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Technologies for Understanding and Preventing Substance Abuse and Addiction

TECHNOLOGIES FOR UNDERSTANDING AND PREVENTING SUBSTANCE ABUSE AND ADDICTION

US Government Office of Technology Assessment

October 18, 1994

CHAPTER 9 POLICY OPTIONS

Issues related to substance abuse and addiction have long occupied the attention of the American public. Congress has: authorized a multitude of federal programs aimed at reducing or preventing the supply and demand of illicit drugs and to regulate the availability of illicit substances, appropriated billions of dollars each year to federal agencies, provided oversight of federal programs, and passed broad-based legislation to coordinate programs as part of the war on drugs.

Congress faces several fundamental difficulties in addressing the causes of substance abuse and addiction:

o No scientific consensus exists as to what is the driving cause of substance abuse and addiction. A range of risk and protective factors have been associated with drug use, abuse, and addiction.

o Federal antidrug efforts, though coordinated by the White House Office of National Drug Control Policy (ONDCP), are spread among many federal agencies, whose authorization and appropriations are the subject of action by numerous congressional committees and subcommittees. ONDCP efforts in drug demand reduction efforts alone involved the efforts of federal agencies across at least 11 Cabinet-level departments. This makes coordinated legislative action difficult to achieve.

o The federal budget deficit is an obstacle to the creation of new domestic programs that target known risk and protective factors in individuals and communities. The framework and literature reviews presented in this report make clear that multiple factors in individuals, groups, and substance abuse and addiction can arise and be influenced by communities. Thus, effective intervention requires prevention practitioners to select from a variety of options, so they can target the specific factors that are especially important for the particular populations and communities they are addressing. This does not mean that everything must be done at once nor that everything be known in advance of taking action. To the contrary, policymakers and practitioners can take small steps at a time, and then, as resources and new knowledge permit, take additional steps that address a fuller range of factors and contexts in greater depth.

o Current drug prevention programs lack scientifically accepted standards for determining their success or failure. While federal supply-side efforts yield hard data (e.g., amount of illicit drugs confiscated, number of persons incarcerated), it is much more difficult to demonstrate and quantify the impact of a domestic program designed, in part or in whole, to prevent drug abuse. Whatever methods are developed, tested, and incorporated into prevention programs, a critical component of success is careful, rigorous evaluation. Answering "what works?" is essential in making advances in preventing substance abuse.

This chapter addresses some of the policy issues brought to the Office of Technology Assessment's (OTA's) attention during the course of this assessment, and possible options for congressional action. The issues and options are broken into four broad categories: federal focus and prevention program structure, research needs, community activity settings, and availability. Given the broad nature of federal antidrug efforts, many important issues relating to federal antidrug efforts remain beyond the scope of this report. Such topics include drug treatment, interdiction and enforcement, and drug legalization.

The order in which the issues and options are presented does not imply priority. Moreover, the options presented under each policy question are intended as a short menu from which Congress can choose one or more options for consideration and implementation, and they are not necessarily mutually exclusive.

FEDERAL FOCUS AND PREVENTION PROGRAM STRUCTURE

Supply vs. Demand Reduction

The federal substance abuse control policy has as its primary focus the eradication of the supply of drugs. The federal government currently spends over $12 billion annually on antidrug efforts, with approximately two-thirds of this amount supporting drug interdiction and law enforcement activities, and the remainder supporting demand- side activities, such as drug treatment, research, and prevention programs. While ONDCP's most recent National Drug Control Strategy argued for a slightly increased percentage of funds for demand-side reduction, the larger percentage of funds remain devoted to supply-side efforts. Congress could decide that existing levels of effort and program approaches in interdiction may need to be continued for a longer period of time before they can succeed in reducing the production, distribution, and local availability of illicit substances. Congress could direct that interdiction efforts, and the balance between supply and demand efforts, continue on the same track.

