amount         Percent
Demand                                        $4,691.9         4,571.9                 $4,970.6         $398.7                8.7
Percentage                                           35%             33%                      33%
Total                                        $13,251.2       13,783.5                 $15,063.5       $1,280.0                9.3%


Demand components
Prevention (w/research)                       $1,738.7        $1618.6                  $1,783.3         $164.7             10.2%
Treatment (w/research)                        $2,953.2       $2,953.3                  $3,187.3         $234.0                7.9%
Demand research, total                          $440.8          $462.4                   $470.2            $7.9               1.7%

                          Note: Detail may not add to totals due to rounding.
                          a
                            Includes the administration’s proposed adjustments to fiscal year 1996 continuing resolution
                          levels.
                          b
                           Demand reduction refers to any activity intended to reduce the demand for drugs such as
                          through drug abuse treatment, education, prevention, research, and rehabilitation. Supply
                          reduction refers to any enforcement activity intended to reduce the supply or use of drugs, such
                          as through international drug control initiatives, foreign and domestic drug enforcement
                          intelligence, interdiction of drugs destined for the United States, and domestic law enforcement,
                          including enforcement directed at users.

                          Source: The National Drug Control Strategy: 1996, ONDCP.



                          Figure I.1 shows the level of federal involvement in drug control efforts.




                          Page 23                                                              GAO/GGD-97-42 Drug Control
                                         Appendix I
                                         Background




Figure I.1: Percentage of Drug Control
Funds by Agency, 1997                                                              Others




                                                   • 22.9%


                                                                   47.4% •         Justice
                                                   •

                                                       •


                                                           15.3%
                                                              •


                                                                                   HHS

                                                                                   7.4%
                                                                                   Treasury

                                                                                   7.0%
                                                                                   VA




                                         Source: ONDCP.




                                         According to the DEA Administrator, if demand does not change, a
                                         depressed price and elevated purity often signal an increased availability
                                         of a specific drug; on the other hand, increased price and declining purity
                                         indicate decreased availability of that drug. As can be seen in table I.2, the
                                         lower end price of cocaine remained the same, while the higher range
                                         price increased from 1988 to 1992. But from 1993 to 1995, the price of
                                         cocaine declined. Figure I.2 shows that the purity of cocaine has remained
                                         relatively constant since 1988.




                                         Page 24                                              GAO/GGD-97-42 Drug Control
                                           Appendix I
                                           Background




Table I.2: U.S. Retail Price Range for 1
Kilogram of Cocaine, 1988-1995             Year                                                                       National price range
                                           1988                                                                           $11,000-$34,000
                                           1989                                                                           $11,000-$35,000
                                           1990                                                                           $11,000-$40,000
                                           1991                                                                           $11,000-$40,000
                                           1992                                                                           $11,000-$42,000
                                           1993                                                                           $10,500-$40,000
                                           1994                                                                           $10,500-$40,000
                                           1995                                                                           $10,500-$36,000
                                           Source: DEA and the National Narcotics Intelligence Consumers Committee.




Figure I.2: Average U.S. Rate of Purity
of Cocaine, 1988-1995                      100    Percent

                                            90

                                            80

                                            70

                                            60

                                            50

                                            40

                                            30

                                            20

                                            10

                                             0

                                             1988           1989        1990       1991         1992        1993           1994       1995

                                             Year

                                                            Kilograms
                                                            Grams



                                           Source: DEA.




                                           Illegal drug use—particularly the use of cocaine and heroin—represents a
                                           continuing health and safety problem in the United States. While the level



                                           Page 25                                                         GAO/GGD-97-42 Drug Control
                                           Appendix I
                                           Background




                                           of consumption of illicit drugs has remained relatively stable during recent
                                           years, a great deal of concern has arisen from the Monitoring the Future,
                                           1996 survey’s findings discussed earlier that drug use by youth in grades 8,
                                           10, and 12 has increased since 1992. According to ONDCP, an upsurge in
                                           drug use by teens reflects the need to refocus and reinvigorate prevention
                                           efforts.


Figure I.3: Adolescent Illicit Drug Use,
1991-1996                                  45   Percent

                                           40

                                           35

                                           30

                                           25

                                           20

                                           15

                                           10

                                            5

                                            0

                                            1991                1992              1993               1994             1995           1996

                                            Year

                                                          8th Grade
                                                          10th Grade
                                                          12th Grade



                                           Source: Monitoring the Future, National Institute on Drug Abuse, 1996.




                                           Page 26                                                             GAO/GGD-97-42 Drug Control
Appendix II

Drug Abuse Prevention and Treatment


               Drug and alcohol abuse continues to be a major problem facing our
Introduction   society. In 1995, among the general population, about 22.7 million
               individuals were estimated to have used at least one illicit drug in the past
               year—17.8 million used marijuana, 3.7 million used cocaine, and 428,000
               used heroin.39 The highest illicit drug use rate among adolescents
               continues to be their use of alcohol. In 1995, about 74 percent of high
               school seniors surveyed had consumed alcohol in the past year.4041

               From 1992 to 1995, the estimated rate of marijuana use in the general
               population increased from 7.9 to 8.4 percent. The rate of cocaine use,
               although still considered to be of epidemic proportions, declined from 2.1
               to 1.7 percent. There was a pronounced rise in the drug use rates among
               school-age youths during this period. The rate of marijuana use by 8th
               grade students in the past year more than doubled, from 7.2 percent to
               15.8 percent; use by 10th graders rose from 15.2 percent to 28.7 percent;
               and for 12th graders, the rate of marijuana use increased from 21.9 percent
               to 34.7 percent. The rate of alcohol use remained above 70 percent
               throughout the period for 12th graders. Increases in students’ past-year
               drug use were also found for 11 other drug types.

               To help combat drug abuse and reduce the demand for drugs in the United
               States, federal, state, and local governments and the private sector fund
               prevention and treatment programs. From fiscal year 1990 through 1994,
               federal funding for drug prevention and treatment activities increased
               from $2.8 billion to $4.4 billion. Combined state, county, and local
               expenditures increased from about $1.3 billion to about $1.6 billion.
               Although data on private sector funding are very limited, available sources
               indicate funding of more than $1 billion for treatment in 1993.42

               In light of the high prevalence of drug use in the United States and the
               human and financial investment in fighting drug abuse, congressional
               members are interested in knowing what drug prevention and treatment
               strategies are being employed to address the drug use problem. This
               appendix discusses

               39
                National Household Survey on Drug Abuse: Population Estimates 1995, Substance Abuse and Mental
               Health Services Administration, 1996.
               40
                 In all states, the purchase and public possession of alcohol beverages by a person who is less than 21
               years of age is illegal. Throughout this report, the use of the term “drug abuse” can also include
               alcohol.
               41
                 Monitoring the Future, National Institute on Drug Abuse, 1996.
               42
                Drug and Alcohol Abuse: Billions Spent Annually for Treatment and Prevention Activities
               (GAO/HEHS-97-12, Oct. 8, 1996).



               Page 27                                                                GAO/GGD-97-42 Drug Control
                  Appendix II
                  Drug Abuse Prevention and Treatment




              •   the nature and objectives of drug prevention and treatment,
              •   the types of prevention approaches currently being used and promising
                  prevention practices for school-age youths,
              •   the types of cocaine treatment approaches currently being used and
                  promising treatment practices for those abusing or addicted to cocaine,
                  and
              •   future research initiatives needed to enhance our knowledge base of
                  prevention and treatment effectiveness.


                  To determine the objectives of drug prevention and treatment, the range of
Scope and         prevention and treatment strategies and approaches being used, and the
Methodology       future research initiatives needed to increase the knowledge base on the
                  effectiveness of prevention and treatment, we identified and reviewed
                  selected literature on drug prevention and treatment research. The
                  documents we reviewed included (1) Institute of Medicine (IOM)
                  publications, (2) the Secretary of the Department of Health and Human
                  Services’ (HHS) third triennial report to the Congress on drug abuse
                  research, (3) the National Institute on Drug Abuse’s (NIDA) series of
                  research monographs, (4) Substance Abuse and Mental Health Services
                  Administration (SAMHSA) monographs, and (5) relevant government
                  contractor reports as well as journal publications by major experts in drug
                  prevention and treatment.

                  To identify promising drug prevention approaches for school-age youths,
                  we first conducted a literature search of prevention practices during the
                  period 1990 to 1995, using medical, social, psychological, and educational
                  reference sources. We extracted and reviewed from the drug prevention
                  literature 10 syntheses written by known experts in the field. The authors
                  reviewed and summarized the evidence of promising prevention
                  approaches used in programs for youths. We also reviewed the supporting
                  outcome data provided for each program to determine the level of
                  evidence behind an author’s designation of a program as promising. In the
                  syntheses in which data either were not provided or were not adequate,
                  we obtained supplementary information from principal investigators who
                  had implemented the prevention approach. This supplementary
                  information was obtained from journal publications, reports, and working
                  drafts. We cited the drug prevention programs as promising if the
                  approach met one of the following criteria that we developed:




                  Page 28                                            GAO/GGD-97-42 Drug Control
    Appendix II
    Drug Abuse Prevention and Treatment




•   the group receiving the experimental intervention demonstrated
    significantly better outcome results than control groups not receiving the
    approach;43 or
•   in cases where the intervention had no comparison or control group,
    outcome results were markedly better (by at least 10 percent) than initial
    baseline scores.

    In addition to these criteria, we sought approaches with follow-up periods
    of at least 6 months. We combined a standardized statistical criterion with
    our professional methodological judgment in developing the criteria.

    To identify promising treatment approaches for cocaine abuse, we used
    information from our June 1996 report.44 For that report, we identified
    studies with current reportable data on two major outcome
    variables—drug abstinence and treatment retention. We reviewed the
    treatment literature published between 1991 and 1995; examined Center
    for Substance Abuse Treatment (CSAT) and NIDA agency records of
    cocaine-related grants awarded during that time period; and, as necessary,
    contacted project investigators for additional information.

    The approximately 65 cocaine-related grants supported by CSAT were still
    in progress when the report was being written; neither abstinence nor
    retention outcome data were available to judge the promise of their
    ongoing work. Many of the NIDA longitudinal cocaine-supported studies
    were also in progress. Promising practices, and their supportive findings,
    were therefore identified from available NIDA abstinence and retention
    study data, cocaine treatment outcome studies published during the 5-year
    period, and documents of unpublished results from federal drug agencies.
    For analytical purposes, we classified the treatment intervention types as
    either cognitive and behavioral or pharmacological. In making
    determinations about which treatment approaches proved promising, we
    gave due consideration to the appropriateness of research design.

    This appendix is not intended to provide an exhaustive evaluation of the
    drug prevention and treatment literature, nor is it to assess the qualitative
    methodology of each study we reviewed. Rather, the primary objective is
    to identify drug abuse prevention approaches for school-age youths and

    43
      To assess whether the experimental intervention group outcome results were statistically better than
    those of the control group participants, we determined whether principal investigators used
    “significance” testing and then assessed the results of those tests. Experimental group findings were
    judged to be “significantly better” when the probability of this occurrence by chance alone was less
    than 5 times in 100 (p < .05).
    44
      Cocaine Treatment: Early Results From Various Approaches (GAO/HEHS-96-80, June 7, 1996).



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                           cocaine abuse or dependency treatment approaches that appear promising
                           and provide illustrative examples of these approaches.


