oversight

Drug Treatment: Some Clinics Not Meeting Goal of Prompt Treatment for Intravenous Drug Users

Published by the Government Accountability Office on 1990-04-30.

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

                       DRUG TREATMENT
                       Some Clinics Not
                       Meeting Goal of
                       Prompt Treatment for
                       Intravenous Drug
                       Users


                                                    141378




                              -... -“. ..”.I   .-
<~AO,~fIItI~-90-8ORR
          United States
GAO       General Accounting Office
          Washington, D.C. 20648

          Human Resources Division

          B-2287 15

          April 30, 1990

          The Honorable Henry A. Waxman
          Chairman, Subcommittee on Health
            and the Environment
          Committee on Energy and Commerce
          House of Representatives

          Dear Mr. Chairman:

          Intravenous (IV) drug abusers- drug addicts who use needles to inject
          themselves-on heroin, cocaine, or other illicit drugs are among those
          with the highest risk of contracting acquired immunodeficiency syn-
          drome (AIDS). When seeking drug treatment, many addicts encounter
          lengthy waiting periods, In response to this health problem, the Con-
          gress enacted the Anti-Drug Abuse Act of 1988, which required certain
          state actions, In particular, for a state to receive alcohol, drug abuse,
          and mental health services (ADMS) block grant funds, it must provide
          assurance to the Department of Health and Human Services (HHS) that
          IV drug abusers will receive treatment from clinics within 7 days of
          request, to the maximum extent practicable.

          At your request, we reviewed the extent to which programs receiving
          ADMS  block grant funds in three states were providing timely treatment
          for IV drug abusers; we also assessed HHS'S oversight of state efforts to
          implement these provisions.

          We performed work at HHS'S Alcohol, Drug Abuse and Mental Health
          Administration to assess federal oversight of the ADMS block grant. For
          California, New York, and Oregon we (1) reviewed IV drug abuse treat-
          ment policies and practices and (2) visited 14 methadone maintenance
          programs and 1 drug-free clinic, We selected these states based on their
          geographic location, organizational structure, estimated number of IV
          drug abusers, and amounts of ADMS block grant funding. We assessed the
          extent to which these states implemented the five provisions under the
          ADMS block grant. These provisions require states to agree to

      l   ensure that local providers receiving ADMS block grant funds, and near-
          ing full capacity, will provide treatment for IV drug abusers within 7
          days of request, to the maximum extent practicable;
      l   develop a plan, when the Secretary of HHS requests it, to provide ser-
          vices for all individuals seeking substance abuse treatment (including
          IV drug abusers) and estimate the resources needed to provide such
          treatment;


          Page 1                       GAO/HRD-90-8OBR   Treatment   for Intravenous   Drug Users
                       R-228716




                   . target ADMS block grant funds earmarked for substance abuse treatment
                     to communities with the greatest need for services or highest prevalence
                     of substance abuse;
                   . require local providers receiving ADMS block grant funds to notify the
                     state when they reach or exceed 90 percent of their treatment capacity
                     for IV drug abusers; and
                   l require local providers receiving ADMS block grant funds to conduct out-
                     reach activities encouraging IV drug abusers to seek treatment.

                       Our work was conducted between September and November 1989, in
                       accordance with generally accepted government auditing standards. We
                       briefed your staff in November 1989 on the preliminary results of our
                       review.


                       The increased incidence of both IV drug abuse and AIDS in the 1980s indi-
Background             cated public health problems of major proportions. States estimated that
                       in 1988, 1.3 million people were IV drug abusers. The number of treat-
                       ment admissions for heroin abusers rose from about 89,000 in 1985 to
                       about 115,000 in 1988, or 29 percent. Studies project 50,000 deaths from
                       AIDS in 1991-more than the cumulative total since the first reported
                       cases of AIDS in 1981. Of reported AIDS cases, about 21 percent are linked
                       to contaminated needles shared among IV drug abusers. Thus, treating IV
                       drug abusers has become an important strategy in reducing the spread
                       of AIDS at the federal, state, and local levels.

                       The federal government recently increased its efforts to provide finan-
                       cial support for state-administered drug treatment programs. In Novem-
                       ber 1988, the Congress reauthorized the ADMS block grant, an important
                       funding source for these treatment programs, as part of the Anti-Drug
                       Abuse Act of 1988. The legislation required states to provide assurance
                       to HI-IS that treatment will be provided to IV drug abusers within 7 days
                       of request, to the maximum extent practicable, as a condition for receiv-
                       ing ADMS block grant funds. The Congress separately appropriated $100
                       million for a 2-year grant program to help states reduce waiting periods
                       of more than 30 days for IV drug abusers seeking treatment.


                       The three states we visited generally implemented each of the five IV
Results in Brief       drug abuse treatment provisions in section 2034 of the Anti-Drug Abuse
             u         Act of 1988. However, some clinics in two of the three states did not
                       always provide drug treatment within 7 days to IV drug abusers request-
                       ing services. Furthermore, while the provision requiring local providers


                       Page 2                      GAO/HRD-SO-SOBR Treatment   for Intravenous   Drug Users
                            B-228715




                            to conduct outreach was being implemented, it was not always consis-
                            tent with the approach described in the statute.

                            In administering the ADMS block grant program, HHS relies on the states’
                            interpretation of the Anti-Drug Abuse Act’s timely drug treatment pro-
                            vision. The states interpreted this provision as a broad goal, rather than
                            a requirement, for them to provide treatment within 7 days “to the max-
                            imum extent practicable.” HHS, through its current reporting system, has
                            not required states to provide sufficient information to measure the pro-
                            gress they are making in reaching this goal.


Waiting Periods for         IV drug abusers seeking treatment waited longer than 7 days in 3 clinics
Treatment Exceeded          in California and 2 in Oregon, of 10 we visited in those states. In 2 of the
                            5 clinics that exceeded the 7-day provision, waiting periods exceeded 3
7 Days                      months. For example, in Long Beach, California, over 200 people were
                            on a waiting list up to 3 months at 1 clinic. Waiting periods did not
                            exceed 7 days in the 5 New York programs we visited because when
                            these local providers reached their capacity, they referred addicts to
                            other treatment programs that were under capacity.

                            All three states had assured HHS that they would provide IV drug treat-
                            ment within 7 days, to the “maximum extent practicable”-which
                            states have interpreted as a goal, not a requirement. HHS, relying on
                            state interpretations of the provision, approved the states’ applications
                            for ADMS block grant funds.


HHS Did Not Request State   As a condition of receiving ADMS block grant funds, states must agree to
Plans, but Elements Were    develop a plan for treatment services, if requested by HHS. HHS did not
                            request states to prepare separate plans to provide services to all indi-
in Place                    viduals seeking substance abuse treatment. The treatment plans were to
                            identify the magnitude of each state’s substance abuse problem and the
                            resources needed to address it. However, HHS recently began working
                            with several states and the National Association of State Alcohol and
                            Drug Abuse Directors to develop a survey instrument to obtain informa-
                            tion on states’ planning for and management of substance abuse ser-
                            vices. Eight states were asked to pilot-test the instrument before HHS
                            requests all states to voluntarily complete the survey.

                            We assessed whether states, on their own, were planning to meet the
                            needs of all IV drug abusers, All three states estimated the number of IV
                            drug abusers in their states and identified the number of treatment slots


                            Page 3                       GAO/HRD-90-80BR   Treatment   for Intravenous   Drug Users
II
                                                                                                                       I




                               B-228715




                               available to serve them. California and New York, however, did not
                               identify the financial and personnel resources required to meet these
                               needs. Only Oregon estimated the number of illicit IV drug abusers it
                               believed would request treatment and the financial and personnel
                               resources that would be needed to serve those people likely to seek
                               treatment,


     States Targeted Federal   The three states targeted federal drug treatment funds to communities
     Treatment Funds           they determined to have the greatest need for services. They based their
                               targeting of ADMS block grant funds on such factors as clinic admissions,
                               number of drug-related arrests, and incidence of communicable diseases.
                               For example, California allocated its ADMS block grant funds for IV drug
                               treatment according to the number of clinic admissions for IV drug abuse
                               and reported AIDS cases.


