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Testimony before the U.S. House of Representatives
Statement
of Bertha Madras Deputy Director, Demand Reduction, White House Office
of National Drug Policy
Committee on House Government Reform Subcommittee on Criminal
Justice, Drug Policy, and Human Resources
July 26, 2006
I. INTRODUCTION
Chairman Souder, Ranking Member Cummings, and distinguished members
of the Subcommittee. I appreciate the opportunity to appear before
you today to discuss the Federal response to Prescription Drug Abuse.
Several classes of controlled prescription drugs, prescribed by physicians
for legitimate medical purposes, have abuse and addiction potential:
narcotic opioid analgesics (for management of pain, cough and other
indications), stimulant drugs (to treat attentional disorders, narcolepsy
and, less frequently, depression), tranquilizing drugs (to treat anxiety)
and sedative drugs (to promote sleep). These drugs are safe, effective
and necessary when used according to doctors' prescriptions and advice.
Abuse or non-medical use of prescription drugs can be defined as use
of drugs not prescribed for an individual, use of drugs solely for
the experience or feelings they cause, or use of drugs by a person
who has made false or inaccurate claims to obtain the drugs.
Last year, the National Survey on Drug Use and Health (NSDUH) uncovered
a higher number of new initiates into non-medical prescription drug
use than initiates into marijuana use. Statistics described below
(Section II. MAGNITUDE OF THE PROBLEM), indicate that misuse and abuse
of controlled and certain over-the counter prescription drugs is a
significant national problem. Notwithstanding the abuse of a range
of controlled and over-the-counter prescription drugs, opioid analgesic
drugs are drawing a higher level of national attention and concern,
because of the higher absolute population numbers, escalating rate
of abuse, high addictive potential, and potential to induce overdose
crises or death due to respiratory failure.
Potential causes. Among the factors postulated to fuel increased diversion
of legitimate prescription drugs are: 1. public perception that prescription
drugs are safer than illicit street drugs, 2. easier availability
via web-based sources or theft of legitimate prescriptions, 3. increased
direct-to-consumer advertising, which fosters the view that prescription
drugs are integral to our lives; 4. increased prescriptions for chronic
pain, sleeping and attentional problems, with increased potential
for diversion. 5. inadequate public perception on guarding prescription
medications. 5. increased web-based sources on how to tamper with
medications. 6. aging of the US population, which requires an increased
level of medications to sustain good health.
Potential profiles of abusers and sources of drugs. Different cohorts
of users require different strategies to prevent non- medical use
of prescription drugs: unintended populations include children, teens,
adults and high risk populations, who can become abusers by acquiring
prescription medications by forgery, internet purchases, robberies,
buying from patients, stealing from home medical sources, and drug
rings. Intended populations include patients who suffer pain, but
misuse drugs, or are co- morbid for opioid abuse, or opioid abusers
who acquire prescription drugs by doctor shopping, pill mills, or
by other means.
Response of various sectors: ONDCP, FDA, DEA, DOJ, SAMHSA, NIDA, pharmaceutical
companies, medical associations, pain management specialists, medical
schools and communities, are developing strategies in response to
this mounting problem, with the ultimate goal of attenuating diversion
of effective medications with abuse potential, while not compromising
the health, comfort and well-being of intended patient populations.
The core problem, misuse and abuse of legitimate medications by unintended
populations, is complex. This emerging challenge requires surveillance,
distribution chain integrity, interventions, and more research by
private and public sectors. Coordinated responses that include federal,
medical partners, public health administrators, state legislators
(e.g. Alliance of States with Prescription Monitoring), and international
organizations are needed to implement educational outreach and other
strategies targeted to a wide swath of distinct populations, including
physicians, pharmacists, intended patient populations, educators,
unintended populations, parents, high school and college students,
high risk adults, the elderly, among others. Effective risk management
plans developed by pharmaceutical companies in collaboration with
the FDA, as well as outreach to physicians and their patients and
pharmacists, need to be complemented by education, screening, intervention
and treatment for those misusing or abusing prescription drugs, the
unintended populations. ONDCP is a key contributor to devising policies
and funding demonstration programs that can survey, detect, intervene
and treat unintended populations that use prescription drugs.
II. MAGNITUDE OF THE PROBLEM
Sources of data. Several Federal agencies generated the data cited
below, including the National Survey on Drug Use and Health (NSDUH)
which monitored 67,760 persons aged 12 or older, treatment episode
data sets (TEDS), Monitoring the Future (MTF) and Drug Abuse Warning
Network (DAWN).