If Congress decided to increase federal efforts in demand reduction efforts, it could adopt any of three methods: 1) increase appropriations for treatment and prevention programs; 2) redirect some of the interdiction funds to increase support for treatment and prevention programs; or 3) require that assets forfeited in drug seizures be increasingly used to support treatment and prevention programs. If Congress chose to simply increase appropriations for additional treatment and prevention programs, this option would require raising the current level of federal spending for drug control efforts at a time when the federal deficit is a key concern. Since costly interdiction and incarceration programs have not eliminated either the supply of illicit substances or the demand for and use of such substances, Congress could decide to increase appropriations for treatment and prevention programs by reallocating funds currently spent in drug interdiction and law enforcement activities; this would mean a drop in supply-side efforts such as drug interdiction and law enforcement activities. The reallocation of assets forfeited in drug seizures to treatment and prevention programs, if done together with closer coordination of local antidrug efforts among law enforcement and treatment and prevention practitioners, may be an attractive small step. Congress could direct that ONDCP monitor the reallocation of such assets, to ensure the flow of funds to programs that directly focus on substance abuse and addiction and, programs that do not directly address substance abuse and addiction but that target risk and protective factors known to be associated with abuse and addiction.

Many stakeholders agree that the federal antidrug effort should be more focused on treatment and prevention. Widespread disagreement exists, however, as to whether such additional treatment and prevention efforts should be created at the expense of, or in addition to, current supply-side efforts.

Structure of ONDCP

Since its creation in 1988, ONDCP has served as the most visible federal entity in the war on drugs. The Director, the so-called drug czar, has the opportunity to galvanize public attention on federal antidrug efforts, and to propose and advocate policies within the White House. ONDCP's effectiveness is limited, however, both in its statute and through its operation as a White House office. Congress could choose to reauthorize ONDCP, and in so doing maintain or alter its mission and authority; or allow ONDCP to expire.

If Congress chooses to reauthorize ONDCP, a number of options exist for altering its mission. Congress could:

o Direct ONDCP to address the full range of the most harmful abusable substances, including alcohol, tobacco, and inhalants. Although federally funded prevention programs address the range of abusable substances, the statute creating ONDCP emphasized illicit substances. As a result, ONDCP has historically provided limited attention on abusable substances that have been associated with higher levels of death and injury than illicit drugs. More recently, ONDCP increased the focus in its National Drug Control Strategy on the illicit use of alcohol and tobacco by minors because of the extensive damage to the health and safety of minors, resulting from the use and abuse of these substances. This approach could be enhanced through congressional authorization.

o Alter ONDCP's leadership structure. ONDCP by statute has a Deputy Director of Supply Reduction and a Deputy Director for Demand Reduction. This structure has, in part, resulted in an ongoing public policy debate regarding the overall federal focus on antidrug efforts, with supply-side and demand-side reduction efforts seen by some as philosophically incompatible (see discussion on supply versus demand reduction earlier in this chapter). By creating an alternative structure, ONDCP may be encouraged to adopt programs that more closely link various elements of the antidrug strategy (e.g., a focus on drug availability could link current supply-side elements that target physical availability of a drug with current demand-side efforts that focus on economic and social availability, as discussed in chapter 4). Despite the advantages that may result from a new organizational structure, the simplicity of the current structure makes it easier to provide a sharper focus on supply and demand elements of the National Drug Control Strategy.

o Give ONDCP increased authority over federal agency antidrug programs. Although ONDCP is charged with leading a war on drugs, its authority is limited to a coordinating function. Congress could provide the Director of ONDCP with specific authority over certain elements of various federal programs, or with additional authority over federal agency budget proposals. Such actions would give the drug czar more substantive authority to direct the war on drugs, but would likely be viewed by some federal agencies as an unwarranted intrusion in agency matters.

o Mandate the size of ONDCP. Because it is part of the Executive Office of the President, ONDCP is subject to increased political manipulation by each administration. Recently, for example, ONDCP took the largest personnel cut of any White House office to meet President Clinton's pledge of a 25 percent reduction in overall size of White House staff. While mandating a specific size for ONDCP might lead to increased effectiveness for the office, it would hamper White House efforts to control staff size.