     Local Clinics Reported    All three states required local providers to report to the state substance
     Treatment Capacity        abuse agency when they reached or exceeded 90 percent of treatment
                               capacity for IV drug abusers. All providers we visited reported the
                               required information.


     Sometimes States, Not     All three states conducted outreach activities for IV drug abusers using
     Local Prov ,iders,        an areawide or clinic-based approach to implement the federal provision
                               contained in section 2034. Of the three states, however, only California
     Conducted Outreach        required local clinics receiving ADMS block grant funds to conduct out-
                               reach activities. Although California requires its local providers to con-
                               duct outreach, it also conducts areawide outreach activities. New York
                               conducted areawide instead of clinic-based outreach. For example, New
                               York’s substance abuse agency contracts with county agencies to imple-
                               ment regional outreach strategies. California and New York believe
                               areawide outreach is as effective as clinic-based outreach. Oregon relied
                               on clinic-based outreach activities that were being provided before the
                               federal requirement. Federal and state officials believe that outreach
                               activities conducted by agencies other than local service providers may
                               be equally effective.

                               Of the 15 providers we visited across the three states, 12 either con-
                               ducted their own outreach activities or relied on existing activities of
                               other agencies to reach IV drug abusers. The other three providers had
                               reached their treatment capacity and believed outreach activities were
                               not necessary for them.


                               Page 4                       GAO/HRD-BO-SOBR Treatment   for Intravenous   Drug Users
                           B-228716




HHS Does Not Currently     HHS cannot presently assure that individual states are making progress

Measure States’ Progress   toward the goal of providing IV drug abusers treatment within 7 days of
                           request. In recent months, HHS has begun to obtain some state-reported
                           information that could be used to generally measure some local provid-
                           ers’ progress in providing timely IV drug abuse treatment; however,
                           these data will not be sufficient to measure individual states’ progress.

                           HHS  currently relies heavily on state-reported data that describe proce-
                           dures for implementing the federal IV drug treatment provisions. Until
                           1987, HHS conducted its own on-site compliance reviews annually in sev-
                           eral states to assesstheir compliance with ADMS block grant require-
                           ments. It now asks selected states to assesstheir own compliance with
                           federal legislation based on a checklist developed by uns. It will conduct
                           an on-site compliance review only if, in its judgment, state-reported
                           information warrants such a review.

                           In addition, HHS requires states to provide several types of state-
                           reported data that describe procedures for implementing substance
                           abuse programs, such as annual applications and program reports. HHS
                           collects data on the number of substance abusers treated and the length
                           of waiting periods for treatment. However, these data do not specifically
                           identify IV drug abusers. III-IS also requires public and nonprofit provid-
                           ers receiving l-year grants to reduce waiting periods to prepare progress
                           reports upon termination of the grant. These reports will identify pro-
                           gress, but the number of grantees is too small to show state-by-state
                           comparisons. As a result, HIIS will not know whether states are making
                           progress toward providing IV drug abusers treatment within 7 days of
                           request in programs funded with ADMS block grant funds.


                           Because HHS has not yet Qbfained data needed to measure states’ per-
Conclusions                formance, it does not know the progress individual states are making to
                           meet the 7-day provision. Existing reporting requirements, such as the
                           states’ annual report describing the use of ADMS block grant funds, do
                           not provide sufficient information to measure such efforts. These
                           reports describe procedures in place, but cannot be used to measure
                           states’ progress in reaching the goal of treatment within 7 days. We
                           believe IIIIS should revise these reports so they can be used to measure
                           states’ progress in meeting this goal.




                           Page 6                       GAO/HRD-9OdOBR   Treatment   for Intravenous   Drug Users
                 B-228715




                 The Secretary of HHS should revise the Department’s reporting system to
Recommendation   ensure that it collects sufficient information that measures individual
                 states’ progress in meeting the goal of providing IV drug abusers treat-
                 ment within 7 days of request.


                 We did not obtain written HHS comments on a draft of this report. We
                 did, however, discuss its contents with cognizant HHS, national associa-
                 tion, and state officials, and their comments were considered in prepar-
                 ing our final report, HHS officials generally agreed that the current
                 reporting system does not provide sufficient information to measure
                 individual states’ performance in meeting the timely IV drug treatment
                 goal.

                 We are sending copies of this report to the House and Senate Appropria-
                 tions Committees, other interested congressional committees and mem-
                 bers, the Secretary of HHS, state substance abuse agencies, and the
                 National Association of State Alcohol and Drug Abuse Directors, We also
                 will make copies available to other interested parties on request.

                 If you or your staff have any questions about this report, please call me
                 on (202) 275-1655. Other major contributors are listed in appendix II.

                 Sincerely yours,




                 Linda G. Morra
                 Director, Intergovernmental
                   and Management Issues




                 Page 6                        GAO/HRD-BO-8OBR Treatment   for Intravenous   Drug Users
Y




    Page 7   G A O / H R D - 9 0 - 8 O B R Treatment for Intravenous D r u g Users
Contents


Letter                                                                                                      1

Section 1                                                                                                  10
Introduction            Reported Cases of IV Drug Abuse and AIDS                                           11
                        Federal Initiatives Support Treatment Programs for Drug                            12
                            Abuse and AIDS
                        Section 2034: IV Drug Abuse Treatment Provisions                                   13
                        Objectives, Scope, and Methodology                                                 14

Section 2                                                                                                 18
States Generally        Timeliness of IV Drug Abuse Treatment                                             19
                        Planning Treatment Services                                                       22
Implemented Federal     Targeting Federal Substance Abuse Treatment Funds                                 24
Treatment Provisions,   Reporting Teatment Capacity                                                       26
                        Outreach to IV Drug Abusers                                                       28
but Some Clinics Are    Conclusions                                                                       30
Not Meeting Prompt
Treatment Goal
Section 3                                                                                                 32
HHS Does Not            HHS Has Not Obtained Information to Measure States’                               33
                            Progress
Currently Measure       HHS Provides Some Technical Assistance                                            35
States’ Progress        Conclusions                                                                       36
                        Recommendation to the Secretary of HHS                                            37
Toward Meeting the
Prompt Treatment
Goal
Appendixes              Appendix I: Substance Abuse Treatment Clinics Selected                            38
                            for Review in Three States
                        Appendix II: Major Contributors to This Report                                    40

Related GAO Products                                                                                      44

Table                   Table 1: State and Local Implementation of Five Federal                           19
               I            IV Drug Abuse Treatment Provisions




                        Page 8                     GAO/HRD-90-SOBR   Treatment   for Intravenous   Drug Users
          Contents




Figures   Figure 1: Introduction                                                             10
          Figure 2: Range of HIV Infection Rates Among IV Drug                               12
               Abusers by State (Fiscal Year 1988)
          Figure 3: Section 2034: IV Drug Treatment Provisions                               14
          Figure 4: Review Objectives                                                        15
          Figure 5: GAO Scope and Methodology                                                16
          Figure 6: Timeliness of IV Drug Abuse Treatment                                    20
          Figure 7: Planning Treatment Services                                              23
          Figure 8: Targeting Federal Funds                                                  25
          Figure 9: Reporting Treatment Capacity                                             27
          Figure 10: Outreach to IV Drug Abusers                                             29
          Figure 11: Conclusions                                                             31
          Figure 12: HHS Does Not Currently Measure States’                                  33
               Progress
          Figure 13: Conclusion                                                              36
          Figure 14: Recommendation                                                          37




