oversight

Drug Abuse: Research on Treatment May Not Address Current Needs

Published by the Government Accountability Office on 1990-10-10.

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

                       United States General Accounting Office   /qd     yo2
                       Testimony


                                                                       142402

For Release              DRUG ABUSE:
on Delivery              Research on Treatment May
Expected at              Not Address Current Needs
1O:OO a.m. EDT
Wednesday
October   10,   1990




                         Statement of Mark V. Nadel
                         Associate Director  for National
                           and Public Health Issues
                         Before   the
                         Select Committee on Narcotics
                           Abuse and Control
                         House of Representatives




          Y




GAO/T-HRD-90-56                                                         GAO   Form   160w/87)
                            DRUG ABUSE TREATMENT RESEARCH
                               SUMMARYQF GAO TESTIMONY
Although    drug abuse is one of our most serious             domestic problems,
knowledge about drug abuse treatment              is limited   in significant
ways.     The National    Institute      on Drug Abuse (NIDA), the principal
federal    agency charged with furthering           research   on drug abuse
treatment,     has had a four-fold        increase    in its budget from 1986 to
1990.     However, to better        assure that such increases         will  advance
knowledge on drug abuse treatment,             NIDA needs to take a more
proactive    approach to planning         its research     and training     programs.
GAO's principal     findings      are:
--    Research        knowledge applicable        to drug abuse       treatment      has
      advanced        slowly   in the last decade.         There    are no
      recently        completed national       evaluations    of    treatment
      programs,        and earlier     evaluations     may have     limited
      applicability          to today's    population     of drug     abusers.
--    Gaps in knowledge have not been overcome partly                       because NIDA
      has not had a strategic             planning   process to assure that the
      research   it funds is targeted             at the most critical         needs.
      Moreover,    research      has not been fully          relevant     to treatment
      practice   because NIDA has not systematically                  involved
      treatment    practitioners,          who will    ultimately     use the results
      of treatment     research,        in its decision-making          regarding
      treatment    research      priorities.
--    NIDA's relatively  low research   budget during most of the
      1980s also accounts in part for the slow progress       on
      knowledge on how to treat   drug abuse during a time when the
      nation's  system of drug abuse treatment     as well as patterns
      of drug abuse were undergoing    fundamental   changes.
--    Despite     recent   increases   in funding  for drug abuse research,
      funding     for training     of drug abuse researchers  has lagged
      behind.
GAO has made recommendations      for improved strategic                  planning     of
research     and for a more systematic  approach to the                 training      of
researchers.
Mr.    Chairman               and Members of the                    Committee:


I am pleased                  to be here            today     to discuss         our recent         report1         on
federal            support          for     research         on drug      abuse treatment.                I will         be
discussing               three       issues:
             --
                        the      current         state      of knowledge         regarding         drug        abuse
                        treatment,
            WV
                        what has influenced                   the     state    of knowledge             on drug         abuse
                        treatment,           and
            --
                        current       activities             at the     National       Institute          on Drug
                        Abuse NIDA aimed at developing                           such knowledge.


We found            that         knowledge         about      drug     abuse treatment             is    limited         in
significant                ways.          This     area     of knowledge           advanced        slowly        during
the    198Os, while                  the     nature        of the      drug    abuse problem
fundamentally                    changed.          NIDA's      relatively          low research           budget
during            the    first       part        of that      decade      accounts      in part          for     this
slow       progress.               The lack          of a strategic            plan    to direct          drug      abuse
research            and the          lack        of emphasis          on the     training     of drug            abuse
researchers                also      slowed        progress         in understanding          how to treat
drug       abuse.




       9


lDrus Abuse:  Research on Treatment                                     Mav Not Address             Current         Needs
GAO/HRD-90-114 (September 1990).
.   *




        BACKGROUND


        Widespread           drug       abuse    is not      a new problem.               What is new is how
        drugs      are being            used and who is using                  them.       Cocaine          and its
        crystalline            form,        crack,      are now more widely                used than           heroin,
        which      was previously               the     larger        problem.         The emergence               of new
        drugs,      such as IIicelt             (smokable         methamphetamine),                  and the       use of
        combinations            of drugs         have confounded               attempts         at treatment.               In
        recent      years       many women have become addicted.                               All     of these          trends
        further       strain          the    capabilities             of the     treatment           system,       which      was
        designed          primarily          to treat       male heroin           addicts,           and point        out     the
        need for          research          targeted      at these         new problems.


        The National            Institute            on Drug Abuse,            an agency within                the
        Department          of Health           and Human Services,                  is the      key federal             agency
        responsible            for     supporting         research         on drug       abuse treatment.                   Until
        1986,      NIDA's       budget        was relatively             small.         Since        then    its     budget
        has increased                dramatically         due to concerns               over     the    growing          drug
        abuse problem                and the     absence         of    information        on the        effectiveness
        of drug       abuse treatment.                   The InstituteVs               funding        grew from about
        $85 million            in fiscal         year     1986 to about              $380 million            in    fiscal
        year      1990.
.