Alternatively, Congress could allow the authorization for ONDCP to expire. While ONDCP has produced National Drug Control Strategies that summarize and set policy for federal efforts, the office lacks the authority to shape the antidrug policies of the federal agencies. Coordination of antidrug efforts is difficult at best when the number of relevant agencies is so large; since antidrug policy involves many federal agencies, it might make sense to disband ONDCP and rely on efforts by diverse federal agencies to continue to address the many aspects of the drug problem. Recent reductions in the size of the ONDCP staff, as a part of the down-sizing of the White House staff, could make this an opportune time to eliminate the office altogether. Terminating ONDCP would, however, be viewed by many as federal abdication of the war on drugs.

Structure of Federal Substance Abuse Prevention Programs

Federal efforts supporting substance abuse prevention programs are housed at a number of agencies. Congress recently reorganized the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA), splitting service-based components into the Substance Abuse and Mental Health Services Administration (SAMHSA) and research-based components--the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute on Drug Abuse (NIDA), and the National Institute on Mental Health (NIMH)-- into the National Institutes of Health (NIH). More recently, the Centers for Disease Control (CDC) has been renamed the Centers for Disease Control and Prevention (CDCP), which has already expanded its title and mission to include prevention. Congress could maintain the current structure if it determines that substance abuse is a problem that has many aspects and deserves to be addressed by many agencies and in many settings.

If Congress decided to create a more centralized structure, it could enact legislation designating a single federal entity as the chief agency for prevention efforts, or merge the components of various agencies under one federal roof. Possibilities include:

o Merging NIDA and NIAAA into a single National Institute on Substance Abuse and Addiction. The use of multiple substances (including alcohol, tobacco, marijuana, cocaine, and heroin) is increasingly reported by researchers and practitioners. Indeed, the gateway theory or hypothesis focuses on the progression in the use of substances, beginning with alcohol and tobacco (which are illegal for youth, but legal for adults) and moving to marijuana, cocaine, and heroin. Since clinicians and researchers have increasingly commented on the progression in substance use and on the co-occurrence of the use of multiple substances, the separation of the major federal research agencies into an alcohol agency (NIAAA) and a drug agency (NIDA) is more and more inconsistent with the shape of the problem. The Center for Substance Abuse Prevention (CSAP) is an integrated substance abuse agency that explicitly focuses on alcohol, tobacco, and other drugs, and all state alcohol and drug abuse agencies are now integrated or located in the same place. To facilitate more integrated and coherent research on the range of abusable substances, NIDA and NIAAA could be combined into a national institute on substance abuse and addiction. Such a merger would further integrate the federal research efforts in substance abuse, but might be seen by some as downplaying the emphasis given to illicit substances.

o Place CSAP in CDCP or in the Health Resources and Services Administration (HRSA). CDCP could give the substance abuse prevention field a solid base in the health and medical sciences, especially in the tracking and prevention of diseases. HRSA could give CSAP a broader health care environment to work within, which includes Community Health Centers and the National Health Service Corps. One disadvantage to the merging of CSAP into either of these other health agencies is that it would emphasize the medical aspects and interventions of drug prevention and downplay the many nonmedical factors and interventions that are important in the onset of substance use and abuse. Merger would also present problems of moving people--CSAP is headquartered in Rockville, Maryland, while CDCP is headquartered in Atlanta, Georgia--and threaten the loss of identity that some proponents of CSAP say is found in an agency that solely addresses substance abuse and prevention. However, the fragmentation of the federal effort on substance abuse prevention has been viewed by some as extreme and counterproductive, and the efforts of ONDCP have not succeeded in achieving coordination across departments.

o Merge federal substance abuse prevention efforts into a single agency, such as CSAP. CSAP has been working collaboratively with the staff in many other federal agencies, and would be seen as a natural leader for this effort. In addition, its recent efforts to begin to develop standards of practice for substance abuse and addiction prevention programs could be continued and more effectively infused into the components of programs currently in other agencies and departments.

Evaluation of Prevention Programs

Current drug prevention programs lack scientifically accepted standards for determining their success or failure. Most evaluations focus on the processes used in formulating and implementing a prevention program (e.g., who was involved, what type of program was used) and outcome evaluation (e.g., how many people were part of the program, how the program was replicated). Congress could allow the current level of process and outcome evaluation related to substance abuse prevention programs to continue.