          Abbreviations

          ADMS       alcohol, drug abuse, and mental health services
          AIDS       acquired immunodeficiency syndrome
          GAO        General Accounting Office
          IIHS       Department of Health and Human Services
          HIV        human immunodeficiency virus
          IV         intravenous
          NASADAD    National Association of State Alcohol and Drug Abuse
                         Directors


          Page 9                      GAO/HRD-90-SOBR   Treatment   for Intravenous   Drug Users
Section 1

Introduction


                             During the 198Os, intravenous (IV) drug abuse increased throughout the
                             country, accompanied by a growing number of reported acquired immu-
                             nodeficiency syndrome (AIDS) cases. Moreover, researchers estimate that
                             more Americans will die of AIDS in 1991 than died since the first
                             reported AIDS cases in 1981. In response to the increasing incidence of IV
                             drug abuse a.nd AIDS, the Congress created and funded several federal
                             programs to treat IV drug abusers and slow the spread of AIDS (see
                             fig. 1).

Figure 1



       0            Introduction

            l       Reported cases of IV drug
                    abuse and AIDS
            l       Federal initiatives support
                    treatment programs for drug
                    abuse and AIDS




                Y




                            Page 10                      GAO/HRD-90-80BR   Treatment   for Intravenous   Drug Users
                       Section 1
                       Introduction




                       Contaminated needles, shared among’lv drug abusers, contributed to the
Reported Cases of IV   increasing incidence of AIDS. As of 1988, 21 percent of all reported AIDS
Drug Abuse and AIDS    victims were associated with IV drug use. Treatment admissions to clin-
                       ics for heroin addiction-the most common IV drug-increased 29 per-
                       cent, from about 89,000 in 1985 to about 115,000 in 1988, in part
                       because of AIDS education and other outreach programs. Heroin users
                       have combined heroin with other drugs, such as cocaine. Over the same
                       3-year period, client admissions related to cocaine increased 239
                       percent.

                       The National Association of State Alcohol and Drug Abuse Directors
                       (NASADAD)   surveyed the states and U.S. territories in 1988 to develop
                       estimates of IV drug use. 1 The 38 responding states estimated a total of
                       1.3 million IV drug abusers in 1988. 2 Several states reported that, in
                       certain areas, most IV drug abusers were infected with the human immu-
                       nodeficiency virus (HIV), generally understood to be the cause of AIDS. Of
                       the 38 states, 24 estimated the percentage of IV drug abusers who were
                       infected with the HIV virus. New York, New Jersey, and Puerto Rico esti-
                       mated that up to 60 percent of their IV drug abusers were HIV infected.
                       The HIV infection rate among IV drug abusers in the other 21 states that
                       reported this information ranged up to 51 percent, with 11 of these
                       states reporting rates of 10 percent or less.




                       ‘For reporting purposes, we refer to the District of Columbia, Guam, and Puerto Rico as “states.”
                       “The National Institute on Drug Abuse estimates that there are approximately 600,000 heroin addicts
                       in the United States. See Methadone Maintenance: Some Treatment Programs Are Not Effective;
                                                                     _ _
                       Greater Federal Oversight Needed (GAO /HRD9(7104,),                   p. a.



                       Page 11                                GAO/HRD-SO-80BR      Treatment   for Intravenous   Drug Users
                                            Section 1
                                            Introduction




Figure 2: Range of HIV Infection Rates Among IV Drug Abusers by State (Fiscal Year 1988)

r




                                                           Not available

                                                 n         i-15percent

                                                           1530   percam

                                                           31-45 percmr

                                                           4640   PefoB"t




                                           Source: National Association of State Alcohol and Substance Abuse Directors, Inc., State Resources
                                           and Services Related to Alcohol and Drug Abuse Problems: State Alcohol and Drug Abuse Profile Data,
                                           Fiscal Year 1988, p. 50.



                                           Several federal programs have been created over the past decade to
Federal Initiatives                        treat drug abuse and slow the spread of AIDS, particularly among popu-
Support Treatment                          lations at higher risk of contracting the virus. The higher risk popula-
Programs for Drug                          tion includes IV drug abusers residing in areas with higher rates of HIV
                                           infection and AIDS. :I These federal programs established national goals
Abuse and AIDS
             Y                             and created key roles for states and local drug treatment providers. In

                                           :jAIDS Education: Reaching Populations at Higher Risk (GAO/PEMD-88-36, Sept. 16, 1988), p. 9.



                                           Page 12                               GAO/HRD-SO-SOBR Treatment        for Intravenous   Drug Users
                            Section 1
                            Introduction




                            fiscal year 1989, the Department of Health and Human Services (HHS)
                            funded (1) a comprehensive community demonstration program to
                            reach, communicate with, and reduce the risk-taking behavior of IV drug
                            abusers and (2) a drug abuse information and referral hotline.

                            In addition, the Congress passed the Anti-Drug Abuse Act of 1988 (P.L.
                            100-690). In part, this act reauthorized the alcohol, drug abuse, and
                            mental health services (ADMS) block grant. It requires states to assure
                            that programs receiving these funds, on reaching 90 percent of their
                            capacity, provide treatment services for IV drug abusers within 7 days
                            of request, to the maximum extent practicable.

                            The Congress subsequently appropriated $765 million for the ADMS block
                            grant in fiscal year 1989, earmarking $519 million (68 percent) for sub-
                            stance abuse programs. States were required to spend at least $59 mil-
                            lion for IV drug abuse services. The Congress also appropriated $100
                            million for grants to public and nonprofit entities; these grants would
                            reduce drug abuse treatment waiting lists by expanding the capacity of
                            existing programs. Each grantee is limited to a l-year grant.

                            For fiscal year 1990, the Congress appropriated $1.2 billion for the ADMS
                            block grant, of which $895 million is earmarked for substance abuse
                            programs. States must set aside at least 17.5 percent of their substance
                            abuse program allocations, or $157 million, for IV drug treatment.


                            Our review focused on section 2034 of the Anti-Drug Abuse Act of 1988.
Section 2034: IV Drug       Section 2034 requires states to assure FIIISthat IV drug abusers will be
Abuse Treatment             provided timely treatment in programs receiving ADMS block grant
Provisions                  funds. Specifically, as summarized in figure 3, by statute, each state is
                            required to agree to

                        . ensure that IV drug abuse treatment programs at or over 90 percent of
                          treatment capacity that are supported with ADMS block grant funds will
                          provide treatment for IV drug abusers within 7 days of request, to the
                          maximum extent practicable;
                        . develop a plan, when the Secretary of HHS requests it, that (1) describes
                          how the state can provide services for all substance abusers seeking
                          treatment and (2) estimates the financial and personnel resources
                          needed to provide such treatment;
                        l target the drug abuse portion of its ADMS block grant funds to communi-
                          ties with (1) the highest prevalence of substance abuse or (2) the great-
                          est need for treatment services, with respect to such abuse;


                            Page 13                     GAO/HRD-907BOBR Treatment   for Intravenous   Drug Users
                             Section 1
                             Introduction




                         l   require local IV drug treatment programs supported with ADMS block
                             grant funds to notify the state substance abuse agency when they reach
                             or exceed 90 percent of their treatment capacity; and
                         l   require local providers receiving ADMS block grant funds to conduct out-
                             reach activities encouraging IV drug abusers to seek treatment.