Non-medical prescription drug use: general. In 2004, an estimated
2.8 million persons used psychotherapeutics non-medically for the
first time within the past year. The numbers of new users of psychotherapeutics
in 2004 were 2.4 million for pain relievers, 1.2 million for tranquilizers,
and 793,000 for stimulants. An estimated 19.4 percent of past year
users of prescription drugs were new users-a statistically significant
increase of 13 percent over 2003's 17.2 percent.
The 2004 NSDUH data estimated that 48 million people ages 12 and older
had used prescription drugs for non-medical purposes in their lifetimes.
Of these, 2.5% (6 million people) were current users. These estimates
are unchanged from 2002 and 2003. Among young adults (aged 18 to 25),
non-medical use of prescription drugs was significantly higher in
2004 compared with 2002 for lifetime use (an increase from 27.7% to
29.2%) and for past month use (from 5.4% to 6.1%).
The mean age of first use of the various types of prescription drugs
is among the highest for any class of drug, equaled only by heroin
at 24.4 years: 23.3 years for pain relievers; 24.5 years for Oxycontin;
25.2 years for tranquilizers; 24.1 years for stimulants; and 29.3
years for sedatives. Only the mean age of first use for tranquilizers
showed any change from 2003, increasing from 22.9 years.
Non-medical prescription drug use: opioids. Narcotic analgesic drugs
are a type of pain reliever derived from natural or synthetic opioids.
Examples of these in common brand names include Vicodin, Percocet,
OxyContin, and Darvon. Pain relievers are the most commonly abused
prescription drugs, representing 75% of non-medical use for the past
month and past year (2004 data). While the numbers of current (4.4
million) and past year (11.3 million) users of pain relievers in 2004
are unchanged from 2002 and 2003, the estimates for lifetime users
increased 7 percent between 2002 and 2004 (from 29.6 million to 31.8
million). Specifically, lifetime use of pain relievers increased (22.1%
to 24.3%), as did past month use of pain relievers (4.1% to 4.7%).
The type of drug for new initiates is an important parameter of current
and possibly future trends. Of the 2.8 million past year initiates
into non-medical use of prescription drugs, 2.4 million (85%) were
pain reliever initiates. Equally concerning is that new users represented
21.5% of past year pain reliever users. Focusing on specific opioids,
1.2 million Americans used Oxycontin non-medically in the past year,
and of these, 50.7% were new users.
Monitoring the Future (MTF) data also may portend future drug trends.
MTF reports that past year use of Oxycontin among 12th graders increased
39.2 percent over three years - from 4.0% in 2002 (the first year
for which data on Oxycontin were collected) to 5.5% in 2005. Past
year use of Vicodin remained stable, averaging 10% among 12th graders.
Non-medical prescription drug use: other drug classes. Of the other
classes of prescription drugs, only sedatives showed any change in
2004 - a 39 percent decrease in the number of current users compared
with 2002 (from 436,000 to 265,000 people) was observed in the general
household population. However, among high school seniors, lifetime
and past year use of sedatives increased 21.5 percent and 25.2 percent,
respectively, since 2001 (from 8.7% to 10.5% and from 5.7% to 7.2%,
respectively).
Use of tranquilizers decreased among 8th and 10th graders. Lifetime
use of tranquilizers among 8th graders decreased 18.8% (from 5.0%
to 4.1%), and 22.9% among 10th graders (from 9.2% to 7.1%). Past year
use decreased 34.8% among 10th graders (from 7.3% to 4.8%).
Non-medical prescription drug use: treatment consequences. The Treatment
Episode Data Set (TEDS) compiles admission to facilities that are
licensed by State substance abuse agencies to provide substance abuse
treatment and are collected by SAMHSA. Although most admissions for
opioid addiction in 2004 were for heroin, TEDS admissions for primary
abuse of opioids other than heroin increased from 2.8 percent of all
admissions in 2003 to 3.4 percent in 2004, and increased from 53,730
to 63,853 individuals.
Non-medical prescription drug use: emergency room consequences. Emergency
department reports of opioid pain relievers and other prescription
drug abuse are increasing. According to SAMHSA's Drug Abuse Warning
Network (DAWN) data system, drug abuse related emergency department
visits involving narcotic analgesics/combinations increased 163 percent
in the nation (from 45,254 visits to 119,185 emergency department
visits) between 1995 to 2002. The greatest increases during this period
occurred for oxycodone/combinations (512%), methadone (176%), hydrocodone/combinations
(159%), and morphine/combinations (116%). Dependence was the most
frequently mentioned motive underlying drug abuse related emergency
department visits involving narcotic analgesics (47%), followed by
suicide (22%), and psychic effects (15%). The drug abuse motive was
unknown for 14% of the analgesic related emergency department visits.