If it chose to improve the quality of program evaluation, Congress could direct NIDA and NIAAA, or CSAP to design, lead, and support a multiyear national process (involving representatives of other federal agencies and of outside organizations) to forge consensus on standardized definitions and outcome measures, using technical reviews, consensus-forming techniques, and technical assistance monographs. These definitions and measures could include substance use, heavy drinking, substance abuse, substance addiction or dependency, and related behavioral problems such as school truancy, unemployment, delinquent and criminal behaviors, and the like. CSAP, NIDA, NIAAA, the Department of Education (DOE), and other federal agencies could be required to increase funding and technical assistance for process and outcome evaluations through grants and contracts. CSAP could focus on process evaluations that may assist program managers throughout the course of a program. NIDA and NIAA could focus on outcome evaluations that are more rigorously designed and conducted by individuals who are independent of the programs being evaluated. DoE could require both process and outcome evaluations by states and by schools, using Drug-Free School monies. NIDA, NIAAA, or CSAP could be directed to provide incentives for researchers and programs to participate in a national program database, using consistent definitions and including data from multiple evaluations. The creation of such a database would allow researchers to extend their own analyses by tapping into data from other program sites and populations that have used consistent definitions and measures.

States could be required by legislation to use a portion of their 20 percent prevention set-asides under the Alcohol and Drug Abuse Block Grant program and a portion of their Drug- Free Schools funds for evaluation of substance abuse prevention programs. Since evaluations of prevention programs can be expensive, Congress could consider increasing block grant funding levels to allow increases in evaluation studies without requiring decreases in programs. If such an option were enacted, Congress could mandate that evaluations be conducted by independent bodies, such as university-based researchers, rather than by state government agencies that have vested interests in demonstrating program effectiveness.

RESEARCH NEEDS

Data Collection

The National Household Survey and the National Survey of High School Seniors have developed credibility over the years for their regular reporting of substance use in households and high schools. These surveys could be allowed to continue, with no substantial changes in the cost, frequency of data collection, focus on target groups, analysis, and sharing of the database.

Because of the methodology employed, national surveys miss or underreport various populations. Much of the data now collected focuses on substance use (e.g., any use within the past 30 days or anytime in a lifetime), rather than on more intense substance abuse and addiction. In addition, questions are substance-specific, and less oriented to the use and abuse of multiple substances. Such polydrug users and abusers are increasingly being identified by researchers and clinicians. While substance use is a key precondition to later abuse and addiction, most individuals who use illicit substances do not go on to addiction. Thus, an important question for the development of prevention policies and programs is: What are the characteristics of individuals who abuse and become addicted to substances, and how do they make the transition from use to abuse and addiction?

If Congress felt that current data do not provide adequate information, it could direct that the Household and High School Surveys be conducted less intensely or less frequently. The expense of these surveys, especially the National Household Survey, is high. In 1992, the High School Survey cost about $3 million, and the Household Survey costover $12 million. Spending could be reduced if the survey data were compiled less intensely (e.g., with fewer questions or from a smaller sample) or less frequently. Alternatively, Congress could direct NIDA to develop and support survey methodology that reaches populations missed by current surveys (notably the homeless, school dropouts, and residents of some inner-city and rural areas), or through legislation, create a mechanism, comparable to the release of economic indicators, for the regular and nonpolitical release of survey data. Data could then be released through a well-defined process that includes careful and timely technical reviews for compliance with high standards of data collection and analysis, rather than being subjected to bureaucratic or political reviews that may delay the release of or bias the data.

Individual Risk and Protective Factors

A substantial body of research has been developed regarding potential risk and protective factors for children and adolescents. A variety of theories has been developed concerning how many and which risk factors increase the chances for a child or adolescent to first use alcohol or other drugs. Historically, one of the flaws with much of the risk and protective factor research has been that studies analyzed one factor in isolation from all others. Increasingly though, researchers are examining a wider variety of factors among different populations, as well as using more complex data analysis procedures. Even so, sophisticated multifactor research studies are still in the minority.