                           In October 1996, we reported that federal, state, county, and local
The Nature and             governments and the private sector contribute billions of dollars annually
Objectives of Drug         to support drug prevention and treatment activities. The latest data
Prevention and             available from the Office of National Drug Control Policy (ONDCP) show
                           that federal funding alone was $4.7 billion in fiscal year 1995. At least 16
Treatment                  federal departments and agencies provide funding for drug abuse
                           prevention and treatment programs. Three departments accounted for 81.9
                           percent of fiscal year 1995 funding—HHS, the Department of Veterans
                           Affairs (VA), and the Department of Education—provided approximately
                           $2.3 billion, $967 million, and $584 million, respectively.

                           The federal agencies fund an array of drug abuse prevention and treatment
                           programs for a variety of targeted population groups. For instance, within
                           HHS, SAMHSA’s Center for Substance Abuse Prevention (CSAP) sponsors the
                           Community Partnership program, the Community Coalition program, and
                           the High Risk Youth program. The Veterans Health Administration
                           operates a network of substance abuse treatment programs in its medical
                           centers, domiciliaries, and outpatient clinics. And within the Department
                           of Education, the Safe and Drug-Free Schools and Communities Act
                           includes funding to prevent youth violence as well as drug and alcohol use.
                           These and other federal programs provide a broad range of drug abuse
                           prevention and treatment activities and services.


Prevention
The Nature of Prevention   Drug abuse prevention activities focus on the general population as well as
Activities                 individuals who may be at risk for alcohol or other drug problems. These
                           activities include (1) providing information and education that increase
                           knowledge of drug abuse and alternative drug-free lifestyles; (2) teaching
                           skills to resist drug influences, solve problems, and make decisions;
                           (3) developing interventions to control the sale and distribution of illegal
                           drugs; and (4) encouraging communities to implement responses to drug
                           use. Prevention activities can be differentiated, according to NIDA, into
                           three distinct types commonly referred to as universal, selective, and
                           indicated. A description of these types follows.




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                          Universal drug abuse prevention interventions are directed at the general
                          population and employ a variety of integrated activities, including social
                          resistance education in the schools, antidrug media campaigns, parent
                          skills training, antidrug coalitions at the neighborhood level, and antidrug
                          policies at the state and local levels. The objective of the universal strategy
                          is to alter social, psychological, and environmental factors that may
                          influence drug prevalence and drug outcomes at the community level.

                          Selective drug abuse prevention interventions are directed at individuals
                          or subgroups who are at risk of developing drug abuse behaviors. The
                          objective of a selective prevention intervention is to reduce “risk factors”
                          and enhance “protective factors” related to drug use onset and the
                          progression to abuse and dependence.

                          Indicated drug abuse prevention interventions are targeted to individuals
                          who use one or more drugs but who do not yet meet diagnostic criteria for
                          a drug disorder. Drug users with mental health disorders may be targeted
                          as well. The objective of indicated interventions is to interrupt the
                          progression from drug use to drug abuse, addiction, and social
                          dysfunctionality.

Goals and Objectives of   The major goals of drug prevention programs are to prevent or eliminate
Prevention Programs       drug use and to avert drug-related problems (such as sexually transmitted
                          diseases and tuberculosis). But many prevention intervention initiatives
                          also identify and address the “intermediate” factors, which have been
                          found, or are perceived, to be related to drug use. These are often referred
                          to as the “risk” and “protective” factors.

                          1. Reduction of individual “risk factors” focuses on trying to minimize the
                          negative effect of factors that impinge on one’s life that have been shown
                          or theorized to be related to drug use. These factors include availability of
                          drugs, community norms favorable to drug use, extreme economic
                          deprivation, family history of problem drug use, favorable parental
                          attitudes and involvement in problem drug use, early and persistent
                          antisocial behavior, academic failure, alienation and rebellion, and friends
                          who engage in problem behavior.

                          2. Enhancement of “protective factors” focuses on increasing an
                          individual’s resilience in dealing with potentially high-risk situations (such
                          as dysfunctional families, schools, and communities). The drug prevention
                          research field has hypothesized that more resilient individuals are less
                          likely to engage in drug use. Increased resiliency in youths may be



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                          described under seven major factors—optimism, empathy, insight,
                          intellectual competence, self-esteem, direction or mission, and
                          determination and perseverance. The coping or life skills associated with
                          these seven factors are emotional management skills, interpersonal social
                          skills, intrapersonal reflective skills, academic and job skills, ability to
                          restore self-esteem, planning and life skills, and problem-solving ability.

                          3. Reduction of environmental and societal risk factors focuses on
                          prevention approaches that seek to reduce the availability illegal and
                          nonprescriptive legal drugs (for example, higher penalties for sale and
                          distribution in and around schools).

                          Prevention programs are conducted in a variety of settings. For school-age
                          youths, drug prevention activities can occur in the classroom, peer
                          support groups, the home setting, and the community (using the media,
                          youth groups, and community leaders), or in a combination of these
                          settings. For adults, drug prevention can be extended to the workplace.


Treatment
The Nature of Treatment   Treatment activities are designed to benefit individuals who have not been
Activities                exposed to or dissuaded by drug abuse prevention programs and have not
                          been able to abstain or control drug use on their own. Drug treatment
                          traditionally has been reserved for drug abusers, or individuals dependent
                          on drugs who require more intensive therapy, and pharmacological
                          medications. The services drug treatment programs provide may include
                          diagnostic assessment, detoxification, pharmacological dosing, and
                          medical, psychiatric, and psychological counseling and psychotherapy.

Goals and Objectives of   The major goals of drug treatment programs are to achieve initial client
Treatment Programs        abstinence and then to maintain such abstinence over time. Individual
                          treatment objectives vary by the type of treatment intervention sought and
                          the nature and severity of a client’s problem. Common objectives include
                          (1) detoxification, when necessary; (2) use of self-help groups (for
                          example, Alcoholics Anonymous and Narcotics Anonymous) throughout
                          treatment and aftercare; (3) social or personal habilitation or
                          rehabilitation (including a focus on improved health and a reduction in
                          psychiatric disorders and psychological problems); (4) better relations
                          with family and significant others; (5) development of a lifestyle free of
                          drugs; (6) avoidance of others using drugs; (7) taking steps toward the
                          attainment of educational and occupational aspirations; (8) a reduction in



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criminal behavior and resolution of legal problems; and (9) improved
personal circumstances (including enhanced coping skills, family and
social support systems, and ability to provide for basic needs). The longer
a client remains in treatment, the greater the possibility of a successful
outcome.

Drug treatment can be administered in different ways and in both inpatient
and outpatient settings. IOM and others identify four types of treatment
modalities in the form of programs and settings.45 The four
modalities—outpatient methadone maintenance, outpatient
nonmethadone and drug-free, chemical dependency, and residential
therapeutic communities are described as follows:

1. Outpatient methadone maintenance is specifically for the group of
clients who are dependent on narcotics, particularly heroin, and who are
able to benefit from the use of methadone as a “substitute” drug.
Methadone is used to ease withdrawal symptoms, reduce heroin craving,
and improve the psychological functioning of the individual.

2. Outpatient nonmethadone and drug-free facilities offer diverse
purposes, programs, and staffing. Generally, clients are seen 1 or 2 days a
week for individual and group counseling sessions. Self-help groups are
thought to be an essential program component. Medication and assistance
with educational, vocational, and health and housing concerns are offered
in some programs.

3. Chemical dependency programs represent the type of inpatient modality
most often assumed by the private sector. Treatment consists of a
psychiatric and psychosocial evaluation, a drug education component,
individual and group therapy, self-help group participation, and aftercare
planning in an intensive outpatient or a residential setting.

4. Residential therapeutic communities incorporate programs that are
designed for the severely dependent clients whose social and occupational
functioning warrant rehabilitative or habilitative care. Therapeutic
communities perceive drug abuse as a deviant behavior that limits one’s
personality development and is associated with chronic deficits in the
individual’s social, educational, and economic skills. Reality-oriented
group and individual psychotherapy with definitive client roles and
responsibilities are provided in a very structured living arrangement. Over

45
   Institute of Medicine, Treating Drug Problems, vol. 1 (Washington, D.C.: National Academy Press,
1990); Research Triangle Institute, Data Tables Comparing Crack and Cocaine Users to Other Drug
Users Entering Drug Treatment, unpublished manuscript.



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                                  an approximate 6- to 24-month inpatient stay, therapeutic community
                                  programs focus on preparing an individual for reentry into society.


                                  Drug prevention strategies generally include one or more approaches
The Types of                      designed to prevent or reduce drug use, some of which include helping
Prevention                        participants deal with other problems in their lives. The strategies
Approaches Currently              commonly used have been categorized under five different
                                  approaches—information dissemination, affective education, alternative
Being Used for                    approaches, social influence, and personal and social skills. The social
School-Age Youths                 influence and personal and social skills approaches both address
                                  psychosocial factors; therefore, for purposes of this report, we refer to
                                  these as the “psychosocial” approach. Also, we include another
                                  approach—the comprehensive approach—to categorize multicomponent
                                  prevention activities involving the participation of two or more social
                                  institutions. (See table II.1 for a description of each approach.)

Table II.1: Types of Prevention
Approaches                        Approach                              Strategy
                                  Information dissemination             Provision of factual information on drugs
                                                                        presented through instruction, discussion,
                                                                        audio-visual presentation, display, posters,
                                                                        pamphlets, or group programs
                                  Affective education                   Promotes individual’s personal and social
                                                                        development with focus on improving
                                                                        one’s self-understanding and acceptance,
                                                                        enhancing interpersonal relationships, and
                                                                        attaining needs-satisfaction through
                                                                        existing social institutions
                                  Alternative approaches to drugs       Engagement in alternative activities in
                                                                        nondrug surroundings as a means of
                                                                        limiting one’s probability of drug
                                                                        use—such as sports, hobbies, and
                                                                        community service
                                  Psychosocial                          Teaching specific skills for resisting drug
                                                                        influences (e.g., familial, peer, and media
                                                                        influences) as well as generic skills for
                                                                        generally coping with life (e.g.,
                                                                        problem-solving and decisionmaking skills)
                                  Comprehensivea                        A multicomponent intervention involving
                                                                        the participation of several social
                                                                        institutions, including the schools, families,
                                                                        community organizations, and the media




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                             a
                               The term “comprehensive” has been utilized by IOM, CSAP, and other experts in the field. Yet it
                             can be defined in different ways. IOM and CSAP, for example, have used the term when referring
                             to coordinated, communitywide interventions. The Seattle Social Development Research Group
                             and Oregon Social Learning Center have used the term to refer to the cooperation or interaction
                             of multiple target groups from various social institutions, such as the school, family and
                             neighborhood. Selected references include: Institute of Medicine, Pathways of Addiction:
                             Opportunities in Drug Abuse Research (Washington, D.C. National Academy Press, 1996), p.
                             141, and William Hansen, “School-based Substance Abuse Prevention: A Review of the State of
                             the Art in Curriculum, 1980-1990,” Health Education Research, 7 (1992), 403-40.


                             Although these prevention approaches or strategies can be used for all
                             ages, they are most often used with youths because youths are very
                             susceptible to peer group and media influences that might encourage
                             negative behaviors. Because youths are apt to experiment with alcohol
                             and drugs, it is important to introduce prevention strategies early in their
                             lives.


Two Prevention               Of the five drug prevention approaches described in table II.1, the
Approaches Show Promise      psychosocial and comprehensive approaches have shown more promise
Among School-Age Youths      for reducing drug use and risk factors and for enhancing protective factors
                             among school-age youths. While the three other approaches have not been
                             shown to be consistently effective when used individually, they have been
                             included in promising comprehensive approaches.