Figure 3



       w         Section 2034: IV Drug Abuse
                 Treatment Provisions
       ~~~


             l   Timeliness of treatment
             l   Planning treatment services
             l   Targeting federal funds
             l   Reporting treatment capacity
             l   Outreach to IV drug abusers



                             The Chairman of the Subcommittee on Health and the Environment,
Objectives, Scope, and       House Committee on Energy and Commerce, asked us to (1) review state
Methodology                  implementation of the ADMS block grant IV drug provisions and (2) assess
                             local implementation of applicable reporting, timeliness, and outreach



                             Page 14                     GAO/HRD-9OBOBR   Treatment   for Intravenous   Drug Users
                               section 1
                               Introduction




                               requirements. The Chairman also asked us to review HHS'S oversight of
                               these provisions. Our review objectives are shown in figure 4.

Figure 4



           G&I Review Objectives

                  l   Examine state and local
                      implementation of five IV drug
                      abuse treatment provisions in
                      the Anti-Drug Abuse Act of
                      1988 (section 2034)
              l       Review HHS’s role in assuring
                      that states implemented the
                      federal provisions for IV drug
                      abuse treatment


                               We agreed with the Subcommittee to limit our study to three states and
                               15 local providers (see app. I). We did not assess the effectiveness of
                               drug treatment services or quality of care. Nor did we verify the accu-
                               racy of waiting list information or the methods states used to allocate
                               ADMS block grant funds to their localities. Our findings are not intended
                               to be projected to other states or local drug treatment programs.




                               Page 16                     GAO/HRD-OOBOBR Treatment   for Intravenous   Drug Users
                                                                                                                      I
                                     Section 1
                                     Introduction




                                     In the three states-California, New York, and Oregon-we reviewed
                                     drug treatment policies and procedures. We selected these states
                                     because they

                                . represent nearly 40 percent of all estimated IV drug abusers;
                                l have varied levels of demand for drug treatment because of population
                                  and provider locations;
                                l have varied organizational structures for service delivery, such as state-
                                  and county-operated treatment programs; and
                                . receive different amounts of ADMS block grant funding.

Figure 5



           w            GAO Scope and Methodology

                   l    Evaluated implementation
                        by visiting 3 states and 15
                        local providers
                        California
                       *New York
                       aOregon
               l        interviewed federal and public
                       uinterest group officials


                                    Page 16                    GAO/HRIb90-SOBR   Treatment   for Intravenous   Drug Users
Section 1
Introduction




Our review included five local IV drug treatment programs in each of the
three states (see fig. 5). We visited 14 methadone maintenance clinics
and 1 alcohol- and drug-free clinic. Methadone-an orally administered,
synthetic narcotic used to treat heroin and other opiate addicts-is the
most common form of treatment. We selected local programs that (1)
received ADMS block grant funds, (2) were geographically dispersed
across the three states, and (3) were at or over 90 percent of their treat-
ment capacity. We interviewed state and local program officials to deter-
mine their policies and practices concerning waiting lists and admission
procedures.

We also obtained a national perspective on IV drug abuse and IIIIS’S over-
sight of state-administered treatment programs supported with ADMS
block grant funds. For this, we interviewed HHS officials in the Alcohol,
Drug Abuse and Mental Health Administration to (1) understand their
approach to oversight of the block grant and (2) identify current policy
guidance to assist states in implementing the federal IV drug provisions,
We also interviewed NASADAD officials to obtain their views on state
responses to these provisions.

On November 7, 1989, we briefed the Subcommittee staff on the prelimi-
nary results of our review. This report summarizes the results of our
analysis and provides observations on approaches used by selected
states and local clinics to provide timely IV drug abuse treatment. We
conducted our work between September and November 1989, in accor-
dance with generally accepted government auditing standards.




Page 17                      GAO/HRD-90-SOBR   Treatment   for Intravenous   Drug Users
Section 2

StatesGenerallyhnplementedFederal                                                                                 ’
Treament Provisions,but SomeClinics Are
Not Meeting Prompt Trea-tmentGoal
                 States, including the three we visited, provided assurances in their fiscal
                 year 1989 applications for ADMS block grant funds that programs receiv-
                 ing these funds would provide IV drug abuse treatment services within 7
                 days of request, to the maximum practicable extent. States also assured
                 HHS that they would implement the other four IV drug treatment provi-
                 sions in section 2034 by: (1) submitting a plan for treatment services if
                 requested by HHS, (2) targeting federal drug treatment funds, (3) requir-
                 ing local providers to report treatment capacities, and (4) requiring local
                 providers to conduct outreach activities.

                 The three states and 15 local providers we visited generally imple-
                 mented each of the provisions in section 2034. We found:

             . Of the 10 local clinics we visited in California and Oregon, 5 had clients
               who waited longer than 7 days after their request for IV drug treatment.
               None of the 5 local providers we visited in New York had clients who
               waited longer than 7 days because programs filled to capacity referred
               persons seeking treatment to other programs.
             . HHS did not request plans for all substance abusers seeking treatment,
               nor did the three states develop such plans on their own to describe how
               they would address the unmet needs of IV drug abusers seeking treat-
               ment. The states did, however, estimate the number of IV drug abusers
               they believed would seek treatment. In addition, Oregon estimated the
               financial and personnel resources needed to provide treatment.
             l The three states targeted ADMS block grant funds to communities they
               determined to be in the greatest need for services or having the highest
               prevalence of substance abuse. These states also required local provid-
               ers to report to the state when they reached or exceeded 90 percent of
               their treatment capacity.
             . California required its local clinics to conduct outreach, but New York
               and Oregon did not. Of the 10 local providers we visited in these states,
               8 either conducted their own outreach or used existing state and county
               AIDS education and awareness programs. 4

                 Our analysis of state and local implementation of the five IV drug provi-
                 sions in section 2034 by the three states and 15 local providers we vis-
                 ited are summarized in table 1.




                 4The other two clinics had exceeded their treatment capacity and they believed outreach activities
                 were not necessary for them.



                 Page 18                                GAO/HRD#N30BR        Treatment   for Intravenous   Drug Users
                                          EJection 2
                                          States Generally Implemented Federal
                                          Treatment Provisions, but Some Cliuics Are
                                          Not Meeting Prompt Treatment Goal




Table 1: State and Local Implementation
of Five Federal IV Drug Abuse Treatment                                           State implemented or required                     Local provider
Provisions                                IV drug abuse treatment                         implementation                          implementationa
                                          provislon                              CA          NY          OR                     CA
                                                                                                                                 ..---- NY      OR
                                                                                                                                                ~~~.
                                          Timeliness    of treatmenP             Yes           Yes            Yes               2 of 5   Yes      3 of 5
                                          Treatment     plan                     Not           Not            Not               NA”      NAC      NAC
                                                                                 requested     requested      requested
                                          Targeting    funds                     Yes           Yes            Yes               NAC      NAC      NAC
                                                                   ~---
                                          Reporting    treatment     capacity    Yes           Yes            Yes               Yes      Yes      Yes
                                                                                       ___-                         . . ..-__
                                          Outreach     to IV druq abusers        Yes           No             No                4 of 5   4 of 5   4 of 5

                                          “Of the five local provders we visited in each state, we identify the number of providers that imple-
                                          mented the applicable provision.

                                          ‘The states interpret the provrsion to provide treatment wtthin 7 days as a goal; we assessed whether
                                          clintcs actually admitted all IV drug abusers wlthin 7 days of their request for treatment.
                                          LNot applicable because the planning and targeting provisions do not apply to local providers


                                          The timely treatment provision in the Anti-Drug Abuse Act of 1988 (sec-
Timeliness of IV Drug                     tion 2034) creates a broad goal for states to provide treatment within 7
Abuse Treatment                           days “to the maximum extent practicable,” but does not require a 7-day
                                          period for admitting IV drug abusers to treatment. All three states
                                          required that programs supported with ADMS block grant funds provide
                                          IV drug treatment within 7 days to the maximum extent practicable (see
                                          fig. 6).