While a substantial amount of risk and protective factor research has focused on children and adolescents, not as much is known about factors among other populations. Recent research has led to interest in the possibility of further analyses in selected populations and/or selected risk or protective factors. Some examples:

o Adults. Additional research in this area could result in learning more about factors associated with long-term drug abuse and addiction as well as the importance of factors more often found in adult populations (e.g., effects of aging, death of a spouse or child, divorce). Data from a recent National Household Survey on Drug Abuse show that individuals aged 18 to 25, and 26 to 34, respectively, have the two highest reported rates for heavy drinking and smoking, past month use of cocaine, crack, marijuana and hashish, or psychotherapeutic drugs. Additionally, gender, racial, and ethnic substance use differences appear within the adult population. Some research has indicated that women who drink heavily do so several years later than men, although the reasons for this remain unclear. Researchers also indicate that black men who drink heavily, do so in their late twenties and early thirties, in contrast to white men whose drinking peaks at age 15 to early twenties. Increased research on the adult population could be useful in developing appropriate substance abuse prevention and treatment programs for adults.

o Race and Ethnicity. The biological and genetic substance abuse studies completed on different racial and ethnic groups have been few in number, mostly limited to alcohol, and inconclusive. While race and ethnicity have not been shown to be biological or genetic predictors for substance use, abuse, or addiction, certain risk factors appear to be unique for specific cultures. To date, however, the racial and ethnic categories used in many large-scale studies are so broad that many researchers consider them useless. Increased federal funding for studies of specific subpopulations living in geographically different areas (e.g., urban versus rural, reservation versus nonreservation) will provide much needed baseline data on which to plan, implement, and evaluate appropriate substance abuse services.

o Poverty. Disagreement exists on the appropriate definition of poverty and its exact relationship to substance abuse. While few researchers deny that the daily stresses associated with living in chronic poverty probably contribute to substance abuse, poverty is certainly not the only factor, or perhaps even the most important. There are after all, more individuals living in poverty who do not abuse substances than who do. However, the consequences of substance abuse appear to be worse in chronically poor areas. Additional research to study the complex relationship between poverty and substance abuse could provide substance abuse practitioners with a framework from which to build programs most suitable for the special needs of chronically poor areas.

Congress can, through its reauthorization and oversight powers, monitor the amount and scope of risk and protective factor research that is being conducted, and redirect federal efforts toward more extensive multifactor research and analysis, as appropriate. Such focus could include factors other than substance use that may contribute to later abuse and addiction, such as other problem behaviors, availability, marketing, psychological factors, social norms in communities, and subcultures. The increased use of ethnographers as part of a multidisciplinary drug abuse prevention research teams could also be encouraged.

Biomedical Research

Biomedical research on substance abuse helps explain the acute and chronic biological effects of substances on the brain and other organs, and also points to appropriate short- and long-term medical treatments for substance abuse. This in turn helps treatment providers understand treatment outcomes and relapse rates for long-term abusers. Most federally supported biomedical research is administered by the 17 institutes that comprise the NIH. With the passage of the Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act of 1992 (Public Law 102-321), NIDA and the NIAAA were moved to NIH. Research targeting substance use, abuse, and addiction is supported primarily by these two institutes, whose combined appropriation level ($580.7 million in fiscal year 1994) is approximately 5 percent of the NIH total.

Congress has historically increased annual appropriations for biomedical research at NIH; if Congress continues this trend, both NIDA and NIAAA annual appropriations will rise, although not at the dramatic levels many scientists would like. If Congress were to decide that substance abuse and addiction should command more of the nation's biomedical research budget, it could substantially raise appropriation levels for NIDA and NIAAA. Such an action would allow increased levels of research in a number of areas including: genetics; drug development; identification of biological factors related to transitions from casual drug use to abuse, addiction, and dependence; the pharmacology of multiple drug use; environmental factors and their effect on individual biological susceptibility; and the biological effects of drug use and abuse on the development of children and adolescents. Given budget realities, however, an increase in the funding levels available for basic biomedical research could mean a decrease somewhere else.

A number of budgetary pressures have recently slowed robust NIH budget growth, including the need to fund disease- specific research (e.g., acquired immunodeficiency syndrome), indirect costs of research, and the increasing pressure to limit discretionary spending. Some scientists identify stable budget growth--as opposed to sporadic increases targeted at particular topics--as most important for continued progress in research. In fiscal year 1994, both NIDA and NIAAA received a 5.2 percent increase in appropriations, following an Administration request that would have raised NIDA's appropriation by less than 1 percent, and decreased NIAAA's appropriation by 1.6 percent. Fluctuations in appropriation levels could impede the development of scientific advances that are necessary to the creation of new medications and therapies.