Disposition of emergency department patients involving narcotic analgesics
was as follows: 53% were admitted for treatment, 44% were treated
and released from the hospital, and 3% that either left against medical
advice, died, or had an unknown outcome.
Other potential secondary consequences to intended patients include
reduced confidence in essential medications, increased physician reluctance
to prescribe pain medications and reduced patient access to needed
analgesic medications.
III. POSITIVE PROGRESS
These data emerge simultaneously with very encouraging reductions
in use of other drugs. Cooperative efforts of the Administration and
Congress have led to a historic 19% reduction in teenage illicit drug
use over the last 4 years. This reduction means that there are approximately
691,000 fewer 8th, 10th, and 12th graders using illicit drugs than
in 2001.
-- This includes a 30% reduction in the number of methamphetamine
lab incidents, in methamphetamine-positive workplace tests, in lifetime
methamphetamine use among youths over the past two years. Furthermore,
there is a significant increase in 12th graders who disapprove of
using amphetamines (MTF). Details for each drug are presented below:
-- Marijuana is the most commonly used illicit drug among this population.
Lifetime, past year, and past 30 day marijuana use decreased 12.9
percent, 15.0 percent, and 19.4 percent. -- Reductions in use of the
hallucinogens LSD and MDMA (ecstasy) since 2001 have been dramatic,
declining as much as a half to nearly two-thirds. Declines in LSD
use in all three prevalence categories are nearly two-thirds and declines
in the use of ecstasy among these categories range from almost half
to nearly two-thirds. -- There were also decreases in some categories
of other club drugs, including rohypnol, GHB, and ketamine. -- Use
of amphetamines in all three prevalence categories dropped by more
than one-quarter: 25.7 percent (from 13.9% to 10.3%), 27.2 percent
(from 9.6% to 7.0%), and 30.7 percent (from 4.7% to 3.3%). -- The
use of steroids was down 38.2 percent, 36.7 percent, and 29.8 percent
for lifetime, past year, and past month use, respectively. -- Lifetime
use of heroin and inhalants for all three grades combined declined
13 percent.
IV. SYNTHETIC DRUG CONTROL STRATEGY: INTRODUCTION
The Administration is concerned about the increase in the abuse of
controlled substance prescription drugs. In response to the data described
above, the Administration released its first-ever Synthetic Drug Control
Strategy in June 2006, which focuses on methamphetamine and prescription
drug abuse. With respect to prescription drug abuse, the Synthetics
Strategy calls for a 15% reduction in the illicit use of prescription
drugs over three years.
The unique nature of this problem, non-medical use of medically approved
prescription drugs, requires a creative balance between aggressively
reducing abuse of controlled prescription drugs while simultaneously
permitting lawful acquisition of controlled prescription drugs in
the practice of medicine. To develop an effective equilibrium between
the two general policy concerns, the Administration is committed to
prevention, education, and enforcement of non-medical, unlawful use
of controlled substances while recognizing the need for legitimate
access to controlled substance prescription drugs.
V. OVERVIEW OF SUPPLY REDUCTION
A significant challenge in developing a strategy to reduce the non-medical
use of controlled substance prescription drugs involves understanding
how the prescription drugs are diverted for illicit use, and which
of those methods are most commonly used. Unlike drugs such as heroin
or marijuana which are presumptively illegal and often obtained through
clandestine, secretive transactions, controlled substance prescription
drugs are available for legitimate purposes through one's physician
and pharmacy. For this reason, mechanisms that are otherwise legal
are often manipulated to acquire controlled substance prescription
drugs for illegal purposes.
The Administration's strategy to reduce opportunities for the diversion
of controlled substance prescription drugs seeks to address each method
of diversion. Because reliable data ranking each of these methods
of diversion by prevalence does not exist, for the first time in 2005,
the NSDUH incorporated questions into the Survey to identify sources
of diverted prescription drugs. These data are expected to be released
in September 2006. The 2006 Survey will seek even more detailed data
from respondents as to methods of diversion.