                             Our review of selected literature syntheses identified several prevention
                             programs that had definitive positive outcome results when using the
                             psychosocial and comprehensive approaches as their core prevention
                             strategy. Although the two approaches can be applied in a variety of
                             settings, the programs cited in the research literature we reviewed were
                             school-based or had a family or community focus. HHS and the Department
                             of Education also recognize some of these programs as noteworthy in
                             decreasing drug use and risk factors.

Programs Incorporating the   The psychosocial approach appears to have some promise, as evidenced
Psychosocial Approach Show   by positive outcome data for the five illustrative programs using this
Promise                      approach in table II.2. Outcome results point to reductions in drug use and
                             risk factors as well as enhanced protective factors.




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Table II. 2: Methodology and Results of
Illustrative School-Age Prevention
Programs                                  Study                                         Study description                           S
                                          Psychosocial approaches
                                          1. Life Skills Training Prevention Programa   3-year school-based intervention            R
                                                                                        consisting of 15 7th-grade sessions, 10
                                                                                        8th-grade sessions, and 5 9th-grade
                                                                                        sessions

                                          2. Project ALERTb                             In 20 schools receiving the intervention   B
                                                                                        curriculum, classes taught by teacher      a
                                                                                        alone or by teacher and an older teen; 10 s
                                                                                        control schools did not receive the
                                                                                        curriculum; the curriculum had 11 lessons,
                                                                                        8 7th-grade sessions, and 3 8th-grade
                                                                                        booster sessions


                                          3. Generic Skills Interventionc               15-session curriculum for grade 7 with 8    M
                                                                                        8th-grade booster sessions




                                          4. Adolescent Alcohol Prevention Triald       4 experimental conditions: normative        R
                                                                                        education and resistance skill training,    3
                                                                                        provided either separately or together




                                          5. Interpersonal Relations Programe           InterPersonal Relations (IPR) classes met H
                                                                                        daily for a full semester (55 minutes per f
                                                                                        day for 4.5 months)                       s
                                                                                                                                  t
                                                                                                                                  m
                                                                                                                                  g
                                          Comprehensive approaches
                                          6. Seattle Social Development Project         6-year elementary school intervention       S
                                          (SSDP)f                                       consisting of teacher training each year    r
                                                                                        and parent training in grades 1, 2, 3, 5,   s
                                                                                        and 6                                       s




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                                  Setting and target
Sample design (size)              population                   Prevention outcome                          Investigator affiliation


Randomized trial (n = 3,597)      School-based: 7th-9th        At 12th-grade follow-up, 44% fewer        Cornell University, New
                                  graders from 56 New York     treatment students used all 3 gateway     York, New York
                                  state schools                drugs once a month or more compared to
                                                               controls; 66% fewer treatment students
                                                               used all 3 substances once a week or more
Blocking by district, restricted School-based: 7th- and        At 15-month follow-up, significantly fewer   RAND, Santa Monica,
and randomized assignment of 8th-grade students from 30        students in experimental intervention        California
schools (n = more than 4,000) diverse California and           groups anticipated using marijuana in the
                                 Oregon schools                future compared to controls; experimental
                                                               subjects also were significantly more likely
                                                               to believe that marijuana and cigarette use
                                                               can bring immediate and negative social
                                                               consequences and result in drug
                                                               dependence
Matched assignment (n = 757) School-based: 7th and 8th         At 9th-grade follow-up, drinking frequency, Cornell University, New
                             graders from 6 New York           amount of alcohol consumed, and intention York, New York
                             City schools with more than       to drink beer or wine were lower in the 2
                             85% minority student bodies       experimental groups relative to controls;
                                                               students in experimental groups used
                                                               drug-refusal skills more often than controls
Random assignment (n =            School-based: 7th-grade      At 1-year follow-up, classes receiving     Wake Forest University,
3,011)                            students in 12 Los Angeles   normative education had significantly      Winston-Salem, North
                                  and Orange County junior     reduced rates of marijuana use and         Carolina
                                  high schools                 alcohol and cigarette consumption relative
                                                               to controls; average increase in initial
                                                               incidence of marijuana use for normative
                                                               group was 64.5% less than controls,
                                                               22.5% less in the case of alcohol
High-risk students assigned       School-based: high-risk      IPR program participants demonstrated       University of Washington,
first come first served to        9th-12th graders from        significantly decreased drug use, fewer     Seattle, Washington
special IPR experimental          Northwest urban high         school disciplinary actions, fewer
training; control group           school serving               problems with family and friends, lower
matched to experimental           predominantly white,         dropout rate, and higher grade point
group (n = 146)                   middle-class students        average relative to controls


School assignment; student        School-based: 1st-6th        By 6-year follow-up, group receiving        University of Washington,
randomization (n = 598            graders in Seattle public    intervention demonstrated significantly     Seattle, Washington
students completing high          schools in high crime rate   greater school commitment and
school: the 6th-year follow-up)   areas; their teachers and    attachment, fewer school problem
                                  parents                      behaviors, less alcohol use, less violent
                                                               behavior, and fewer sexual partners
                                                               compared to controls
                                                                                                                            (continued)




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Study                                        Study description                            S
7. Midwestern Prevention Project, known      Social influence approach school-based       T
locally as Project Star or I-Starg           component plus media, parent, and            K
                                             community organization programs and          I
                                             drug use policy changes; 11-13-session
                                             school program followed by 5 session
                                             boosters
8. Safe Haven Program (a cultural version of Focus of the intervention for the 6 to 12  Q
the Strengthening Families Program, SFP)h    year old children was on risk and          n
                                             protective factors. The parental and adult g
                                             family intervention targeted both drug use
                                             and family management, communication
                                             issues in 12 weekly structured sessions



9. Adolescent Transitions Program (ATP)i     4 experimental conditions: parent focus      R
                                             (developing effective, noncoercive family    e
                                             management practices), teen focus            q
                                             (enhancing adolescent self-regulation,       (
                                             competence), parent and teen focus, and
                                             self-directed group that received only the
                                             materials; 12 weekly 90-minute sessions
10. Project Northlandj                       Experimental curricula consisting of 3       2
                                             years of parental involvement and            s
                                             education programs, behavioral curricula,    t
                                             peer participation, and community task       c
                                             force activity




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                                  Setting and target
Sample design (size)              population                      Prevention outcome                                    Investigator affiliation
Two-group design (n = 5,400       School- and                     20%-40% net change in 2 drugs over 3                  University of Southern
Kansas City, 3,192                community-based: 6th or         years for program participants                        California, Los Angeles,
Indianapolis)                     7th graders in 50 Kansas                                                              California
                                  City schools and 57
                                  Indianapolis schools

Quasi-experimental design,        Family-focused: 6- to           At follow-up, parents in both the high and            University of Utah, Salt Lake
nonequivalent comparison          12-year-old children            low substance abuse groups reported                   City, Utah; Detroit City
group (n = 88)                    substance using parents         significant decreases in drug use for                 Health Department,
                                  were admitted to a Detroit      themselves and their families; children in            Michigan
                                  drug treatment center;          high substance abuse group showed
                                  effectiveness of the Safe       significant reductions in school problems,
                                  Haven Program compared          aggression, delinquency, and hyperactivity
                                  families of low and high
                                  substance use
Random assignment to              Family-focused and              At 1-year follow-up, mothers in parent and Oregon Social Learning
experimental intervention,        neighborhood based:             teen group reported significantly less        Center, Eugene, Oregon
quasi-experimental control        6th- to 8th-grade high-risk     family conflict than controls and significant
(n = 158)                         adolescents and their           reductions in adolescent problem
                                  families                        behavior; teen focus intervention had
                                                                  negative effect

20 school districts blocked by    Communitywide: 6th-8th          Students in experimental intervention                 University of Minnesota,
size and randomized to either     graders and their               districts had significantly lower tendency            Minneapolis, Minnesota
the experimental or the control   communities in mostly rural,    to use alcohol by the end of 8th grade;
condition (n = 1,901)             lower middle-class              among baseline nonusers of alcohol,
                                  Minnesota                       percentage of students reporting
                                                                  marijuana and cigarette use was also
                                                                  significantly lower in the intervention
                                                                  districts at 8th-grade follow-up;
                                                                  intervention group significantly more likely
                                                                  to report being able to resist alcohol at a
                                                                  party or dance
                                               a
                                                 Sources for the Life Skills Training Prevention Program are Gilbert J. Botvin, “Preventing
                                               Adolescent Drug Abuse Through Life Skills Training: Intervention Approach and Evaluation
                                               Results,” Community Epidemiology Work Group (CEWG), June 1996, 451-459; and Gilbert J.
                                               Botvin et al., “Long-term Follow-up Results of a Randomized Drug Abuse Prevention Trial in a
                                               White Middle-Class Population,” Journal of the American Medical Association, 273:14 (1995),
                                               1106-12.
                                               b
                                                The source for Project ALERT is Phyllis L. Ellickson, Robert M. Bell, and Ellen R. Harrison,
                                               “Changing Adolescent Propensities to Use Drugs: Results from Project ALERT,” Health Education
                                               Quarterly, 20:2 (summer 1993), 227-42.
                                               c
                                                 The source for the Generic Skills Intervention program is Gilbert J. Botvin et al., “Effectiveness of
                                               Culturally Focused and Generic Skills Training Approaches to Alcohol and Drug Abuse
                                               Prevention Among Minority Adolescents: Two-Year Follow-Up Results,” Psychology of Addictive
                                               Behaviors, 9:3 (1995), 183-94.




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d
 The source for the Adolescent Alcohol Prevention Trial is William B. Hansen and John W.
Graham, “Preventing Alcohol, Marijuana, and Cigarette Use Among Adolescents: Peer Pressure
Resistance Training Versus Establishing Conservative Norms,” Preventive Medicine, 20 (1991),
414-30.
e
  The source for the Interpersonal Relations Program is Leona L. Eggert et al., “Effects of a
School-Based Prevention Program for Potential High School Dropouts and Drug Abusers,”
International Journal of the Addictions, 25:7 (1990), 773-801.
f
 The sources for the Seattle Social Development Project are an unpublished document by J.
David Hawkins et al. entitled “Promoting Academic Success and Preventing Crime in Urban
America: Six-Year Follow-Up Effects of the Seattle Social Development Project” and a set of
unpublished 6-year follow-up documents from Hawkins et al. provided to GAO on November 28,
1996. The principal investigator of the SSDP considers this program comprehensive because it is
a cooperative program that targets students, parents, and teachers and seeks to change the
entire school environment.
g
 The sources for the Midwestern Prevention Project are an unpublished draft by Mary Ann Pentz
entitled “Preventing Drug Abuse Through the Community: Multi-component Programs Make the
Difference” and Mary Ann Pentz’s “Benefits of Integrating Strategies in Different Settings.”
h
  Although the program might not necessarily include several social institutions, the Safe Haven
Program follows a comprehensive, family-focused curriculum in that it includes three
components: (1) children’s skills training; (2) parent training; and (3) if needed, community
support services such as child care, meals, transportation, and support with basic needs
(groceries and clothing). The source for the Safe Haven Program is G. Aktan, K. L. Kumpfer, and
C. Turner, “The Safe Haven Program: Effectiveness of a Family Skills Training Program for
Substance Abuse Prevention With Inner City African-American Families,” International Journal of
the Addictions, 31 (1996), 158-75.
i
 While The ATP program does not necessarily involve a multiple of social institutions, it is a
family-focused program that has a comprehensive strategy because it includes parents and
adolescents as well as community wraparound services if needed, such as family therapy, case
management, transportation, and food services. The source for the Adolescent Transitions
Program is Thomas J. Dishion and David W. Andrews, “Preventing Escalation Problem Behaviors
with High-Risk Young Adolescents: Immediate and 1-Year Outcomes,” Journal of Consulting and
Clinical Psychology, 63:4 (1995), 538-48.
j
The source for Project Northland is Cheryl L. Perry et al., “Project Northland: Outcomes of a
Communitywide Alcohol Use Prevention Program During Early Adolescence,” American Journal of
Public Health, 86:7 (1996), 956-65.