The Congressional Budget Office (CBO), in its March 1994 report to Congress, Reducing the Deficit: Spending and Revenue Options, identified a reduction in funding for NIH research as one of nearly 200 policy options. As noted by CBO, a reduction in NIH funding could have adverse effects on biomedical research and might cause some researchers to leave the field. NIH cannot currently fund the majority of grants it approves; in addition, funding is insufficient to support some important areas of research. According to a 1992 General Accounting Office report on Drug Abuse Research: Federal Funding and Future Needs, antidrug research appears now to have a very modest role, with only about 4 percent of total drug strategy spending devoted to research and development.

COMMUNITY ACTIVITY SETTINGS

Substance abuse and addiction occur in communities around our Nation. Those who believe that drug abuse and addiction are closely related to social and economic problems argue that antidrug programs should more directly address the risk and protective factors that have been identified by researchers. Many prevention program providers also argue that the most successful programs are those that are more comprehensive in scope (i.e., tailored to address the many community settings in which drug abuse can occur) rather than addressing one or two risk factors in isolation.

In conducting this assessment, OTA surveyed literatures addressing substance abuse and addiction in various community settings--families and homes, schools and peers, workplaces, and recreational settings (see ch. 8). The literature reviews presented in this report make clear that substance abuse and addiction can arise and be influenced by multiple factors in individuals, groups, and communities. Thus, effective intervention ideally should be comprehensive, employing multiple services and addressing the many factors that cause drug abuse and addiction; and community-based, sensitive to and directed at the needs of the local population.

Still, three problems arise in assessing policy options related to community settings:

1. There is the inherent difficulty in drawing a link between many social services and their effect on drug abuse and addiction.

2. Since broad-based social services are provided through the work of many federal agencies, further analysis (e.g., by ONDCP or a congressionally enacted national commission) could identify which federal agencies are best suited to implement the variety of options that Congress may wish to employ.

3. The federal budget deficit is an obstacle to the creation of new domestic programs that target known risk and protective factors in individuals and communities.

Schools and Peers

The primary focus of federal efforts at community-based drug prevention is programs aimed at our nation's schoolchildren. In fiscal year 1993, Congress appropriated $598 million to DOE under the Drug-Free Schools and Communities Act of 1986. The federal government could continue to fund school-based prevention programs, with a continued emphasis on prevention curricula and evaluations that are limited to substance use prevention. The likely limited effects on preventing abuse among high-risk youth would continue. Other school-based prevention programs would continue to be implemented sporadically, without significant evaluation and with few or unknown effects.

If Congress decided that more rigorous evaluation of school- based programs was called for, it could mandate DOE to spend a set percent of its Drug Free Schools monies on research and evaluation of prevention curricula and the dissemination of findings. A special initiative could be launched to test prevention curricula for high-risk youth and for different racial and ethnic groups, since most of the research and evaluation to date has been based on samples of schools with middle income white youth. Special expertise would need to be brought in, on staff and as advisers, to assure the research and evaluation meet high standards of methodological rigor. This could be achieved by hiring staff with research and evaluation expertise, detailing staff from the NIDA, setting up an interdepartmental advisory group that guides and oversees a research and evaluation program, or appropriating funds directly to NIDA (e.g., as a set- aside from the Drug-Free Schools appropriation) to support such a research and evaluation program. Also, easier access to information about the many drug prevention curricula that exist could help school personnel select curricula that fit their needs. DOE could be directed to prepare and disseminate more widely information about the purposes, design, methods, resources required, and evaluations (if any) of drug prevention curricula currently available, and to inform school personnel of the limitations of school- based curriculum approaches and the growing availability of supplementary and alternative approaches. If Congress decided that Drug-Free Schools funds should be used more widely to target risk and protective factors found in school-aged populations, it could require DOE to set aside a certain percentage of Drug-Free Schools funds for a variety of activities that target high-risk youths and to work individually with them and their families. Such targeting could enhance activities already carried out under the Drug- Free Schools Act (e.g., Drug Abuse Resistance Education, replication of successful programs, local programs for high- risk youth, school personnel training). However, congressional mandates could reduce state and local flexibility in tailoring programs best suited to local needs, and could increase administrative costs associated with implementing the Drug-Free Schools Act.