Although there are no firm data that rank methods of acquisition of
prescription drugs for non-medical purposes by frequency, specific
methods of diversion have been identified. The Administration's Synthetics
Strategy seeks to address each specific method: doctor shopping or
other prescription fraud, shipping illegal prescriptions from online
pharmacies, over- prescribing, theft and burglary (from residences,
pharmacies, etc.), selling pills to others, receiving at little or
no cost, from friends or family.
Strategy to Reduce Doctor Shopping or Other Prescription Fraud: Prescription
Drug Monitoring Programs. The 2004, 2005, and 2006 National Strategies
recognized the problem of prescription drug diversion via "doctor
shopping." Generally, this term refers to the visit by an individual-who
may or may not have legitimate medical needs-to several doctors, each
of whom writes a prescription for a controlled substance. The abuser
or addict will visit several pharmacies, receiving more of the drug
than intended by any single physician, typically for the purpose of
using the drug for psychoactive effects. Associated illegal activities
may include the forgery of prescriptions, further multiplying the
extent of diversion, or the sale or transfer of the drug to others.
In many states, physicians and pharmacists have not been able to automatically
cross-check other prescriptions given to the same patient.
In 2004, the Administration announced its intent to respond to this
problem by supporting Prescription Drug Monitoring Programs (PDMPs).
These programs are designed to reduce prescription fraud and doctor
shopping by giving physicians and pharmacists more complete information
about a patient's controlled substance prescriptions. These programs
vary by State, but generally share the characteristic of allowing
prescribers (e.g., a physician) and dispensers (e.g., a pharmacist)
to input and receive accurate and timely controlled substance prescription
history information, while ensuring patient access to needed treatment.
Most States also have some mechanism for law enforcement to receive
this information in cases where criminal activity is suspected. Health
care providers can use this information as a tool for early identification
of patients at risk for addiction and initiate appropriate medical
interventions. The justice system can use this information to assist
in the enforcement of laws controlling the sale and use of controlled
substance prescription medication.
At the beginning of this Administration, approximately 15 PDMPs were
in existence in the Nation. The program has expanded to 33 States
with active or planned PDMPs-more than double the number in existence
in 2001.
A critical avenue of Federal support for States is through the Harold
Rogers Prescription Drug Monitoring Grants Program at the Department
of Justice. These grants can be used to implement or enhance PDMPs
at the State level. The 2007 Budget continues funding for the Rogers
Program at the Justice Department, following the funding stream approved
by the Congress since 2003. The President has requested that Congress
provide $9.9 million for the program in fiscal year 2007 in order
to expand the program to new States and enhance the program where
it already exists. Officials at ONDCP, the Department of Health and
Human Services, and the Department of Justice work with state policymakers
to better understand best practices where the programs already exist.
Strategy to Reduce Illegal Access to Controlled Prescription Medications:
Internet pharmacies. As the number of Americans with Internet access
has increased, so too have opportunities for individuals to acquire
controlled substance prescription drugs over the Internet.
The benefits of allowing individuals with a valid prescription to
get their prescriptions over the Internet, from a legitimate pharmacy
are acknowledged, particularly for people living in rural areas or
individuals who are homebound due to illness, disability or other
factors. There are legitimate pharmacies that provide services over
the Internet and that operate well within the bounds of both the law
and sound medical practice. The National Association of Boards of
Pharmacy has established a registry of pharmacies that operate online
and meet certain criteria, including compliance with licensing and
inspection requirements of their State and each State to which they
dispense pharmaceuticals.
However, the anonymity of the Internet has enabled proliferation of
Web sites that facilitate illicit transactions for controlled substance
prescription drugs. These rogue online pharmacy Web sites and links
to those sites enable controlled substances to be ordered without
a valid prescription. The sites have given drug abusers/ drug addicts
and illegal providers a venue to circumvent the law and medically
approved prescribing practices by physicians.
Also in existence are Web sites that advertise themselves as pharmacies,
but do not operate in the same manner as legitimate pharmacies. Many
of these Web sites advertise the sale of controlled substances without
a prescription. Such online Web sites usually act as a facilitator,
or link, between an individual seeking controlled substance prescription
drugs and a doctor and a pharmacy willing to provide these drugs without
determining whether the individual has a legitimate medical need.
Of particular concern is the "pseudoexam", a cursory, abbreviated
medical interaction provided by the Internet site to facilitate a
cursory consultation by a doctor via computer or telephone for customers.
This consultation is unable to elicit meaningful health information,
because the doctor writing the prescription does not see the patient
to verify the information provided by the individual. For example,
Web sites have no independent means to verify the age of the recipient,
enabling a minor to log onto a Web site and claim an inaccurate age.