    KHOWLEDGEREGARDING DRUG
    s&T                              IS LIMITED


    NIDA funded                research          has led to significant                       advances        in knowledge
    of the       behavioral,                biomedical,            and neurobiological                     factors
    involved         in drug              abuse.          These discoveries                 may eventually              lead     to
    the      development             of new treatments                    for      drug     abuse.        Despite         such
    advances,            however,           knowledge         applicable             to drug           abuse treatment            is
    limited.             In particular,                we found           three      problems.


    First,       no large-scale                    evaluations            of drug         abuse treatment               programs
    have been completed                         in recent      years.              During        the    1970s and early
    198Os, NIDA funded                      two broad         long-term             studies        of treatment
    results:             the     Drug Abuse Reporting                      Program,          which       tracked        a sample
    of clients            who were enrolled                   in treatment                from     1969 to        1973,     and
    the      Treatment           Outcome Prospective                      Study,         which     tracked        clients        who
    were enrolled                in treatment               from     1979 to         1981.         NIDA also         funded       a
    large       effort         to    collect         data     on the         characteristics                of treatment
    programs.             The studies               were completed                 in the     early       1980s and
    because        of a lack               of    funding      no new studies                 were initiated.                The
    data      collection             effort         was terminated                with      the    advent        of block
    grants.         While           the     two long-term                studies         showed that         treatment           was
    effective            in reducing               drug     abuse,        reducing          criminal        activity,          and
    increasing            employment,                these     may have limited                    applicability            to
    today's        treatment               system     and population                 of drug           abusers     due to
    dramatic         changes              in patterns         of drug           use and treatment.

                                                                     3
’   ‘.




         In addition,            treatment          evaluations                 are      limited         by methodological
         problems          such as the        lack         of a standard                  measure         of treatment
         effectiveness.                Second,         little           is known about                 the      effectiveness            of
         certain          components       of treatment                  programs,             such as the              use of
         relapse          prevention       strategies                  in aftercare.                  Relapse       prevention           is
         intended          to prevent        patients                 from     returning           to drug        abuse by
         providing          them with        strategies                 to ensure          that        they      can maintain            a
         life      free     of drug       dependence.                   There      is also            limited       knowledge           on
         how to match           patients         with           the     most appropriate                  treatment.             This
         is considered            important            given           major     differences              among patients                and
         treatments           and because           better             matching          could        potentially            increase
         effectiveness            and efficiency                      in providing             treatment.


         Third,      although          cocaine         abuse became a widespread                                problem       during
         the      198Os,      knowledge       on how to treat                      it     is     in the         early      stages       of
         development.             NIDA's      support             of extramural                  research         on the
         development           of new treatments                       places      greatest            emphasis          on opiate
         abuse,      although          cocaine/crack                   abusers          now far        outnumber           opiate
         abusers.           NIDA only        more recently                     has placed             added emphasis             on
         developing           therapies       for       cocaine              abuse.


         NIDA is taking            action        in a number of areas                            to    address          limitations
         in knowledge.                 However,         the       results          of most of these                     initiatives
         will      not     be available          for      several              years.
       A HAS NOT IMPLEMENTED A
          FlGICTAN              FOR    ITS      RESEARCH



Gaps in knowledge                    on drug              abuse treatment                      have not been overcome
partly          because         NIDA has not had a strategic                                      planning            process        to
assure          that      the      research          it       funds            is targeted              at the most critical
needs.           This      process           is particularly                          important          given         substantial
increases              in NIDA's        research                   budget            since     fiscal         year      1987.        up to
1987,          NIDA's      research           budget               was smaller                than      the budgets           of any of
the      research          institutes               within               the National             Institutes             of Health.
As a result               of low funding                    levels             for     drug      abuse treatment                  research
during          most of the           198Os,              little              new knowledge              on treatment
services          and clients              was generated                        during         that      decade.           This      was at
a time          when the        nation's             system               of drug            abuse treatment               as well          as
patterns          of drug           abuse were undergoing                                fundamental             changes.


With      a four-fold               increase              in NIDA's                  budget     between          1986 and 1990,
the      Institute          now has the                   opportunity                  to     significantly              advance
knowledge              on drug       abuse treatment.                                Recognizing          a need for              overall
long-term              planning       of      its         research,                  NIDA did         begin      in     1989 to
design          a strategic           planning               process.                  However,          the     Institute           has
not      yet     fully       implemented              this               process        and has not              yet     developed           a
long-term              strategic        plan         for           its        research         program.


Such a plan               is particularly                     important                for     the      drug     abuse treatment
area,       which        must address                changing                  patterns          of drug         use.        Planning
    *

                                                                          5
is     also    critical            for    ensuring             that     the     large       recent       increases        in
NIDA's        budget       are allocated                 in a manner that                  maximizes           the
development             of knowledge               in this            area.