                                          Page 19                                  GAO/HRD-OO-BOBR Treatment          for Intravenous       Drug Users
                                  States Generally Implemented FederaI
                                  Treatment Provisions, but Some Clinics Are
                                  Not Meeting Prompt Treatment Goal




Figure   6




             GM      Timeliness of IV Drug
                     Abuse Treatment
             State Level                                           Local Level

             Did states require                                   Did providers treat clients
             treatment within 7                                   within 7 days of request?
             days of request?
             California--Yes                                      California--Not always
                                                                  (3 of 5 exceeded 7 days)
             New York--Yes                                        New York--Yes
             Oregon--Yes                                          Oregon--Not always
                                                                  (2 of 5 exceeded 7 days)



                                  At the time of our visit, 5 of the 10 California and Oregon clinics did not
                                  admit some IV drug abusers into treatment programs within 7 days of
                                  request. Three of these clinics were in California; the other two were in
                                  Oregon (see fig. 6). Waiting periods in these two states were as long as 3
                                  months at some clinics. In New York, waiting periods did not exceed 7
                                  days in the five local programs we visited because programs filled to
                                  capacity referred persons seeking treatment elsewhere.




                                  Page 20                             GAO/IIRD-90-90BR   Treatment   for Intravenous   Drug Users
             Section 2
             States Generally Implemented Federal
             Treatment Provisions, but Some Cliuics Are
             Not Meeting Prompt Treatment Goal




California   California drug abuse officials notified ADMS block grant recipients of
             the 7-day provision in March 1989, and it became effective in July. Cali-
             fornia surveyed local clinics in June 1989 to identify those with drug
             abusers waiting for treatment. The survey identified over 2,000 clients
             statewide waiting for methadone maintenance treatment. More than 85
             percent of them had waited longer than 7 days. State alcohol and drug
             abuse program officials said that during the period reviewed, insuffi-
             cient financial resources were the primary reason clients did not receive
             treatment within 7 days. California officials said other factors contrib-
             uted to waiting periods longer than 7 days at the three clinics with wait-
             ing lists. These factors included barriers to developing new facilities,
             such as obtaining local permits.

             Of the five local clinics we visited in California, three did not provide IV
             drug treatment within ‘7 days; each had a waiting list. For example, the
             West County Medical Clinic in Long Beach had over 200 people on a
             waiting list for up to 3 months. In Monterey and San Bernardino coun-
             ties, waiting periods averaged at least 2 months. The clinics usually
             treated pregnant women and HIV-infected clients, however, within 7
             days.

             IV drug abusers waiting for publicly funded slots generally waited longer
             for treatment. This was particularly true for clients receiving Medicaid.
             One reason for this is that California generally does not allow Medicaid
             funds to be used to pay for methadone treatment.


New York     New York required all publicly funded drug treatment providers to
             admit IV drug abusers seeking treatment into their programs within 7
             days of request. This requirement applies to those providers receiving
             federal funds, state funds, or both. New York officials notified ADMS
             block grant recipients and other state-funded treatment programs of the
             ‘I-day provision in August 1989.

             Of the five local providers we visited, none had waiting periods longer
             than 7 days. At the time of our visit, four providers exceeded 90 percent
             of capacity and the other provider exceeded 100 percent. When they
             reached 100 percent of treatment capacity, these providers usually
             referred IV drug abusers to other programs with available treatment
             slots. For example, Lower Eastside Service Center, Inc., and Albert Ein-
             stein clinic administrators said they either try to admit drug abusers
             into their treatment programs within 7 days or refer them to another



             Page 21                            GAO/HRD-90-SOBR   Treatment   for Intravenous   Drug Users
                     Section 2
                     States Generally Implemented Federal
                     Treatment Provisions, but Some Clinics Are
                     Not Meeting Prompt Treatment Goal




                     local provider. These two providers did not monitor the progress of cli-
                     ent referrals, however, to ensure timely admission to alternative pro-
                     grams. New York does not have a central intake system or a mechanism
                     in place to track referrals-which     is generally done informally when the
                     provider of choice is at its capacity. New York’s fiscal year 1990-91
                     budget proposal contained a demonstration project for central intake.


Oregon               Oregon required local clinics to admit IV drug abusers into a drug treat-
                     ment program within 7 days of request, to the maximum extent practi-
                     cable. The Bridgeway and Jackson County programs had waiting lists
                     and did not provide treatment within 7 days; waiting periods ranged
                     from 2 to 3 months at the time of our visit. In March 1990, Oregon
                     amended all community contracts with local providers to include the
                     federal provision for timely treatment.

                     The length of waiting periods depended on the client’s source of funds
                     and ability to pay for treatment. For example, at the two clinics with
                     waiting lists, Medicaid clients had to wait longer than clients with other
                     funding sources.


                     The Secretary of HIISdid not use his statutory authority to request
Planning Treatment   states to “devise and make available” a plan that would (1) describe
Services             how states can provide services to all substance abusers seeking treat-
                     ment services and (2) provide an estimate of the financial and personnel
                     resources necessary to provide such treatment. However, HHS recently
                     began working with several states to develop a survey instrument to
                     obtain information on states’ planning for and management of substance
                     abuse services. Eight states were asked to pilot-test the instrument
                     before IIIIS requests all states to voluntarily complete the survey.

                     The three states we visited did not prepare separate substance abuse
                     plans on their own. They believed that their fiscal year 1989 ADMS block
                     grant applications sufficiently described how the states planned to pro-
                     vide services for IV drug abusers. We assessed whether these applica-
                     tions met the spirit of the provision. Our review of the 1989 applications
                     showed that these states did address some of the elements specified in
                     the federal provision that were to be included in the plan. All three
                     states estimated the total number of IV drug abusers needing treatment
                     and the number of treatment slots available. Only Oregon, however, esti-
                     mated the financial and personnel resources needed to serve those drug
                     abusers likely to seek treatment.


                     Page 22                             GAO/HRD-90-80BR   Treatment   for Intravenous   Drug Users



                                                           :**r
                                                                                                         ,
                                   Section 2
                                   States Generally Implemented Federal
                                   Treatment Provisions, but Some Clinics Are
                                   Not Meeting Prompt Treatment Goal




Figure         7
 l..ll-“ll.l




                   w       Planning Treatment Services

                       0 HHS did not request states to
                        develop plans that would
                        describe how states can serve
                        all substance abusers seeking
                        treatment
                       l   States estimated the number
                           of IV drug abusers and their
                           current treatment capacity




California                         At the request of the state legislature, California’s Department of Alco-
                                   hol and Drug Programs has begun to identify treatment needs of
                                   unserved IV drug a.busers. The state intends to identify the number of
                                   additional treatment slots needed to serve eligible drug abusers. Califor-
                                   nia relaxed certain treatment standards for readmission to other drug
                                   programs, such as the number of times clients have failed or dropped
                                   out of previous drug treatment programs. Because the state has not
                                   identified the number of additional treatment slots needed, it cannot
                                   estimate the financial resources needed to serve all IV drug abusers.




                                    Page 23                            GAO/HRD-BO-8OBR Treatment   for Intravenous   Drug Users
                    Section 2
                    States Generally Implemented Federal
                    Treatment Provisions, but Some Clinics Are
                    Not Meeting Prompt Treatment Goal




New York            New York estimated the number of drug abusers-including heroin
                    addicts and other daily narcotics users-statewide and identified the
                    state’s current treatment capacity and unmet needs. New York intends
                    to increase treatment capacity statewide from 48,000 to 65,000 drug
                    treatment slots for all treatment methods. In March 1990, New York
                    officials developed data to show the magnitude of the IV drug abuse
                    problem and the treatment services needed at the county level to pro-
                    vide such services.