In addition to Drug-Free Schools programs, comprehensive primary health, mental health, and social services can be provided in many school-based clinics. School-based clinics can be supported by a variety of federal funding sources, including Medicaid, the Maternal and Child Health Block Grant, Drug-Free Schools, and Special Education funds. DOE and the Department of Health and Human Services could be encouraged or directed to collaborate on the support of such services in schools.

Since researchers have found that peers and other social influences strongly affect substance use, programs that strengthen total school environments may be potent in preventing substance use and abuse. Models that involve school restructuring, parent involvement, mental health components, and elevated expectations for achievement have been developed and are being tested. The hypothesis is that engaging high-risk youth in positive educational environments and experiences can profoundly influence their behaviors for the better. Congress could expand research on the effects of restructuring of school environments on substance abuse by appropriating funds for extensive large- scale longitudinal research that could be supported by DOE, NIDA, the Centers for Disease Control and Prevention (CDCP), and other federal agencies that conduct and support research on youth outcomes.

Homes and Families

Congress appropriates funds for federal programs addressing substance abuse and addiction in homes and families, which are supported by the HUD and HHS' Administration on Children, Youth, and Families (ACYF) and CSAP. Also relevant to the health and welfare of families are health funding programs (e.g., Medicaid and Medicare) and welfare programs (e.g., Aid to Families with Dependent Children). Through its oversight, authorization, and appropriations of these programs, and others that impact on the quality of family life, Congress can support a number of preventive interventions that are both comprehensive and intensive. Programs can be initiated by almost any local service or support setting, such as health care, school, family preservation, juvenile justice, and housing authority, with coordination with other services and settings. Such interventions can include health care, counseling, intensive in-home services, neighborhood patrols, clean sweeps of public housing, and family and parent education for all family members.

Because substance abuse and other related problems can be influenced by so many family factors and programs, a long- term effort to identify family needs may be desired. Congress could enact legislation to create a Presidential commission or task force to formulate a national family policy and create a blueprint for long-term national efforts to shore up the many families, rich and poor, that would benefit from more guidance, skills, and support. Such a national policy could be framed in the near-term, based on the many studies and program interventions that have been documented so far. Alternatively, it could be formulated later, after additional research and program interventions have been supported and major gaps in knowledge have been filled.

Workplaces

Congress could allow current activities that focus on providing workplace employees with information, development of drug-free workplace policies, drug testing, and employee assistance programs to continue. These programs are scattered among many federal agencies, with some leadership by the Department of Labor (DOL), CSAP, and the Office of Management and Budget.

If Congress chose to increase efforts in workplace antidrug prevention, it could mandate that federal agencies increase the information that is made available to workplaces about drug-free workplace programs and policies. For example, DOL is implementing an electronic database, with information about workplace substance abuse treatment, prevention, and other control programs and research. Such a database, if properly supported, publicized, and accessed by businesses and unions, could help workplaces identify and implement approaches that can meet their needs in affordable ways.

Recreational and Community Settings

Congress currently funds community partnership demonstration programs administered by CSAP. These partnerships foster public/private sector partnerships that create and preserve comprehensive strategies for addressing substance abuse prevention within communities. A major advantage of these partnerships is the ability to create programs that address substance abuse prevention within individual communities. As with other drug prevention programs, however, evaluation has generally been limited. Congress could, through appropriations and authorization, direct CSAP to expand the provision of technical assistance and expand the national process and outcome evaluation of partnerships. More site visits would be possible, with additional resources for national and regional workshops, conferences, and training.