Illustrations of successful psychosocial programs include the Life Skills
Training Program46 and the Adolescent Alcohol Prevention Trial.47
Three-year follow-up results of a randomized trial of more than 3,500 7th
to 9th grade students showed 66 percent fewer program participants using
three drugs (alcohol, tobacco, and marijuana) at least once a week,


46
 Gilbert J. Botvin, “Preventing Adolescent Drug Abuse Through Life Skills Training: Intervention
Approach and Evaluation Results,” Community Epidemiology Work Group (CEWG), June 1996,
451-459; and Gilbert J. Botvin et al., “Long-term Follow-up Results of a Randomized Drug Abuse
Prevention Trial in a White Middle-Class Population,” Journal of the American Medical Association,
273:14 (1995), 1106-12.
47
 William B. Hansen and John W. Graham, “Preventing Alcohol, Marijuana, and Cigarette Use Among
Adolescents: Peer Pressure Resistance Training Versus Establishing Conservative Norms,” Preventive
Medicine, 20 (1991), 414-30.



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                             compared with control group participants not receiving the intervention. A
                             1-year follow-up of approximately 3,000 California 7th graders
                             participating in the Adolescent Alcohol Prevention Trial demonstrated that
                             the increase in the initial incidence of marijuana use for the experimental
                             group was 65-percent less than control group participants and 23-percent
                             less than control group participants for initial alcohol use.

                             Common features of these programs include increasing awareness of the
                             social influences that promote drug use, modifying normative expectations
                             concerning drug use, teaching skills for resisting drug use pressures, and
                             teaching more generic personal and interpersonal problem-solving skills.
                             All the programs we cite as using the psychosocial approach are delivered
                             in the school setting and target students in grades 7 through 12.

Programs Incorporating the   The comprehensive approach also appears to show some promise, as
Comprehensive Approach       illustrated by the five programs using this approach (see table II.2). In one
Show Promise                 program, the Seattle Social Development Project,48 6-year follow-up results
                             demonstrated that elementary school students participating in the full
                             parent-teacher intervention had significantly fewer annual school problem
                             behaviors than control group participants (4.77 problems versus 3.36
                             problems), drank less alcohol (15 percent of experimental subjects drank
                             10 times per year or more compared with 25 percent for control group
                             participants), had a lower lifetime prevalence of violent delinquency
                             (60 percent versus 48 percent), and had fewer sexual partners (50 percent
                             versus 62 percent.) Likewise, in the Midwestern Prevention Project (also
                             known as Project Star or I-Star)49 3-year follow-up results demonstrated a
                             20-to 40-percent net change in two drugs for program participants.

                             While some of the multicomponent interventions are centered on a school
                             setting, others tend to be family focused and address both parent and child
                             behaviors. For example, the Safe Haven Program achieved reductions in
                             family drug use as well as significant student reductions in school problem
                             behavior, aggression, and delinquency.




                             48
                               J. David Hawkins and others, “Promoting Academic Success and Preventing Crime in Urban America:
                             Six-Year Follow-Up Effects of the Seattle Social Development Project” and a set of unpublished 6-year
                             follow-up documents from Hawkins and others provided to us on November 28, 1996.
                             49
                               Mary Ann Pentz,”Preventing Drug Abuse Through the Community: Multi-Component Programs Make
                             the Difference” and Mary Ann Pentz “Benefits of Integrating Strategies in Different Settings,” in
                             A. Elster, S. Panzarine, and K. Holt (eds.). American Medical Association State of the Art Conference
                             on Adolescent Health Promotion Proceedings: National Center for Education in Maternal and Child
                             Health, Arlington, VA, 1993, pp. 15-34.



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                        Common features of programs using a comprehensive approach included
                        multistrategies to target multiple aspects of youths’ lives, such as the
                        individual, family, peer group, school, and community. We discussed the
                        importance of comprehensive approaches in community-based adolescent
                        drug prevention programs in our January 1992 report.50 Although no
                        definitive evidence was available at the time to demonstrate the
                        effectiveness of the community prevention programs we reviewed, we
                        reported that the comprehensive strategy was a feature present in the
                        most promising programs or at least those that appeared to be making
                        more headway than others.51 The comprehensive approaches addressed
                        multiple dimensions of youths’ lives (such as the individual, family, peer
                        group, school, and community) and used a variety of services.


Federal Agencies        NIDA  and CSAP, within HHS, and the Department of Education recognized as
Recognize Programs as   noteworthy several of the drug prevention programs we cite from the
Noteworthy              literature as having positive outcome results (for example, the Adolescent
                        Alcohol Prevention Trial, Life Skills Training, the Midwestern Prevention
                        Project, and the Seattle Social Development Project). The agencies
                        recognized these programs because they have either demonstrated
                        decreases in drug use and the risk factors that lead to drug use or they
                        have shown an increase in the protective factors promoting drug-free
                        lifestyles. In addition to the programs we cite in table II.2, numerous other
                        programs (such as Project PRIDE, GAPS, and the Youth Gang Drug
                        Prevention Program) have been cited as effective or exemplary in
                        reducing risks for drug use among adolescents. However, according to
                        NIDA, some of these science-based drug abuse prevention interventions and
                        principles are not being widely used in schools and communities across
                        the country.


                        Drug treatment strategies have a common goal of eliminating, or at least
The Types of            reducing, an individual’s drug abuse. The strategies in use incorporate
Approaches Currently    various approaches and modalities as a means of treating drug abusers or
Being Used to Treat     drug-dependent individuals. Although different approaches have been
                        used, IOM has adopted a paradigm that distinguishes drug abuse treatment
Cocaine Addiction

                        50
                         Adolescent Drug Use Prevention: Common Features of Promising Community Programs
                        (GAO/PEMD-92-2, Jan. 16, 1992).
                        51
                         CSAP is currently conducting a national evaluation of the Community Partnership Demonstration
                        Program the agency supports. According to CSAP, national results of this effort should be available in
                        1998.



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                             approaches as falling under the rubric of pharmacotherapy or
                             psychosocial treatment.

                             Pharmacotherapies involve the use of medications to deal with client
                             overdose, detoxification, dependence, and relapse prevention. Methadone,
                             for example, is the prime pharmacotherapy determined to be useful in the
                             treatment of heroin. However, none of the major medications tested have
                             proven effective consistently in the treatment of cocaine.

                             Psychosocial treatment includes counseling, different forms of
                             psychotherapy, cognitive skill development, and contingency
                             management. Counseling is oriented toward the effective management of
                             specific, concrete problems, while psychotherapy attempts to help a client
                             deal with more dysfunctional cognitive and behavioral processes. The use
                             of acupuncture represents a new strategy in the treatment of drug
                             addiction.

                             Research suggests that psychosocial treatment offers a promising
                             approach to treating cocaine abuse and dependency. Within the
                             psychosocial treatment rubric, cognitive and behavioral therapies are
                             showing promise in cocaine treatment research. As we reported in
                             June 1996, data from a review of the literature show positive results in the
                             use of three cognitive and behavioral approaches to cocaine treatment.52
                             Because cocaine therapies are still in their early stages of development,
                             treatment outcome results cannot be generalized to all cocaine users.


Three Cognitive-Behavioral   Early research indicates that relapse prevention, community
Treatments Show Promise      reinforcement and contingency management, and neurobehavioral therapy
in Outpatient Settings       are potentially promising cocaine-addiction treatment approaches for
                             cocaine abusers and cocaine-dependent clients. These approaches appear
                             to promote extended periods of client abstinence and treatment retention
                             in outpatient treatment settings. Table II.3 provides an overview of
                             cognitive and behavioral study methodologies and results.




                             52
                               Cocaine Treatment: Early Results From Various Approaches (GAO/HEHS-96-80, June 7, 1996).



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Table II.3: Methodology and Results of
Illustrative Cognitive-Behavioral        Study group (publication date)         Study period                             S
Studies                                  Relapse prevention
                                         1. Carroll and others (1994)a          12 weeks                                 R




                                         2. Carroll and others (1991)b          12 weeks                                 R




                                         3. Washton and Stone-Washton (1993)c   About 28 weeks                           C
                                                                                                                         a




                                         4. Wells and others (1994)d            24 weeks                                 A
                                                                                                                         a




                                         Community reinforcement and contingency management
                                         5. Higgins and others (1991)e          12 weeks                                 C
                                                                                                                         a




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                                            Drug Abuse Prevention and Treatment




Sample design (size)   Client diagnosis/demographics              Treatment outcome                         Investigator affiliation


Random (n = 121)       Clients met criteria for cocaine           Cocaine-abstinent at least 70% of the     Yale University,
                       dependence                                 time in treatment                         New Haven, Connecticut

                       average age: 29
                       male: 79%
                       white: about 50%
                       unemployed: about 40%
                       single/divorced: about 70%
                       at least high school graduate: about 80%
Random (n = 42)        Clients met criteria for both cocaine      54% of high-severity cocaine users        Yale University,
                       abuse and dependence                       were able to attain at least 3 weeks of   New Haven, Connecticut
                                                                  continuous abstinence; only 9% of
                       average age: 27                            high-severity cocaine users receiving
                       male: 67%                                  standard psychotherapy could achieve
                       white: 67%                                 this
                       average years of education: 13




Consecutive            Clients met criteria for severe            More than 60% abstinent from cocaine      Washton Institute,
admissions (n = 60)    psychoactive drug dependence (85%          during 6-to- 24-month follow-up period    New York, New York
                       were cocaine addicts)

                       average age: about 35
                       male: about 80%
                       white: about 70%
                       employed: about 90%
Alternative            Cocaine was primary drug of choice         Average number of days of cocaine use University of
assignment (n = 110)                                              cut by 71% within 6 months            Washington, Seattle,
                       average age: 29                                                                  Washington
                       male: 64%
                       white: 84%
                       employed full time for past 3 years: 68%
                       average years of education: 13


Consecutive            Clients met criteria for cocaine           46% were continuously abstinent from      University of Vermont,
admissions (n = 25)    dependence                                 cocaine for 8 treatment weeks             Burlington, Vermont

                       average age: 29
                       education ≥12 years: 46% employed:
                       62%
                       single: 54%
                                                                                                                          (continued)




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Study group (publication date)          Study period                             S
6. Higgins and others (1993)f           24 weeks                                 R




Contingency management only
7. Silverman and others (1994, 1995)g   12 weeks                                 F
                                                                                 o
                                                                                 u
                                                                                 w
                                                                                 t




Neurobehavioral therapy
8. Shoptaw and others (1994)h           12 months                                R




9. Rawson and others (1993)i            6 months                                 O




10. Rosenblum and others (1994)j        6 months                                 R




11. Magura and others (1994)k           6 months                                 R
                                                                                 (