Oregon              Oregon identified IV drug abuse treatment as a “desirable” priority in its
                    current biennial needs assessment. Oregon’s substance abuse agency
                    submits reports to its legislative and executive branches of government
                    identifying unmet drug treatment needs. The state projects that an addi-
                    tional $3.5 million would be required to serve an estimated 4,500 IV drug
                    abusers who would most likely seek treatment if it were available. Ore-
                    gon estimated that additional staffing resources at both the state and
                    local levels would be required, and included requests for these resources
                    in its budget proposals.


                    The three states developed procedures to target ADMS block grant funds
Targeting Federal   for IV drug treatment to communities they determined to have the great-
Substance Abuse     est need for such services. The federal provision defines these high-
Treatment Funds     demand communities as areas with the highest incidence of AIDS, drug
                    abuse, and prevalence of drug-related crime (see fig. 8).




                    Page 24                             GAO/HRD-9080BR   Treatment   for Intravenous   Drug Users
                        section 2
                        St&es Generally Irmpleaented Federal
                        Treatment Prov-iaioua, but Some Clhics   Are
                        Not Meeting Prompt Treatment Goal




Figure 8


           w   Targeting Federal Funds

               Did states target federal
               substance abuse treatment
               funds to localities they
               determined had the greatest
               need?
               *California--Yes
               *New York--Yes
               l Oregon-Yes

California              California allocates funds to communities based on (1) clinic admissions
                        for IV drug treatment and (2) the number of reported AIDS cases. It also
                        considers such factors as community income levels and number of
                        minorities. The amount of federal ADMS block grant funds targeted to
                        treat IV drug abusers totaled $5.7 million in fiscal year 1988 and $12.5
                        million in 1989.


New York       y        New York distributes its funds based on the number of drug-related hos-
                        pital emergency room admissions and arrests, as well as clinic use rates,



                        Page 25                              GAO/HRD-90.80BR   Treatment   for Intravenous   Drug Users




                                                      ,’:
-                                                                                                       ,
                      Section 2
                      States Generally Implemented Federal
                      Treatment Provisions, but Some Clinics Are
                      Not Meeting Prompt Treatment Goal




                      among other factors. It targeted $9 million of its fiscal year 1988 ADMS
                      block grant funds for methadone maintenance treatment. ADMS block
                      grant funds earmarked for methadone treatment totaled $5.1 million in
                      1989.

    -......-----__~
Oregon                Oregon distributes drug treatment funds based on clinic use rates and
                      targets them to communities with high demands for services, Federal
                      ADMS block grant funding targeted to treat IV drug abusers totaled more
                      than $600,000 in 1988 and $1.3 million in 1989.


                      The three states required local providers to notify the states’ substance
Reporting Treatment   abuse agency when they reached or exceeded 90 percent of their treat-
Capacity              ment capacity, and all 15 providers did so. Each of the 15 providers we
                      visited reported treatment capacity monthly (see fig. 9).




                      Page 26                             GAO/HRD-90-SOBR Treatment   for Intravenous   Drug Users
                           Stat.4~~Generally Implemented Federal
                           Treatment Protilous,    but Some Clhics        Are
                           Not Meeting Prompt Treatment Goal




Figure 9



       GAO Reporting Treatment Capacity

           State Level                                      Local Level
       Did states require local                             Did providers report when
       providers to report when                             they reached 90 percent
       they reached 90 percent                              or treatment capacity?
       of treatment capacity?
       California--Yes                                      California--Yes

       New York--Yes                                        New York--Yes

       Oregon--Yes                                          Oregon--Yes




California                 California required ADMS block grant recipients to report to the state
                           substance abuse agency when they reach 90 percent of their treatment
                           capacity. Although California included this requirement in grants to its
                           counties, effective July 1989, it had a similar requirement before the
                           Congress enacted the federal provision. The information reported, how-
                           ever, is not used to notify other methadone maintenance programs at or
                           over capacity of available publicly funded treatment slots. In March
                           1990, a California official said, the state began collecting such data for
                           publicly funded treatment slots.




                           Page 27                              GAO/HRD-SO-IOBR   Treatment   for Intravenous   Drug Users



                                                                     ‘.
                         Section 2
                         States Generally Implemented Federal
                         Treatment Provisions, but Some Clinics Are
                         Not Meeting Prompt Treatment Goal




                         California local clinics report treatment capacity monthly through their
                         county governments. Of the five clinics visited, four exceeded 90 per-
                         cent of their treatment capacity, and one was over 100 percent.


New York                 New York has required its local providers to report treatment capacity
                         since August 1989. New York, like California, implemented a require-
                         ment to report capacity that met or exceeded 90 percent before the fed-
                         eral provision. The state relies on monthly use reports from local
                         providers to allocate its funds among other methadone maintenance pro-
                         grams. New York officials monitor more closely those providers that are
                         consistently under 90 percent of their contractual capacity and inform
                         them that they risk losing treatment slots unless they increase enroll-
                         ment. Of the five providers visited, four exceeded 90 percent of their
                         capacity, and one exceeded 100 percent.

..---   ._____--______
Oregon                   Oregon required local clinics to report treatment use levels before the
                         federal reporting provision. The state required each clinic to maintain
                         use at 100 percent or risk losing treatment slots if clinic use fell below
                         100 percent for 3 consecutive months.

                         Although none of the five clinics in Oregon were aware of the federal
                         reporting requirement, they provided monthly reports on treatment
                         capacity to the state substance abuse agency. Of the five clinics visited,
                         four exceeded 100 percent of their authorized capacity and the fifth was
                         under 100 percent for about 1 month.


                         All three states we visited conducted outreach activities to encourage IV
Outreach to IV Drug      drug abusers to seek treatment. Only California required its local clinics
Abusers                  to conduct outreach activities for treatment programs supported with
                         ADMS block grant funds (see fig. 10). Of the 15 local providers visited, 12
                         either conducted their own outreach activities for IV drug treatment ser-
                         vices or relied on existing areawide AIDS education and awareness out-
                         reach programs rather than clinic-based outreach. RThe three states
                         believed that these outreach activities fulfilled the requirement.




                         “The other three clinics had exceeded their treatment capacity and believed outreach activities were
                         not necessary for them.



                         Page 28                                GAO/HRD-SO-SOBR Treatment        for Intravenous   Drug Users
     i
                              section2
                              States Generally Implemented Federal
                              Treatment Provisions, but Some Cliuics Are
                              Not Meeting Prompt Treatment Goal




Figure   10



          G&I Outreach to IV Drug Abusers

          State Level                                               Local Level

          Did states require loca                                   Did providers conduct
          providers to conduct                                      outreach?
          outreach?
          California--Yes                                           California--Not always
                                                                    (1 of 5 did not)

          New York--No                                              New York--Not always
                                                                    (1 of 5 did not)

          Oregon--No                                                Oregon--Not always
                                                                    (1 of 5 did not)



California                    California required local clinics to conduct outreach activities, and it
                              notified the clinics by sending a letter to each county. Staff at the five
                              local clinics we visited said that they were notified of this requirement
                              before our visit in October 1989. Four of the five clinics conducted out-
                              reach activities before the state’s notification. These activities were
                              targeted to populations believed to be at risk of contracting AIDS, includ-
                              ing the Hispanic community, migrant workers, and prostitutes. The
                              clinic in Long Beach did not conduct outreach activities; it had over 200
                   Y
                              drug abusers waiting for treatment.