However,         NIDA's         planning           of    its      overall        research         priorities          has
not     addressed         the       long-term            future         direction          of NIDA's           research
program.          Its     planning              has been driven                 by its         annual     budget
process.          That       is,        much of NIDAls                 funding         is a 18continuation
base,"        determined            by past         priorities.                 The setting             of new
priorities           tends         to    focus      on new funds                resulting             from budget
increases.              Thus,       planning            usually         takes      place        on the margin.
While     NIDA has developed                      some long-term                 plans,         these     are    focused
on specific             areas       of research                and do not          comprehensively               address
NIDA's        overall        research            priorities.


Another        issue      in setting              priorities                 is the     role     of practitioners.
NIDA has been criticized                          by representatives                      of the        drug    abuse
treatment         community              for     not     considering             the     needs of
practitioners,               those        who will             ultimately          apply        the     knowledge
gained        from      research,              in planning             its     treatment         research        agenda.
NIDA officials               acknowledged                to us that             they     have not
systematically               involved            practitioners                 in their         decision-making
regarding         treatment              research         priorities.


NIDA has recently                   taken        steps         to establish             a strategic            planning
unit     and an advisory                  board         in order             to help     plan     the     direction         of

                                                                  6
its    research               for      the     next     5 years.           NIDA officials                 have told           us
that      this         new strategic                 planning          process       will         include     the         active
participation                     of members of the                treatment             practice         community.               We
hope that              NIDA will             follow      through          on these          initiatives             and
implement              an improved              planning         process          that      will     give     us more
knowledge              to     improve         drug      abuse treatment.


FUNDING FOR RESEARCH TRAINING HAS
FOT KEPT PACE WITH RESEARCH FUNDING


Research          progress             depends          not     only     on funding            projects            today,        but
also    on nurturing                   graduate          students          and new researchers                      to assure
continued              progress           and the vitality                 brought          by entry         level
researchers.                   Therefore,             training          funds      are a necessary                  part      of a
comprehensive                  system        of research               support.


Funding          for        the     training          of drug          abuse researchers                  has not kept             up
with    increases                 in    funding         for     drug     abuse research.                    This     limited
funding          for        training         has slowed           progress          in the          development             of
knowledge              on drug         abuse treatment.                   Training           is     important          to
maintain          an adequate                supply           of researchers              capable         of conducting
drug    abuse treatment                      research,           particularly               in light         of the
increased              availability                 of research          funds.           For example,              the     need
for    qualified               clinical             researchers          has grown as a result                       of recent
increases              in funding             for     the development               of pharmacologic
therapies.

                                                                  7
NIDA recognizes                that     low funding             for      training                has been a problem
and has recently                 begun to increase                    this         funding.           However,        neither
NIDA nor the             Alcohol,         Drug Abuse,            and Mental                  Health
Administration,                which      oversees NIDA, has information                                   on the
current       supply          of and future             need for             drug         abuse treatment
researchers.              This        information         is needed                 in order          to plan        the
appropriate            amount of          funding        to be allocated                         to research
training.


RECOMMENDATIONS


In summary,            although         drug   abuse has been identified                                  as one of the
nation's        leading         domestic       priorities,                   there         are significant             gaps
in understanding                the     relative         effectiveness                     of existing          treatments
and in developing                 new treatments.                 This             lack     of knowledge             is due i n
part      to the       lack      of a strategic             planning                process         at NIDA.          Other
factors       include          low levels          of    funding             for     drug         abuse research
before       fiscal       year        1987 and limited                 funding             for     the    training         of
researchers.              These recent             budget        increases                 will     not    necessarily
lead      to advances            in knowledge            on drug             abuse treatment                 unless        NIDA
takes       a more proactive               approach         to planning                    its     research      and
training        programs.


In our       report,          we made two recommendations                                 concerning         these
issues.         First,         to help      ensure        that         NIDA-supported                    treatment

                                                            8
c

    research       addresses              the      treatment               needs of the           drug-abusing
    population,            the     Secretary            of Health              and Human Services                 should
    direct       NIDA to          implement            its      strategic             planning       process       and
    develop       a plan          that      sets       forth         its      long-term          overall      treatment
    research       objectives.                  This         plan     should          specify      the     relative
    priorities        assigned             to the            different          categories           of treatment
    research.         It     should          consider               current          and anticipated             trends      of
    drug     abuse and the                needs of practitioners                          from the         drug    abuse
    treatment       community.


    In addition,            the     Secretary                should         direct      ADAMHA or NIDA to
    determine       how many researchers                             are needed to carry                   out    planned
    research       and take              appropriate             action         to ensure          their     availability.
                                                                 - - - -


    This     concludes           my statement,                 Mr.         Chairman.        I would         be happy to
    answer       any questions               you may have.




                                                                      9