Page 46                                                GAO/GGD-97-42 Drug Control
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Sample design (size)     Client diagnosis/demographics                 Treatment outcome                           Investigator affiliation
Random (n = 38)          Clients met criteria for cocaine              42% were continuously abstinent from        University of Vermont,
                         dependence                                    cocaine for 16 treatment weeks              Burlington, Vermont

                         average age: 29
                         male: 89%
                         white: 100%
                         unmarried: 89%
                         completed high school: 63%
                         employed: 42%


Frequency                Clients met criteria for heroin and           Nearly 50% of the clients receiving         Johns Hopkins University,
of cocaine- positive     cocaine dependence                            vouchers for cocaine-free urine             Baltimore, Maryland
urine during initial 5                                                 remained continuously abstinent from
weeks of methadone       average age: 36                               cocaine for 7 to 12 weeks
therapy (n = 37)         black: 26%
                         married: 16%
                         completed at least high school: 74%
                         employed full time: 47%



Random (n = 146)         Clients met criteria for stimulant abuse or   36% remained continuously abstinent         Matrix Institute,
                         dependence                                    from cocaine for at least 8 treatment       Los Angeles, California
                                                                       weeks; 38% were abstinent from
                         average age: 31                               cocaine at 6-month follow-up
                         male: 84%
                         white: 63%
                         Hispanic: 25%
                         average years of education: 13
                         unmarried: 78%
Open trial (n = 486)     Cocaine-using clients                         At least 40% at two treatment sites         Matrix Institute,
                                                                       remained continuously abstinent from        Los Angeles, California
                         average age: 30                               cocaine through 6 months of treatment
                         male: 74%
                         white: 76%
                         average years of education: 14
                         single: 54%
Random (n = 77)          Methadone clients who met criteria for        Clients attending 3 to 19 sessions          National Development
                         cocaine dependence                            reduced past-month cocaine use by           and Research Institutes,
                                                                       5%; those attending 85 to 133 sessions      Inc.,
                         age 24 to 43: 87%                             reduced past-month cocaine use by           New York, New York
                         Hispanic: 64%                                 60%
                         black: 31%
                         unemployed: 77%
                         married/common law: 38%
                         completed at least high school: 42%
                                               a
                                                 The source for Carroll and others is Kathleen Carroll et al., “Psychotherapy and
                                               Pharmacotherapy for Ambulatory Cocaine Abusers,” Archives of General Psychiatry, 51 (1994),
                                               177-87.




                                               Page 47                                                          GAO/GGD-97-42 Drug Control
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                     b
                      The source for Carroll and others is Kathleen Carroll et al., “A Comparative Trial of
                     Psychotherapies for Ambulatory Cocaine Abusers: Relapse Prevention and Interpersonal
                     Psychotherapy,” American Journal of Drug and Alcohol Abuse, 17:3 (1991), 229-47.
                     c
                       The source for Washton and Stone-Washton is Arnold Washton and Nannette Stone-Washton,
                     “Outpatient Treatment of Cocaine and Crack Addiction: A Clinical Perspective,” National Institute
                     on Drug Abuse Research Monograph #135 (Rockville, Md.: National Institute on Drug Abuse,
                     1993), pp. 15-30.
                     d
                      The source for Wells and others is Elizabeth Wells et al., “Outpatient Treatment for Cocaine
                     Abuse: A Controlled Comparison of Relapse Prevention and Twelve-Step Approaches,” American
                     Journal of Drug and Alcohol Abuse, 20:1 (1994), 1-17.
                     e
                       The source for Higgins and others is Stephen Higgins et al., “A Behavioral Approach to
                     Achieving Initial Cocaine Abstinence,” American Journal of Psychiatry, 148:9 (1991), 1218-24. To
                     test the accuracy of self-reported client data, researchers at the University of Vermont compared
                     self-reports to urine test results. In 98 percent of the cases in which a client indicated nonuse,
                     urinalysis data confirmed the report.
                     f
                      The source for Higgins and others is Stephen Higgins et al., “Achieving Cocaine Abstinence With
                     a Behavioral Approach,” American Journal of Psychiatry, 150:5 (1993), 763-69.
                     g
                      The sources for Silverman and others are K. Silverman et al., “Differential Reinforcement of
                     Sustained Cocaine Abstinence in Intravenous Polydrug Abusers,” in L. S. Harris (ed.), Problems
                     of Drug Dependence 1994: Proceedings of the 56th Annual Scientific Meeting, The College on
                     Problems of Drug Dependence. National Institute on Drug Abuse Research Monograph 153
                     (Rockville, Md.: National Institute on Drug Abuse Research, 1995), p. 212, and K. Silverman et al.,
                     “Voucher-Based Reinforcement of Cocaine Abstinence: Effects of Reinforcement Schedule,” in
                     L. S. Harris (ed.), Problems of Drug Dependence 1995: Proceedings of the 57th Annual Scientific
                     Meeting, The College on Problems of Drug Dependence. National Institute on Drug Abuse
                     Research Monograph, in press. Also cited in NIDA Notes, 10:5 (September-October 1995), 10
                     and 14.
                     h
                       The source for Shoptaw and others is Steven Shoptaw et al., “The Matrix Model of Outpatient
                     Stimulant Abuse Treatment: Evidence of Efficacy,” Journal of Addictive Diseases, 13:4 (1994),
                     129-41.
                     i
                     The source for Rawson and others is Richard Rawson et al., “Neurobehavioral Treatment for
                     Cocaine Dependency: A Preliminary Evaluation,” Cocaine Treatment: Research and Clinical
                     Perspectives. National Institute on Drug Abuse Research Monograph #135 (Rockville, Md.:
                     National Institute on Drug Abuse, 1993), pp. 92-115.
                     j
                     The source for Rosenblum and others is Andrew Rosenblum et al., “Treatment Intensity and
                     Reduction in Drug Use for Cocaine-Dependent Methadone Patients: A Dose Response
                     Relationship.” A prior version of this paper was presented at the American Society of Addiction
                     Medicine Annual Conference, New York, N.Y., April 1994.
                     k
                      The source for Magura and others is Stephen Magura et al., “Neurobehavioral Treatment for
                     Cocaine-Using Methadone Patients: A Preliminary Report,” Journal of Addictive Diseases, 13:4
                     (1994), 143-60.




Relapse Prevention   Relapse prevention provides users with the ability to recognize triggering
                     events, places, people, and situations, and it develops alternative coping
                     strategies that help the user resist those specific triggers. Clients who
                     received relapse prevention treatment have demonstrated favorable
                     abstinence rates not only during the period of treatment but also during



                     Page 48                                                              GAO/GGD-97-42 Drug Control
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                          Drug Abuse Prevention and Treatment




                          follow-up periods as well. Client retention results also appear to be
                          favorable. For example, cocaine-dependent clients participating in a
                          12-week Yale University program53 focusing on relapse prevention were
                          able to remain abstinent from cocaine at least 70 percent of the time while
                          in treatment. A year after treatment, gains were still evident: clients
                          receiving relapse prevention treatment and a placebo medication were
                          reported to have used cocaine, on average, fewer than 3 days in the past
                          month.

                          Positive outcome results were also found in a program conducted by the
                          Washton Institute in New York:54 more than 60 percent of the primarily
                          middle-class, cocaine-addicted clients attending the program were
                          abstinent from cocaine during the 6- to 24-month follow-up period.
                          Similarly, in the Seattle area,55 cocaine-using clients cut their average
                          number of days of cocaine use by 71 percent within 6 months.

                          Among high-severity cocaine addicts participating in another Yale
                          program,56 54 percent receiving relapse prevention therapy were able to
                          attain at least 3 weeks of continuous abstinence, while only 9 percent of
                          those receiving the interpersonal psychotherapy could remain abstinent
                          for that period of time.

                          Retention rates of clients in programs were also favorable: 67 percent of
                          the relapse prevention clients completed the entire 12-week Yale program,
                          and more than 70 percent completed the Washton program.


Community Reinforcement   Community reinforcement and contingency management programs are
and Contingency           intended to help the client achieve initial abstinence as well as an
Management                extended drug-free lifestyle. The therapy consists of several key
                          community-oriented components, including the participation of a client’s
                          family member or friend in the treatment process; management incentives

                          53
                           Kathleen Carroll et al., “Psychotherapy and Pharmacotherapy for Ambulatory Cocaine Abusers,”
                          Archives of General Psychiatry, 51 (1994), 177-87.
                          54
                           Arnold Washton and Nannette Stone-Washton, “Outpatient Treatment of Cocaine and Crack
                          Addiction: A Clinical Perspective,” National Institute on Drug Abuse Research Monograph #135
                          (Rockville, Md.: National Institute on Drug Abuse, 1993), pp. 15-30.
                          55
                            Elizabeth Wells et al., “Outpatient Treatment for Cocaine Abuse: A Controlled Comparison of Relapse
                          Prevention and Twelve-Step Approaches,” American Journal of Drug and Alcohol Abuse, 20:1 (1994),
                          1-17.
                          56
                           Kathleen Carroll et al., “A Comparative Trial of Psychotherapies for Ambulatory Cocaine Abusers:
                          Relapse Prevention and Interpersonal Psychotherapy,” American Journal of Drug and Alcohol Abuse,
                          17:3 (1991), 229-47.



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or rewards for drug abstinence; employment counseling when needed; and
the encouragement of client participation in recreational activities as
pleasurable, healthy alternatives to drug use. Community reinforcement
and contingency management therapy teaches clients about the
consequences of their actions and aims to strengthen family and social
ties.

Almost half (46 percent) of the cocaine-dependent clients participating in
a 12-week community reinforcement and contingency management
program at the University of Vermont57 were able to remain continuously
abstinent from cocaine through 2 months of treatment. When the program
was extended to 24 weeks,58 42 percent of the participating
cocaine-dependent subjects were able to achieve 4 months of continuous
abstinence. By comparison, only 5 percent of those in the control group
receiving drug abuse counseling alone could remain continuously
abstinent for the entire 4 months.

A year after clients began treatment, community reinforcement and
contingency management effects were still evident—65 to 74 percent of
those in the community reinforcement group reported 2 or fewer days of
cocaine use in the past month. Only 45 percent of those in the control
group achieved such gains.

Contingency management was also studied independently in an inner-city
Baltimore program.59 Positive results were found when tying the 12-week
voucher reward system to cocaine drug testing. Nearly half of the
cocaine-abusing and cocaine-dependent clients (who were also heroin
users) given vouchers for cocaine-free urine test results were able to
remain continuously abstinent for 7 to 12 weeks. Among clients receiving
vouchers unpredictably—not tied to urine test results—only one client
achieved abstinence for more than 2 weeks.

57
 Stephen Higgins et al., “A Behavioral Approach to Achieving Initial Cocaine Abstinence,” American
Journal of Psychiatry, 148:9 (1991), 1218-24.
58
 Stephen Higgins et al., “Achieving Cocaine Abstinence With a Behavioral Approach,” American
Journal of Psychiatry, 150:5 (1993), 763-69.
59
 K. Silverman et al., “Differential Reinforcement of Sustained Cocaine Abstinence in Intravenous
Polydrug Abusers,” in L. S. Harris (ed.), Problems of Drug Dependence 1994: Proceedings of the 56th
Annual Scientific Meeting, The College on Problems of Drug Dependence. National Institute on Drug
Abuse Research Monograph 153 (Rockville, Md.: National Institute on Drug Abuse Research, 1995), p.
212, and K. Silverman et al., “Voucher-Based Reinforcement of Cocaine Abstinence: Effects of
Reinforcement Schedule,” in L. S. Harris (ed.), Problems of Drug Dependence 1995: Proceedings of the
57th Annual Scientific Meeting, The College on Problems of Drug Dependence. National Institute on
Drug Abuse Research Monograph, in press. Also cited in NIDA Notes, 10:5 (September-October 1995),
10 and 14.