                              Page 29                            GAO/HRD-90-BOBR Treatment   for Intravenous   Drug Users
              Section 2
              States Generally Implemented Federal
              Treatment Provisions, but Some Clinics Are
              Not Meeting Prompt Treatment Goal




New York      New York did not require local providers to conduct outreach activities
              for treatment programs funded with ADMS block grant money. The New
              York State Division of Substance Abuse Services notified all local treat-
              ment programs receiving federal or state funds of the outreach provi-
              sion in January 1990, and it plans to ensure compliance during its
              monitoring visits. The division conducted outreach activities and con-
              tracts with county and other local agencies. These agencies conducted
              outreach before the federal provision was enacted, Four of the five
              providers visited conducted their own outreach activities; the other pro-
              vider did not but was located in an area covered by the state’s outreach
              programs. New York encourages IV drug treatment programs to conduct
              outreach activities as appropriate.


Oregon        Oregon did not require its local clinics supported with ADMS block grant
              funds to conduct outreach activities. Of the five clinics we visited, four
              conducted outreach before the federal provision, using federal- and
              state-funded AIDS education programs. The state and county AIDS educa-
              tion outreach workers target IV drug abusers and distribute coupons
              redeemable for free detoxification treatment. The Jackson County clinic
              did not accept outreach funding because, given county officials’ con-
              cerns for outreach workers’ safety, they were opposed to these activi-
              ties. Beginning in 1990, state officials said, they plan to fund outreach
              activities with ADMS block grant funds.


              States have generally implemented the IV drug treatment provisions, but
Conclusions   some local clinics are not always providing treatment within 7 days.
              While two of the three states’ outreach activities may not be consistent
              with the clinic-based approach described in statute, they do use other
              approaches to provide outreach, which they believe to be equally effec-
              tive (see fig. 11).




              Page 30                            GAO/H.RD-SO-SOBR Treatment   for Intravenous   Drug Users
    3

                              Section 2
                              S tates G e n e r a l l y Im p l e m e n t e d Federal
                              Treatment Provisious, but S o m e Clinics A r e
                              Not M e e t i n g P r o m p t Treatment G o a l




Figure   11




          w       C o n clu s ions

              l   S ta tes g e n e rally i m p l e m e n te d
                  th e five IV d r u g tre a tm e n t
                  p rovisio n s
              l   S o m e local clin ics a re n o t
                  a lways p roviding IV d r u g
                  tre a tm e n t w ith in 7 d a ys




                  Y




                              Page 31                                      G A O / H R D 9 0 4 3 O B R Treatment for Intravenous D r u g Users
Section 3

HHS DoesNot Currently MeasureStates’
ProgressToward Meetingthe Prompt
Treament Goal
              HHS cannot currently assure that states are making progress toward the
              goal of providing IV drug abusers treatment within 7 days of request.
              However, HHS has recently increased its efforts by (1) working with
              states to design a national drug services research survey and (2) requir-
              ing progress reports from treatment providers receiving l-year grants to
              reduce drug abuse treatment waiting lists. In addition, HHS provides
              some technical assistance to help states implement federal IV drug provi-
              sions affecting programs that receive ADMS block grant funds.

             However, these efforts cannot be used to measure states’ progress, such
             as changes in the length of waiting periods for IV drug abusers seeking
             treatment or the number of IV drug treatment slots needed. As a result,
             HI-IS will not necessarily be able to assess states’ progress in implement-
             ing the federal IV drug 7-day treatment provision in all programs funded
             with ADMS block grant funds (see fig. 12).




             Page 32                      GAO/HRD-90-30BR   Treatment   for Intravenous   Drug Users
                        Section 3
                        HHS Does Not Currently Measure States’
                        Progress Toward Meeting the Prompt
                        Treatment Goal




    GAO HHS Does Not Currently
        Measure States’ Progress
          l   HHS has not yet obtained data
              needed to measure individual
              states’ progress toward
              meeting the goal of prompt IV
              drug abuse treatment in
              programs funded with the
              ADMS block grant




                       In recent months, HHS has begun to obtain some state-reported data that
HHS Has Not Obtained   could be used to generally measure some local providers’ progress in
Information to         meeting the timely IV drug abuse treatment goal. These data, however,
Measure States’        may not be sufficient to measure individual states’ progress. MIIScur-
                       rently relies heavily on state-reported data to determine whether states
Progress               are complying with the ADMS block grant legislation, including the IV
                       drug treatment provisions. It does this by reviewing the periodic self-
                       compliance review checklists, state block grant applications, and state
                       annual program reports. In addition, HHS is developing a new national
                       survey of substance abuse treatment services and is requiring semi-
                       annual progress reports from those grantees receiving the l-year drug



                       Page 33                           GAO/HRD-9043OBR Treatment   for Intravenous   Drug Users
                                                                                         .
Section 3
HIiS Does Not Currently Measure States’
Progress Toward Meeting the Prompt
Treatment Goal




treatment waiting list reduction grants. These reports are to describe
efforts to provide timely treatment; however, they will not measure out-
comes, such as changes in the number of IV drug abusers waiting for
treatment. For example, the progress reports on the waiting list grants
will provide specific progress information for that program, but the
number of grantees is too small to show state-by-state progress. (See p.
36.) As a result, HHS may not know the extent to which individual states
are making progress in admitting IV drug abusers into treatment pro-
grams within 7 days of request.

Until 1987, HHS conducted its own compliance reviews in several states
each year to determine state compliance with federal requirements. It
now asks selected states to assess their own compliance with federal
legislation based on a checklist developed by HHS. In 1989, HHS mailed
compliance review checklists to eight states. These states provided doc-
umentation that HHS used to determine whether they were in compliance
with federal requirements. For 1990, HHS plans to mail compliance
review checklists to six states and conduct on-site reviews in three
others based on state-reported data. HHS will conduct an on-site review
only if, in its judgment, state-reported information indicates the need for
such a review.

States annually submit ADMS block grant applications to HIIS for review
and approval. These applications describe states’ intended use of ADMS
block grant funds and provide assurances that they will implement fed-
eral requirements. In 1989, the three states we visited provided the
required assurances that they would implement the federal provisions
for IV drug abuse treatment.

Under the ADMS block grant, states agree to prepare annual program
reports. These reports describe how states used ADMS block grant funds,
including IV drug abuse activities. The fiscal year 1989 reports are due
to HHS by May 15, 1990. In a March 1990 letter to the states, HHS
described the information to be included in this report and asked the
states to describe how they implemented the IV drug treatment provi-
sions. HHS also uses the annual block grant program report as a source of
information on the number of substance abusers treated and the length
of waiting periods for treatment. However, HHS does not require states to
identify the length of waiting periods for IV drug abusers seeking
treatment.

HHS collects national data on substance abuse activities, but these data
cannot be used to measure states’ progress in meeting the timely IV drug


Page 34                            GAO/HRD-90-80BR   Treatment   for Intravenous   Drug Users




                                          ‘,
      *


                       Section 3
                       ?iHS Does Not Currently Measure States’
                       Progress Toward Meeting the Prompt
                       Treatment Goal




                       abuse treatment goal. HHS worked with the Office of National Drug Con-
                       trol Policy and NASADAD to develop two national data collection surveys.
                       Since 1982, NASADAD has annually collected data from the states on sub-
                       stance abuse activities on a voluntary basis. Beginning in 1986, as part
                       of its survey, NASADAD asked states to estimate the total number of IV
                       drug abuse treatment admissions and the total number of IV drug abus-
                       ers. HHS also recently initiated a survey of a national sample of sub-
                       stance abuse treatment programs, covering such items as the number of
                       slots available for substance abuse treatment and how long clients
                       would wait for such services.