Doctors, frequently paid by the number of prescriptions they sign
in this system, have no incentive to spend time seeking additional
patient information. Law enforcement has discovered Web site-affiliated
doctors who sign hundreds or thousands of prescriptions a day. After
receiving the prescription from the doctor, the facilitator will then
submit the prescription to a cooperating pharmacy. Because there is
no identifying information on the Web site, it is difficult for law
enforcement to track the individuals supervising the Web site.
The Administration is using available tools to conduct investigations
of rogue Internet-facilitator Web sites, with the purpose of intercepting
controlled substance prescriptions illegally sent into the United
States through the mail system. For example, the DEA's Internet investigation
unit at its Special Operations Division coordinates Internet cases.
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The DEA has issued immediate suspensions of numerous Internet pharmacies.
DOJ has prosecuted doctors and pharmacies who illegally distribute
via the Internet. States can also play a significant role in addressing
the problem of online facilitators, particularly through PDMPs.
As part of the Administration's work with States regarding PDMPs over
the next three years, States will be encouraged to consider addressing,
either by statute, regulation, or interstate agreement, situations
in which:
-- Pharmacies in the State dispense or deliver controlled substance
prescription drugs to an address of a patient in another State;
-- Pharmacies or other dispensers located in another State dispense
or deliver controlled substance prescription drugs to an address of
a patient in their own State; and
-- Pharmacies or other dispensers in another State that dispense or
deliver controlled substance prescription drugs to a patient with
an official address in their own State.
The Administration will continue to use the tools at its disposal
to target, investigate, prosecute, and dismantle illicit online pharmacies.
Strategy to Reduce Improper Prescribing. The overwhelming majority
of prescriptions written in America are responsibly issued on the
basis of legitimate medical reasons. A small number of physicians
over-prescribe controlled substances, either carelessly, or deliberately.
This source of prescriptions drugs facilitates drug addiction. The
number of physicians responsible for this problem is a very small
fraction of those licensed to dispense controlled substances in the
United States. Law enforcement conducts investigations to establish
whether the prescribing practice is consistent with sound medical
judgment and prevailing medical standards. As part of the Administration's
strategy to reduce opportunities to divert controlled substance prescriptions,
law enforcement will continue to examine situations where prescriptions
for controlled substances are unusually and obviously high, in the
absence of legitimate circumstances.
VI. OVERVIEW OF PREVENTION AND TREATMENT
Approximately 35% of the Federal drug budget is targeted to prevention
and treatment of drug abuse and addiction. These programs give states
and local authorities flexibility in meeting drug-related challenges
their communities face, including the mounting problem of prescription
drug abuse. Our strategies in prevention and treatment of prescription
drugs are both targeted specifically to prescription drugs and to
programs that enable prevention, intervention and treatment of addictions,
which can have a significant impact on prescription drug abuse.
Preliminary data suggests that the most common way in which controlled
substance prescriptions are diverted may be through friends and family.1
A person with a lawful and medical need for a certain amount of a
controlled substance may use only a portion of the prescribed amount
and responds to a family member's complaint of pain, by sharing excess
medication. Alternatively, for a family member addicted to controlled
substance prescription drugs, the mere availability of unused controlled
substance prescriptions in the house may prove to be an irresistible
temptation. The solution to this problem lies with the medical community
and the intended recipient of prescription medications: medical education
programs that inform the physician on how to identify the opioid-seeker,
counsel patients from losing control of their prescription medications,
reducing the number of doses, if feasible, refer pain patients to
specialists, and monitor opioid use, by biometric analysis. Patients
require information on strategies to retain control of their medications.
Strategies Specific for Physicians Prescribing Controlled Prescription
Drugs: Medical Education. The Medical Profession has been alerted
through a number of organizations, meetings, medical journals, and
medical associations and via pharmaceutical companies of the mounting
problem of prescription drug abuse. Notwithstanding the responsible
and considered response of the medical community, current statistics
indicate that a more concerted effort is required to diminish this
escalating public health problem in our society. The administration
recognizes the need for a closer partnership between the general medical
community, and pain and addiction specialists. To this end, we are
organizing several events later this year to facilitate the dissemination
of pain and addiction information to the general medical community.
Representatives of the medical and pharmaceutical communities will
be called together to develop an concerted, effective strategy of
change to address this public health problem. It will encourages medical
professionals, pharmacists and pharmaceutical companies to take a
leading role in educating physicians and patients as to the importance
of retaining control of prescriptions medications with abuse liability.