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                          Client retention in treatment programs was also high. Within the Vermont
                          community reinforcement and contingency management group, 85 percent
                          of the clients completed the 12-week program, compared with only
                          42 percent of those in the 12-step drug counseling control group. The
                          24-week program was completed by about five times as many clients in the
                          community reinforcement group as those receiving drug counseling
                          therapy (58 percent versus 11 percent).


Neurobehavioral Therapy   Neurobehavioral therapy is a comprehensive, 12-month outpatient
                          treatment approach that includes individual therapy, drug education,
                          client stabilization, and self-help group involvement. Five major stages of
                          recovery are distinguished during the treatment process with emphasis on
                          addressing the client’s behavioral, emotional, cognitive, and relational
                          problems at each stage of recovery.

                          Several programs have demonstrated that a neurobehavioral therapeutic
                          approach can also be effective in promoting cocaine abstinence and
                          treatment retention. Thirty-six percent of the cocaine-abusing and
                          cocaine-dependent clients participating in a neurobehavioral therapy
                          program through the Matrix Institute in California60 succeeded in
                          remaining continuously abstinent from cocaine for at least 8 consecutive
                          weeks while in treatment. Follow-up results obtained 6 months after
                          treatment entry showed that 38 percent of these clients still tested drug
                          free. In a separate examination of two neurobehavioral outpatient
                          treatment sites,61 at least 40 percent of the cocaine clients in each site
                          remained continuously abstinent through the entire 6-month course of
                          therapy.

                          Given the high rate of cocaine use among methadone clients, the
                          neurobehavioral model was adapted in New York for use among
                          methadone clients meeting the diagnostic criteria for cocaine dependence.
                          In an intensive 6-month program,62 a strong relationship was found
                          between the number of sessions attended and cocaine use reduction.
                          Clients attending 3 to 19 sessions experienced a 5-percent reduction in

                          60
                           Steven Shoptaw et al., “The Matrix Model of Outpatient Stimulant Abuse Treatment: Evidence of
                          Efficacy,” Journal of Addictive Diseases, 13:4 (1994), 129-41.
                          61
                           Richard Rawson et al., “Neurobehavioral Treatment for Cocaine Dependency: A Preliminary
                          Evaluation,” Cocaine Treatment: Research and Clinical Perspectives. National Institute on Drug Abuse
                          Research Monograph #135 (Rockville, Md.: National Institute on Drug Abuse, 1993), pp. 92-115.
                          62
                            Andrew Rosenblum et al., “Treatment Intensity and Reduction in Drug Use for Cocaine-Dependent
                          Methadone Patients: A Dose Response Relationship.” A prior version of this paper was presented at
                          the American Society of Addiction Medicine Annual Conference, New York, New York, April 1994.



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                         cocaine use during the previous month. Those attending 85 to 133 sessions
                         experienced a 60-percent reduction in their past 30-day use of cocaine. In
                         another New York study63 with cocaine-addicted methadone clients,
                         individuals receiving neurobehavioral treatment demonstrated a
                         significant decrease in cocaine use between entering treatment and
                         6-month follow-up; the control group showed no statistically significant
                         decrease.

                         Neurobehavioral retention rates also proved favorable. In the California
                         study of two treatment sites, clients were retained an average of about 5
                         months and 3 months; in the other California study, the average length of
                         stay for cocaine users was about 4-1/2 months. For the first New York
                         study, a total of 61 percent of the cocaine-dependent methadone clients
                         completed the initial 6-month cocaine treatment regimen.


                         In our literature search, we found that early research has demonstrated
Additional Research      that psychosocial and comprehensive approaches to drug prevention have
Initiatives Identified   led to decreased use of drugs among school-age youths as well as
for Prevention and       reductions in risk factors and the enhancement of protective factors.
                         Relapse prevention, community reinforcement and contingency
Treatment                management, and neurobehavioral therapy have resulted in increased
Effectiveness            abstinence and extended periods of treatment retention among
                         cocaine-abusing and dependent clients. Although these research results in
                         the 1990s demonstrate promising approaches to drug prevention for
                         school-age youths and treatment for cocaine abuse and dependence, some
                         of these strategies have not been tried, tested, and evaluated in different
                         settings, for different target populations, in various combinations, and
                         over long periods of time. Therefore, there is still a wide array of research
                         initiatives that can be pursued to better understand what promise these
                         approaches hold for effectively preventing, reducing, or treating drug
                         problems. Some of the prevention initiatives suggested by IOM and cocaine
                         treatment initiatives recommended by cocaine abuse experts follow.
                         Additional treatment initiatives can be found in our 1996 cocaine
                         treatment report.64


Prevention               Testing the utility of booster sessions. Prevention training programs
                         frequently take place over the course of only one or two grades (for

                         63
                          Stephen Magura et al., “Neurobehavioral Treatment for Cocaine-Using Methadone Patients: A
                         Preliminary Report,” Journal of Addictive Diseases, 13:4 (1994), 143-60.
                         64
                           Cocaine Treatment: Early Results From Various Approaches (GAO/HEHS-96-80, June 7, 1996).



                         Page 52                                                           GAO/GGD-97-42 Drug Control
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            example, Project ALERT takes place in the 7th and 8th grades). While we
            have seen that immediate, or short-term, outcome results can be quite
            promising, positive successes can begin to fade as other negative stimuli
            and pressures confront the individual. Booster sessions have been shown
            in limited trials to reinforce initial training sessions and help maintain
            positive outcome findings. However, because boosters are infrequently
            used, there is limited supporting evidence on the appropriate content of
            booster sessions for different age groups. Such knowledge is important for
            maintaining positive prevention and treatment outcome gains over time.

            Determining the mix of program components that yield the most
            significant outcome results. Outcome results of various promising
            practices have shown that sizable percentages of the intervention group
            had not become drug users at the time of the follow-up. Whether these
            results can be substantially improved with a different mix of prevention
            approaches and program components remains to be demonstrated.

            Evaluating how best to disseminate positive findings to the larger
            community. In many instances, the promising practice prevention
            programs supported by the federal government are not being adopted at
            the local level. Further research is, therefore, necessary to determine how
            best to market the more effective prevention programs to the user
            community.

            Assessing the types of program approaches that work best for different
            target populations, in diverse environmental settings, with varying
            trainers. Many prevention programs have been evaluated only with
            restricted target audiences (for example, 7th graders in a limited
            geographic area) by the principal investigator and staff. The extent to
            which one can generalize from these prevention approaches remains to be
            determined. Also, further research directed at how these programs can be
            modified for various target groups, while maintaining the essential
            components of the intervention program, is needed. In addition, the effect
            that trainers other than the principal investigator will have on the outcome
            results will broaden the knowledge base of the widespread applicability of
            these approaches.


Treatment   Identifying improved additional cognitive/behavioral strategies to reduce
            relapse. Additional study of the promising treatment approaches is
            warranted to (1) identify optimal sanction systems to be used in
            contingency management practices, (2) obtain a more in-depth



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understanding of the triggers that promote drug use, and (3) identify the
appropriate intensities and durations of treatment necessary for the
successful implementation of each of the promising practices. The results
of this research could lead to increasing a client’s ability to avoid relapse
and, thereby, minimize substance abuse third-party payments.

Testing the effectiveness and safety of new medications to prevent or
reduce drug intake. Advancement in the pharmacological area rests on a
better understanding of brain functioning, the immune system, and actions
of the specific illicit drugs. This requires further development and testing
of medications to (1) block a drug’s toxicity and aid in the withdrawal
process, (2) reduce craving for the drug, and (3) inhibit the euphoric
“high” induced by the drug. With the craving reduced and the euphoric
high diminished, it follows that the use of the drug will decline.

Identifying the necessary components of promising cognitive/behavioral
strategies and medications that lead to successful outcomes. This is of
particular importance when disseminating these model cocaine treatment
practices to the local practitioner. The practitioner may have little time to
be trained, may need to streamline use of the approach down to its bare
essentials to fit in with other schedule requirements, and may need to
know where local adaptations can be incorporated.

Substantiating outcome results through further research and evaluation is
an important step in advancing promising drug prevention and treatment
approaches. It is also important in helping policymakers to better focus
efforts and resources on proven effective drug abuse prevention and
treatment programs. In light of federal efforts to establish national goals in
an overall drug strategy and to assess results through program
performance measures and evaluation, definitive research can be an
important prerequisite to focusing and maximizing the use of federal
resources.




Page 54                                              GAO/GGD-97-42 Drug Control
Appendix III

Coast Guard Has Made Progress, but
Challenges Remain in Developing Antidrug
Strategic and Performance Plans
                   A component of the Department of Transportation, the Coast Guard is the
                   federal agency primarily responsible for providing many maritime services
                   and enforcing related laws and regulations. Its staff and equipment are
                   involved in multimissions that range from national security to
                   environmental protection. For fiscal year 1997, the Coast Guard’s budget is
                   about $3.84 billion.

                   The Coast Guard is the lead federal agency for maritime drug interdiction.
                   It shares lead responsibility with the U.S. Customs Service for air
                   interdiction. The Coast Guard’s antidrug authority covers domestic waters
                   (12 miles from U.S. shores), including navigable waters of the United
                   States and international waters. Where bilateral agreements permit, the
                   Coast Guard has special jurisdiction in foreign waters. For fiscal year 1997,
                   the Coast Guard estimated that its budget for antidrug activities is about
                   $336 million.

                   The Coast Guard has made progress in developing antidrug performance
                   measures that conform with GPRA requirements; however, challenges
                   remain. Government Performance and Results Act (GPRA) requires federal
                   agencies65 to develop two types of plans—a strategic plan66 by the end of
                   fiscal year 1997 and annual performance plans,67 the first of which is to
                   cover fiscal year 1999. The Coast Guard’s preliminary plans represent a
                   start at incorporating a results-oriented approach to drug interdiction, but
                   as could be expected at this early date, they also reflect a need for
                   additional work. The Coast Guard has recognized three areas that require
                   more attention:

               •   developing data to measure the results of antidrug actions,
               •   developing goals and ways of achieving them, and




                   65
                     Under GPRA, “agency” is defined as an executive department, a government corporation, and an
                   independent establishment. The Coast Guard is implementing GPRA in support of the Department of
                   Transportation.
                   66
                     Under GPRA, a strategic plan is the starting point for agencies to set annual goals for programs and
                   to measure the performance of the programs in achieving those goals. GPRA requires each federal
                   agency to develop strategic plans that cover a period of at least 5 years and include the agency’s
                   missions statement; identify the agency’s long-term strategic goals; and describe how the agency
                   intends to achieve those goals through its activities and though its human, capital, information, and
                   other resources.
                   67
                    The annual performance plan provides the direct linkage between the strategic goals outlined in the
                   agency’s strategic plan and what managers and employees do day-to-day. The plan is to contain the
                   performance goals the agency will use to gauge its progress toward accomplishing its strategic goals
                   and identify the performance measures the agency will use to assess its progress.



                   Page 55                                                                GAO/GGD-97-42 Drug Control
                           Appendix III
                           Coast Guard Has Made Progress, but
                           Challenges Remain in Developing Antidrug
                           Strategic and Performance Plans




                       •   identifying the wide variety of constraints that could influence the Coast
                           Guard’s ability to deter the flow of drugs into the United States via
                           maritime routes.