Other federal activities in this area remain limited and largely uncoordinated. Major current programs are administered by the Department of Agriculture's Cooperative Extension Service (with its 4-H program, which is refocusing its efforts on high-risk youth) and CSAP (through some of its High Risk Youth Demonstration Grants). The President's Council on Physical Fitness addresses one aspect of recreational and leisure activities--that is, physical fitness. If Congress decided to provide more information and support more research on recreational, leisure, and other youth development programs, an information clearinghouse could be established to share information about federal and non-federal recreational, leisure, and youth development activities. The purpose would be to help communities and program developers identify and develop such programs especially for youth at risk of drug use and abuse. The clearinghouse could be managed in-house or under contract, and could be located in the Cooperative Extension Service (which is now attempting to redirect 4-H programs to address high-risk youth); ACYF; or CSAP (perhaps in the existing National Center for Alcohol and Drug Information, a federally sponsored clearinghouse).

The dearth of recreational places, especially in highly developed urban areas, can be remedied by an enhanced national effort to acquire land and facilities for park and recreation purposes. Such an effort could focus especially, but not exclusively, on rural and inner city areas where low property values make the acquisition of such properties financially attractive as long-term investments in the future development and enrichment of communities. Such a national effort could be comparable in scope and long-termcommitment to the development of the national park system, but could contribute to a broader national system of parks owned and managed by the federal, state, and local governments specifically for more intense human uses. Such a system could focus on the developmental needs of youth, especially in urban areas, where usable open spaces are often in short supply. Congress could designate a lead federal agency for such an effort (e.g., Department of Interior or HUD), and could acquire properties outright or by encouraging and subsidizing the acquisition of properties by nonprofit groups and by state and local governments. The latter approach would require less federal funding and administration. Possible sources of land and facilities include: closed military bases, holdings of the Resolution Trust Corporation, assets forfeited through drug seizures, individual gifts and bequests, and corporate and philanthropic gifts.

AVAILABILITY

The primary current focus of federal antidrug efforts is stemming the physical supply of illicit drugs. A multitude of policy issues arise in addressing drug availability, most of which are beyond the scope of this report. The discussion in chapter 4, however, touches on two availability issues currently on the congressional agenda.

Taxes

The federal government currently levies excise taxes on alcoholic beverages and tobacco products. Excise taxes on all types of alcoholic beverages were raised in 1990 to their current levels. Currently, for example, beer (six pack, 12-ounce cans) carries a 33 cent federal excise tax, a 750 ml bottle of wine carries a 21 cent federal excise tax. A pack of cigarettes carries a federal excise tax of 24 cents. If Congress takes no action, current federal levies will remain in effect.

Congress could enact legislation raising the federal excise tax on a variety of tobacco and alcohol products if it sought to decrease consumption of such products, to recover estimated societal costs (i.e., health costs, injury,

death) resulting from consumption of such products, or to raise revenue for federal spending programs. Such tax hikes could be targeted at all tobacco and alcohol products, or at selected products in these industries. Advocates of increased excise taxes have argued that abuse of and addiction to tobacco and alcohol products cost the United States more than any illicit substance; that increased taxes would make such products less economically affordable and hence less used and abused; that increased taxes could be used to pay for financial damages arising from the use of such products; and that such excise taxes, which have increased less rapidly than the general rate of inflation, should be adjusted upward to reflect inflation. Opponents of taxation have argued that excise taxes are regressive in that they target primarily low- and middle- income taxpayers, that increased taxes would result in significant losses to major companies that are important players in the American economy, and that targeting so-called sin taxes unfairly singles out millions of Americans who use tobacco and alcohol products.

Alcohol Labeling

Federal law currently requires that each alcoholic beverage container bear a specific warning statement that is conspicuously and prominently located (27 USC 215). This requirement was enacted by Congress in 1980. Both Congress and States have authority regulating alcohol advertising. At least 35 states regulate alcohol advertising, and self-policing by segments of industry places some limits on advertising (e.g., the distilled spirits industry code prohibits the advertising of liquor on radio or television).

Congress has considered legislation that would require warnings on all alcohol beverage advertising, both print and electronic media. Congress could amend current alcohol labeling law to require stricter labeling (e.g., multiple labels, rotating labels, specific messages). Opponents of such action argue that no significant relationship has been found between exposure of individuals to alcoholic beverage advertising and/or labeling and drinking behaviors. _

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Technologies for Understanding and Preventing Substance Abuse and Addiction