                       In addition, HHS is requiring public and nonprofit entities receiving l-
                       year grants to reduce drug abuse treatment waiting periods to prepare
                       semiannual progress reports. These reports are to include such informa-
                       tion as the number of new treatment slots established, the type of treat-
                       ment provided, the total number of persons on waiting lists on date of
                       application and at conclusion of grant period, and problems encountered
                       in meeting goals. When this information is reported, it will be limited to
                       about 360 grantees receiving the $100 million to reduce waiting periods.
                       These funds will provide 21,000 treatment slots, of which about 9,500
                       are for IV drug abuse treatment. In 1989, there were about 115,000 IV
                       drug treatment admissions nationwide.

                       While these approaches may provide national trend data, none will pro-
                       vide sufficient data to measure individual states’ progress in meeting
                       the 7-day provision. For example, states’ descriptions of their procedu-
                       ral activities cannot be used to measure their progress in reducing the
                       length of waiting periods for IV drug abusers seeking treatment.


                       HIIS focuses its technical assistance primarily on administrative proce-
HHS Provides Some      dures. For example, IIHS held three regional conferences that covered
Technical Assistance   several procedures, such as how to draw down ADMS block grant funds
                       and how states can apply for waivers of federal requirements. It also
                       sent a technical guidance letter to all states in June 1989, notifying them
                       of new ADMS block grant requirements. In addition, HHS is pilot-testing a
                       survey instrument to collect information on states’ planning for and
                       management of substance abuse services, and HHS is funding 41 demon-
                       stration programs to assist states in identifying appropriate outreach
                       strategies to encourage IV drug abusers and people with AIDS to seek
                       treatment.




                       Page 36                           GAO/HRD-90-SOBR Treatment   for Intravenous   Drug Users
                                                                                                             I




                             Section 3
                             HHS Does Not Currently Measure States’
                             Progress Toward Meeting the Prompt
                             Treatment Goal




                             Because HHS has not yet obtained data needed to measure states’ per-
Conclusions                  formance, it does not know whether individual states are making pro-
                             gress in treating all IV drug abusers within 7 days of request. Existing
                             reporting requirements, such as the states’ annual program reports
                             describing the use of ADMS block grant funds, do not provide sufficient
                             information to measure such efforts. We believe HHS should revise these
                             reports so they can be used to measure states’ progress in their efforts
                             to provide timely IV drug treatment (see fig. 13).

Figure 13



        w           Conclusion

            l       HHS does not currently know
                    whether individual states
                    are making progress toward
                    treating IV drug abusers within
                    7 days of request




                Y




                             Page 36                           GAO/HRD-SO-SOBR Treatment   for Intravenous       Drug Users
                          Section 3
                          IUiS Does Not Currently Measure States’
                          Progress Toward Meeting the Prompt
                          Treatment Goal




                          The Secretary of HHS should revise the Department’s reporting system so
Recommendation to         that it can measure individual states’ progress in meeting the goal of
the Secretary of HHS      providing IV drug abusers treatment within 7 days of request (see
                          fig. 14).

Figure   14




          GAO Recommendation

              l   The Secretary of HHS should
                  revise the Department’s
                  reporting system so that it
                  measures individual states’
                  progress in meeting the goal
                  of providing prompt IV drug
                  abuse treatment




                          Page 37                           GAO/HRD-SO-BOBR Treatment   for Intravenous   Drug Users
Appendix I

SubstanceAbuse Treatment Clinics Selectedfdr
Review in Three States

               West County Medical Clinic
California     Long Beach (Los Angeles County)

               Community Human Services, Salinas Valley
               Salinas (Monterey County)

               Inland Health Services (IHS) - San Bernardino
               San Bernardino (San Bernardino County)

               San Joaquin County Methadone Clinic
               Stockton (San Joaquin County)

               Moorpark Methadone Clinic
               San Jose (Santa Clara County)


               Beckman/Trinity   Downtown Hospital
New York       New York City

               Lower Eastside Service Center, Inc.
               New York City

               Albert Einstein College of Medicine
               Division of Substance Abuse
               New York City

               Niagara County Drug Abuse Program
               Methadone Maintenance Treatment Program
               Niagara Falls (Niagara County)

               Tremont Commonwealth Council, VIP, Inc.
               Methadone Maintenance Treatment Program
               New York City


               Bridgeway
Oregon         Salem (Marion County)

               Marion County Drug Treatment Program
               Salem (Marion County)

               CODA Methadone Treatment Service
               Portland (Multnomah County)


               Page 38                     GAO/HRD-SO-BOBR Treatment   for Intravenous   Drug Users
Appendix I
Substance Abuse Treatment    Clinks   Selected
for Review in Three States




Lane County Alcohol and Drug Offender Pro@&&
Methadone Unit
Eugene (Lane County)

Jackson County Methadone Program
Medford (Jackson County)




Page 39                                GAO/HRD+9O-SOBR Treatmeatt far Intcavenaas Jhg   Uwra



                                                 :
Appendix II

Major Contributors to This Report


                          John M. Kamensky, Assistant Director, (202) 275-6169
Human Resources           Truman Hackett, Assignment Manager
Division,                 Mark E. Ward, Evaluator-in-Charge
Washington, D.C.          Linda C. Diggs, Evaluator
                          Jennifer L. Mummert, Secretary


                          Robert R. Poetta, Evaluator
New York Regional
Office

                          Patricia L. Elston, Site Senior
San Francisco             Karen D. Wright, Evaluator
Regional Office

                          Patricia K. Yamane, Evaluator
Seattle Regional Office




                          Page 40                       GAO/HRD-9OSOBR   Treatment   for Intravenous   Drug Users
Page 41   GAO/HRD-9080BR   Treatment   for Intravenous   Drug Users
Y




    Page 42   G A O / H R D - O O B O B RTreatment for Intravenous D r u g Users
.




    Y




        Page 43   GAO/~90-8OBR   Treatment   for Intravenous   Drug Users
~ RelatedGAO Products                                                                            .a


  --..-
               1111s
                   Cannot Currently Measure States’ Progress in Meeting the Prompt
               Treatment Goal for Intravenous Drug Users (GAO/T-HRD-90-25, Apr. 30,
               1990).

               Methadone Maintenance: Some Treatment Programs Are Not Effective;
               Greater Oversight Needed (GAO/HRD-90-104, Mar. 22, 1990).

               Preliminary Findings: A Survey of Methadone Maintenance Programs
               (GAO/T-HRD-89-33, Aug. 2, 1989).

               AIDS:Views on the Administration’s Fiscal Year 1989 Public Health Ser-
               vice Budget (GAO/HRD-88-104~R, Jun. 2, 1988).

               Controlling Drug Abuse: A Status Report      (GAOIGGD-88-39,     Mar. 1, 1988).

               Drug Abuse Prevention: Further Efforts Needed to Identify Programs
               That Work (GAO/HRD-88-26, Dec. 4, 1987).




 (llnnon)      Page 44                    GAO/HRD-90-80BR     Treatment   for Intravenous   Drug Users
                                         I,


     __“_..           “.l._,l   . .   ---.,“-_..   I   _..,_,..   _ _...   __I   .I   .__...   ..^.                                       ..__   ___




------l-l_-----.--”                                                                                   ._...--_..--.   -.----.




                                                                                                                                Ilt~qrwsls for copies of (;A() rt~p0rt.s should bc* stbul, t,o:




                                                                                                                                ‘I’ht~ firs0 five cwpiw of each report are free. AdtiiCiond       copies are
                                                                                                                                $2.00 t5wIr.

                                                                                                                                ‘I’ht~w is a 26”0 discouuC ou orders for 100 or more copies mailtd        Lo a
                                                                                                                                s iugle ;tddress.
                             ./
-_-   -                           j, ,

          I   First-Class   Mail ‘7      ;