                           The Coast Guard has taken action toward implementing the principles of
Coast Guard Has            GPRA for its antidrug activities. Under GPRA, the Coast Guard has defined its
Made Progress              results-oriented performance goal as “reducing the amount of illegal drugs
Toward Implementing        entering the country through maritime routes by 25 percent over five
                           years.” The primary indicator it plans to use in measuring progress toward
GPRA Principles            achieving this goal is data comparing the amount of drugs seized and
                           deterred with the amount bound for the United States via maritime routes.
                           The Coast Guard also plans to use a variety of secondary indicators, such
                           as surveillance coverage and intercept rates.68

                           The preliminary goal and indicators show progress in conforming with
                           certain GPRA principles in that the goal covers a period of 5 years, is results
                           oriented, and is potentially measurable. However, as the next sections
                           discuss, Coast Guard efforts at conforming with the full extent of GPRA is a
                           work in progress.


                           GPRA  requires agencies to measure the results of their programs. Measuring
Measuring Results of       the results of drug-control actions is difficult because data on illegal drugs
Drug Interdiction          entering the country are more difficult to develop than data on most legal
Presents Challenges        commodities. Without knowing how much was shipped or what got
                           through, the amount of contraband seized does not yield a meaningful
                           measure of effectiveness. The ONDCP-sponsored Semiannual Interagency
                           Assessment of Cocaine Movement has made some progress in developing
                           estimates on the amount of cocaine entering the United States via surface,
                           air, and maritime routes. The Coast Guard is using these data as a primary
                           indicator of its antidrug activities. If reasonably accurate, these data could
                           aid the Coast Guard in measuring the results of its cocaine interdiction
                           program. According to an ONDCP official, ONDCP is working with the
                           intelligence components of federal agencies involved in foreign and
                           domestic drug control programs to develop a comprehensive baseline on
                           heroin production and trafficking. Developing a heroin flow model will be
                           part of this project.

                           68
                             The Coast Guard defines “surveillance coverage” as the area covered divided by the area assigned per
                           24-hour period. It defines “intercept” as directing the movement of a Coast Guard asset to the scene of
                           an identified target to support the collection of additional information and to take further action, if
                           appropriate. The “interception rate” is defined as the number of intercepts divided by the number of
                           intercepts attempted.



                           Page 56                                                               GAO/GGD-97-42 Drug Control
                        Appendix III
                        Coast Guard Has Made Progress, but
                        Challenges Remain in Developing Antidrug
                        Strategic and Performance Plans




                        A second factor that makes the measurement of results difficult is that of
                        separating the impact of the Coast Guard’s actions from those of other
                        agencies. For example, a decrease in the amount of drugs entering the
                        United States via maritime routes could be the result of greater efforts by
                        other federal agencies to control drugs in the source country, lower
                        domestic demand due to demand-reduction efforts, or better intelligence
                        rather than Coast Guard interdiction efforts. In this regard, Coast Guard
                        officials recognize that measures showing the overall result of the U.S.
                        drug control effort are needed. For example, they stated that placing
                        additional resources in key choke points could result in reduced
                        smuggling activity in one area; however, smugglers may still ship drugs to
                        the United States through other transportation means or routes. Thus,
                        while the actions of one agency may result in success in its area of
                        responsibility, only interagency measures of effectiveness and the
                        attendant data would provide a basis to gauge the success of the total U.S.
                        effort.


Coast Guard Officials   Coast Guard officials acknowledge that complying with the GPRA
Acknowledge That        requirements to develop results-oriented performance goals and to
Developing Goals and    identify methods of achieving them is a work-in-progress. Coast Guard
                        officials indicated that the extent to which they reduce illegal drugs
Methods for Achieving   entering the United States via maritime routes over the next 5 years is
Them Still Need to Be   largely dependent on additional resources. Coast Guard officials expect
Refined                 that additional resources and assets will deter smugglers from using a
                        particular route, cause them to stop smuggling entirely, or result in
                        interdiction of about 90 percent of all maritime smuggling traffic in
                        high-risk areas (if the Coast Guard has a “contact rate” of 40 percent with
                        the smuggling community).69 The officials base this expectation on a 1989
                        study that collected opinions from convicted smugglers on their view of
                        the risk level that would stop them from smuggling drugs.70 Coast Guard
                        officials believe that a greater presence and interdiction actions in targeted
                        areas will result in smugglers’ perception that the chances of being caught
                        are high, contributing to the deterrence or interdiction of about 90 percent
                        of smuggling traffic in target areas.


                        69
                          According to Coast Guard officials, they have not developed an estimate of the amount of additional
                        resources needed to achieve a 40-percent “contact rate”; however, they plan to determine this amount
                        in the future. The Coast Guard defines “contact rate” as the frequency with which Coast Guard assets
                        make contact with maritime traffic in targeted areas, including interdiction and boarding known or
                        suspected smugglers. According to the Coast Guard, it currently has a contact rate of 12 percent,
                        which results in deterrence or interdiction of 29 percent of smugglers using maritime routes.
                        70
                          Measuring Deterrence - Approach and Methodology, Rockwell International Special Investigations,
                        Inc., Decisions Science Applications, Sumner Associates, Oct. 27, 1989.



                        Page 57                                                              GAO/GGD-97-42 Drug Control
Appendix III
Coast Guard Has Made Progress, but
Challenges Remain in Developing Antidrug
Strategic and Performance Plans




Information from another study suggests that more resources make a
difference in reducing the supply of illegal drugs coming into the United
States, but the difference may not be significant. A recent study conducted
for ONDCP examined the impact of more resources in disrupting the flow of
drugs in the transit zone.71 The study estimated that smugglers
successfully moved about 560 tons of cocaine in the transit zone in 1994,
and it evaluated the potential impact of committing an additional
$200 million and $500 million to the transit zone. It projected that
smugglers would successfully move 470 metric tons (11-percent reduction)
in the transit zone under the $200 million option and that they would
successfully move 430 metric tons (16-percent reduction) under the
$500 million option. According to the study, “given that annual U.S.
cocaine consumption is less than 300 tons, the impact of the additional
resources in the transit zone does not seem significant enough to affect
U.S. drug use.”

On the basis of this analysis, the study concluded that “[i]t does not appear
that the potential benefit of decreased trafficker smuggling success rate in
the transit zone is significant enough to warrant additional resources.” The
study noted that the federal policy challenge is not only to determine the
benefits from direct investment in the transit zone but also to consider
whether the investment of a similar level of resources elsewhere in the
drug strategy might produce even more benefits.72 The study, however,
contained several methodological limitations, including a low level of
confidence in its predictions and a limited scope, such as not analyzing the
potential benefits of investing resources in the source countries.

Coast Guard officials generally agreed with the analysis in the study but
disagreed with the conclusions. Officials agreed that the amount of
cocaine deterred in the transit zone would total about 90 metric tons, or an
11-percent reduction, if an additional $200 million were to be committed to
the transit zone. Unlike the study, Coast Guard officials believe that this
level of reduction would be a good return on the investment. Officials
pointed out that at the time of the study, the additional resources



71
 The National Drug Control Strategy, 1996: Program, Resources, and Evaluation. Office of National
Drug Control Policy, Washington, D.C., pp. 48-51.
72
 The study suggested the following order of priority if funding is increased: (1) increase intelligence,
which because of its relative low cost has the greatest leverage and is critical for responding to the
maritime threat; (2) improve disruption capability because, without it, law enforcement would be
unable to respond to the targets identified by increased and improved intelligence; and (3) increase
detection and monitoring to fill geographic gaps and ensure an ability to link intelligence and
disruption capability.



Page 58                                                                 GAO/GGD-97-42 Drug Control
                                 Appendix III
                                 Coast Guard Has Made Progress, but
                                 Challenges Remain in Developing Antidrug
                                 Strategic and Performance Plans




                                 ($200 million) needed for this level of reduction was only about
                                 1.6 percent of the total federal antidrug budget.


Coast Guard Officials            GPRA  requires an identification of key factors external to the agency and
Identify Constraints Other       beyond its control that could significantly affect the achievement of its
Than Funding That Affect         goals and objectives. In developing its preliminary plans, the Coast Guard
                                 has identified the level of resources as a primary factor that influences its
Their Antidrug Efforts           ability to achieve the goal that it ultimately establishes. However,
                                 identifying and interdicting maritime drug smuggling is affected by other
                                 constraints as well. Following are several constraints that the Coast Guard
                                 says also affect its antidrug efforts:

                             •   Covering large geographic areas is problematic. When smugglers use
                                 maritime routes, they may not ship the drugs directly to the United States,
                                 but instead they may ship the drugs to Mexico or Central American
                                 countries and then to the United States via land or air routes. An estimated
                                 180 metric tons of cocaine are transported annually from Colombia to
                                 Mexico or other Central American countries via maritime routes in the
                                 eastern Pacific Ocean, according to the ONDCP-sponsored Semiannual
                                 Interagency Assessment of Cocaine Movement. Coast Guard officials
                                 stated that this is an area of concern because success in deterring drugs in
                                 the Caribbean could result in more smuggling activity in the Pacific. Coast
                                 Guard officials noted that unlike the Caribbean, where specific routes and
                                 choke points have been identified, interdiction and deterrence in the
                                 eastern Pacific presents greater challenges because of the size of the area.
                             •   Sovereignty constraints. Coast Guard officials cited sovereignty issues
                                 with foreign-flag vessels as another factor that complicates their antidrug
                                 efforts. Coast Guard officials stated that bilateral maritime
                                 counternarcotic agreements are being sought with countries such as
                                 Colombia, Jamaica, Mexico, Barbados, and Nicaragua.73 According to
                                 Coast Guard officials, these agreements provide them with greater
                                 flexibility to carry out their antidrug activities. Such agreements outline
                                 the criteria for boarding and pursuing foreign-flag vessels. Also, they may
                                 authorize the Coast Guard to fly over foreign airspace, to order suspect
                                 aircraft to land in the host nation, to investigate suspect vessels in foreign
                                 waters, or authorize the Coast Guard to conduct other law enforcement
                                 activities, such as boardings, in foreign waters.


                                 73
                                  By December 1996, antidrug bilateral agreements had been signed with 16 countries: Antigua and
                                 Barbuda, Bahamas, Belize, Dominica, Dominican Republic, Grenada, Haiti, Netherlands Antilles,
                                 Panama, St. Kitts and Nevis, St. Lucia, St. Vincent/Grenadines, Trinidad and Tobago, Turks and Caicos,
                                 United Kingdom, and Venezuela.



                                 Page 59                                                              GAO/GGD-97-42 Drug Control
    Appendix III
    Coast Guard Has Made Progress, but
    Challenges Remain in Developing Antidrug
    Strategic and Performance Plans




•   Increasing use of technology by smugglers. Coast Guard officials also
    noted that smugglers are using more sophisticated means to conceal and
    transport drugs, such as the use of global positioning systems and
    camouflaged vessels to avoid detection. According to Coast Guard
    officials, the use of the positioning systems allows traffickers to determine
    airdrop coordinates prior to departure, thus reducing the amount of radio
    communication needed. Officials noted that the increasing use of
    technology makes it more difficult to gather the information needed to
    track and interdict the shipment of illegal drugs through the Caribbean
    because traffickers can detect whether they are being followed.




    Page 60                                             GAO/GGD-97-42 Drug Control
Appendix IV

Major Contributors to This Report


                        Weldon McPhail, Assistant Director, Administration of Justice
General Government        Issues
Division, Washington,   Richard B. Groskin, Evaluator-in-Charge
D.C.                    Carolyn S. Ikeda, Senior Evaluator
                        Dennise R. Stickley, Evaluator
                        David P. Alexander, Senior Social Science Analyst
                        Pamela V. Williams, Communications Analyst


                        Bernice Steinhardt, Director, Health Financing and
Health, Education,        Public Health Issues
and Human Services      James O. McClyde, Assistant Director, Health Financing
Division, Washington,     and Public Health Issues
                        Jared Hermalin, Senior Evaluator
D.C.
                        Jess T. Ford, Associate Director, International Relations and
National Security and     Trade
International Affairs   Allen C. Fleener, Senior Evaluator
Division, Washington,
D.C.
                        John H. Anderson, Jr., Director, Transportation and
Resources,                Telecommunications Issues
Community, and
Economic
Development
Division, Washington,
D.C.
                        Randall B. Williamson, Assistant Director,
Seattle Field Office      Transportation and Telecommunications Issues
                        Neil T. Asaba, Senior Evaluator


                        Nancy Finley, Senior Attorney
Office of the General
Counsel, Washington,
D.C.


                        Page 61                                            GAO/GGD-97-42 Drug Control
Page 62   GAO/GGD-97-42 Drug Control
Page 63   GAO/GGD-97-42 Drug Control
Related GAO Products74


              Substance Abuse Treatment: VA Programs Serve Psychologically and
1996          Economically Disadvantaged Veterans (GAO/HEHS-97-6, Nov. 5, 1996).

              Drug and Alcohol Abuse: Billions Spent Annually for Treatment and
              Prevention Activities (GAO/HEHS-97-12, Oct. 8, 1996).

              Customs Service: Drug Interdiction Efforts (GAO/GGD-96-189BR, Sept. 26,
              1996).

              Drug Control: U.S. Heroin Control Efforts in Southeast Asia
              (GAO/T-NSIAD-96-240, Sept. 19, 1996).

              Drug Control: Observations on Counternarcotics Activities in Mexico
              (GAO/T-NSIAD-96-239, Sept. 12, 1996.)

              Terrorism and Drug Trafficking: Technologies for Detecting Explosives
              and Narcotics (GAO/NSIAD/RCED-96-252, Sept. 4, 1996).

              Substance Abuse Surveys (GAO/HEHS-96-179R, July 19, 1996).

              Drug Control: Observations on Counternarcotics Efforts in Mexico
              (GAO/T-NSIAD-96-182, June 12, 1996).

              Drug Control: Counternarcotics Efforts in Mexico (GAO/NSIAD-96-163,
              June 12, 1996).

              Cocaine Treatment: Early Results From Various Approaches
              (GAO/HEHS-96-80, June 7, 1996).

              Drug Control Observations on U.S. Interdiction in the Caribbean
              (GAO/T-NSIAD-96-171, May 23, 1996).

              Drug Control: U.S. Interdiction Efforts in the Caribbean Decline
              (GAO/NSIAD-96-119, Apr. 17, 1996).

              Terrorism and Drug Trafficking: Threats and Roles of Explosives and
              Narcotics Detection Technology (GAO/NSIAD/RCED-96-76BR, Mar. 27, 1996).

              At-Risk and Delinquent Youth: Multiple Federal Programs Raise Efficiency
              Questions (GAO/HEHS-96-34, Mar. 6, 1996).

              74
               For a list of GAO’s federal drug control products issued before January 1, 1993 (covering fiscal years
              1988 through 1993), see Drug Control: Reauthorization of the Office of National Drug Control Policy
              (GAO/GGD-93-144, Sept. 29, 1993).



              Page 64                                                               GAO/GGD-97-42 Drug Control
       Related GAO Products74




       Drug Control: U.S. Heroin Program Encounters Many Obstacles in
       Southeast Asia (GAO/NSIAD-96-83, Mar. 1, 1996).


       Review of Assistance to Colombia (GAO/NSIAD-96-62R, Dec. 12, 1995).
1995
       Drug War: Observations on U.S. International Drug Control Efforts
       (GAO/T-NSIAD-95-194, Aug. 1, 1995)

       Treatment of Hardcore Cocaine Users (GAO/HEHS-95-179R, July 31, 1995).

       Drug War: Observations on the U.S. International Drug Control Strategy
       (GAO/T-NSIAD-95-182, June 27, 1995).

       Drug Courts: Information on a New Approach to Address Drug-Related
       Crime (GAO/GGD-95-159BR, May 22, 1995).

       Honduras: Continuing U.S. Military Presence at Soto Cano Base Is Not
       Critical (GAO/NSIAD-95-39, Feb. 8, 1995).


       Border Control: Revised Strategy Is Showing Some Positive Results
1994   (GAO/GGD-95-30, Dec. 29, 1994).

       Drug Activity in Haiti (GAO/OSI-95-6R, Dec. 28, 1994).

       Drug Control: U.S. Antidrug Efforts in Peru’s Upper Huallaga Valley
       (GAO/NSIAD-95-11, Dec. 7, 1994).

       U.S. Postal Service: Drug Investigation Data (GAO/GGD-95-29FS, Dec. 6, 1994).

       Drug Control: U.S. Drug Interdiction Issues in Latin America
       (GAO/T-NSIAD-95-32, Oct. 7, 1994).

       Drug Control in Peru (GAO/NSIAD-94-186R, Aug. 16, 1994).

       Drug Control: U.S. Counterdrug Activities in Central America
       (GAO/T-NSIAD-94-251, Aug. 2, 1994).

       Drug Control: Interdiction Efforts in Central America Have Had Little
       Impact on the Flow of Drugs (GAO/NSIAD-94-233, Aug. 2, 1994).




       Page 65                                                  GAO/GGD-97-42 Drug Control
       Related GAO Products74




       INSDrug Task Force Activities: Federal Agencies Supportive of INS Efforts
       (GAO/GGD-94-143, July 7, 1994).

       Disability Benefits for Addicts (GAO/HEHS-94-178R, June 8, 1994).

       Social Security: Major Changes Needed for Disability Benefits for Addicts
       (GAO/HEHS-94-128, May 13, 1994).

       Weed and Seed: Program Objectives (GAO/GGD-94-128R, May 10, 1994).

       Foster Care: Parental Drug Abuse Has Alarming Impact on Young Children
       (GAO/HEHS-94-89, Apr. 4, 1994).

       Money Laundering: The Volume of Currency Transaction Reports Filed
       Can and Should Be Reduced (GAO/GGD-94-113, Mar. 15, 1994).

       Money Laundering: U.S. Efforts to Fight It Are Threatened by Currency
       Smuggling (GAO/GGD-94-73, Mar. 9, 1994).

       Money Laundering: Project Gateway (GAO/GGD-94-91R, Feb. 15, 1994).

       Social Security: Disability Benefits for Drug Addicts and Alcoholics Are
       Out of Control (GAO/HEHS-94-101, Feb. 10, 1994).

       Residential Care: Some High-Risk Youth Benefit, but More Study Needed
       (GAO/HEHS-94-56, Jan. 28, 1994).


       Drug Use Among Youth: No Simple Answers to Guide Prevention
1993   (GAO/HRD-94-24, Dec. 29, 1993).

       Border Management: Dual Management Structure at Entry Ports Should
       End (GAO/T-GGD-94-34, Dec. 10, 1993).

       Illicit Drugs: Recent Efforts to Control Chemical Diversion and Money
       Laundering (GAO/NSIAD-94-34, Dec. 8, 1993).

       Financial Management: Customs’ Accountability for Seized Property and
       Special Operations Advances Was Weak (GAO/AIMD-94-6, Nov. 22, 1993).

       Drug Control: The Office of National Drug Control Policy—Strategies
       Need Performance Measures (GAO/T-GGD-94-49, Nov. 15, 1993).



       Page 66                                              GAO/GGD-97-42 Drug Control
Related GAO Products74




Money Laundering: Characteristics of Currency Transaction Reports Filed
in Calendar Year 1992 (GGD-94-45FS, Nov. 10, 1993).

Money Laundering: Progress Report on Treasury’s Financial Crimes
Enforcement Network (GAO/GGD-94-30, Nov. 8, 1993).

Mandatory Minimum Sentences: Are They Being Imposed and Who Is
Receiving Them? (GAO/GGD-94-13, Nov. 4, 1993).

Drug Control: Expanded Military Surveillance Not Justified by Measurable
Goals or Results (GAO/T-NSIAD-94-14, Oct. 5, 1993).

The Drug War: Colombia Is Implementing Antidrug Efforts, but Impact Is
Uncertain (GAO/T-NSIAD-94-53, Oct. 5, 1993).

Drug Control: Reauthorization of the Office of National Drug Control
Policy (GAO/GGD-93-144, Sept. 29, 1993).

Drug Control: DOD Operated Aerostat Ship Although Conferees Denied
Funds (GAO/NSIAD-93-213, Sept. 10, 1993).

Drug Control: Heavy Investment in Military Surveillance Is Not Paying Off
(GAO/NSIAD-93-220, Sept. 1, 1993).

The Drug War: Colombia Is Undertaking Antidrug Programs, But Impact Is
Uncertain (GAO/NSIAD-93-158, Aug. 10, 1993).

Confronting the Drug Problem: Debate Persists on Enforcement and
Alternative Approaches (GAO/GGD-93-82, July 1, 1993).

Customs Service and INS: Dual Management Structure for Border
Inspections Should Be Ended (GAO/GGD-93-111, June 30, 1993).

Drug Use Measurement: Strengths, Limitations, and Recommendations for
Improvement (GAO/PEMD-93-18, June 25, 1993).

Drugs: International Efforts to Attack a Global Problem (GAO/NSIAD-93-165,
June 23, 1993).

Money Laundering: The Use of the Bank Secrecy Act Reports by Law
Enforcement Could Be Increased (GAO/T-GGD-93-31, May 26, 1993).




Page 67                                             GAO/GGD-97-42 Drug Control
           Related GAO Products74




           Drug Control: Revised Drug Interdiction Approach Is Needed in Mexico
           (GAO/NSIAD-93-152, May 10, 1993).

           War on Drugs: Federal Assistance to State and Local Drug Enforcement
           (GAO/GGD-93-86, Apr. 29, 1993).

           Indian Health Service: Basic Services Mostly Available; Substance Abuse
           Problems Need Attention (GAO/HRD-93-48, Apr. 9, 1993).

           Drug Control: Coordination of Intelligence Activities (GAO/GGD-93-83BR,
           Apr. 2, 1993).

           Drug Education: Limited Progress in Program Evaluation (GAO/T-PEMD-93-2,
           Mar. 31, 1993).

           Community-Based Drug Prevention: Comprehensive Evaluations of Efforts
           Are Needed (GAO/GGD-93-75, Mar. 24, 1993).

           Needle Exchange Programs: Research Suggests Promise as an AIDS
           Prevention Strategy (GAO/HRD-93-60, Mar. 23, 1993).

           U.S. Customs Service Performance Indicators (GAO/AFMD-93-47R, Mar. 10,
           1993).

           Drug Control: Increased Interdiction and Its Contribution to the War on
           Drugs (GAO/T-NSIAD-93-4, Feb. 25, 1993).

           Drug Control: Treatment Alternatives to Street Crime (GAO/GGD-93-61,
           Feb. 11, 1993).

           Drug Control: Status Report on Counterdrug Technology Development
           (GAO/NSIAD-93-104, Jan. 28, 1993).




(186765)   Page 68                                             GAO/GGD-97-42 Drug Control
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