ONDCP is also convening a medical conference to assemble leading medical
professional associations to focus on medical education on addictions,
and specifically on prescription medications.
Multi-Disciplinary Dissemination of Prescription Drug Strategies:
Fentanyl. In response to deaths reported in eight states to be associated
with fentanyl-laced heroin and cognizant of the view that illegal
manufacture and distribution of fentanyl poses unique challenges,
ONDCP is convening a Demand Reduction Forum in Philadelphia this Friday,
July 28/2006. The forum brings together law enforcement and public
health officials, treatment providers, and prevention specialists
from Federal, State, and local government to discuss response mechanisms
and techniques and the threat to public health arising from abuse
of fentanyl. By Friday July 21, 2006, over 100 professionals have
registered to attend this important conference.
Other recent outreach efforts include two meetings in Chicago convened
by the Chicago Police Department, the Drug Enforcement Agency, and
the Chicago High Intensity Drug Trafficking Area, a weekly inter-agency
telephone conference initially convened by CDC and SAMHSA to share
information on recent developments, and warning alerts sent out by
SAMHSA to treatment providers and CDC to public healthcare professionals,
including state and local health departments and poison control centers.
Prevention Strategies Specific for People with Access to Controlled
Prescription Drugs: Media Campaign. Reductions in prescription drug
abuse also require the dissemination of information to various sectors
of our society that encounter this class of drugs. Foremost, patients
in possession of controlled prescription drugs need to be educated
about the legal, social, medical and behavioral consequences of providing
a controlled substance to a friend or family member. Patient-parents
also need to become aware of the need to restrict access to their
drugs. Finally, youth and adults need to become aware of the potentially
severe adverse consequences of drugs. ONDCP's National Youth Anti-
Drug Media Campaign is addressing the rise in prescription drug abuse
by teens. Prescription Drug Use is featured on the Youth and Parents
Websites visited by almost two million people a month. The Parent
Website has extensive information on the dangers of prescription drugs,
ways to prevent this drug use, and resources for parents to help teens
who have a problem. All of the parenting resources (handbooks, CD-ROMs,
brochures, websites, advertisements, press messages) have solid information
on monitoring techniques that are effective against prescription drug
use, along with other risky behaviors. The Media Campaign recently
added a specific advice page on how to deal with prescription drug
use into their interactive parenting guide.
The Media Campaign is also reaching parents with press outreach; for
example, on July 18th Director Walters held a press conference that
focused on the need for parents to monitor their teens internet usage
to avoid the drug threat. Starting last Friday, a new open letter
ad from ONDCP's National Youth Anti- Drug Media Campaign will run
in People magazine, alerting parents to the pro-drug influences to
which young people are exposed by technologies like the Internet,
text messaging, and social networking sites.
The ad specifically addresses the risk of prescription and over- the-counter
drug abuse by young people. The E-Monitoring Open Letter to Parents
also appeared in Sunday's New York Times, as well as top newspapers
in 27 media markets across the country and consumer publications like
Newsweek. Seven health, parenting, and media education organizations
signed the E-Monitoring Open Letter to Parents, including the PTA
and the American Academy of Pediatrics.
Established Programs: Community Coalitions. Communities across the
country have formed local anti-drug community coalitions that coordinate
prevention and intervention efforts. These coalitions bring together
community leaders and professionals in health care, law enforcement,
and education to provide local, grassroots solutions to the challenges
drug and alcohol abuse pose to their neighborhoods. Coalitions work
to develop a model for all sectors to work together to change community
norms and send the same no- use messages to young people. The Administration
supports the efforts of many of these coalitions by providing $79.2
million in the President's FY 2007 Budget through the Drug-Free Communities
(DFC) Support Program. Through the establishment of community coalitions,
the DFC program is designed to complement the development and implementation
of the Strategic Prevention Framework in communities across America.
Community Coalitions: Prescription Drug Tracking. Currently, there
are over 700 funded DFC coalitions, which exist in every state and
form the backbone of the Nation's community prevention system. Under
this program, each grantee receives up to $100,000 annually for up
to five years to develop a comprehensive community plan to address
substance abuse problems. Of the over 700 DCF grantees, 365 work on
prescription drug abuse, including education efforts to prevent abuse
and the tracking of amphetamines, barbiturates, and oxycodone.
Established Programs: Prevention and Intervention by Biometric Identification:
Student Drug Testing. The President stated in his 2004 State of the
Union Address that drug testing is an effective part of a community-based
strategy to reduce the demand for illicit substances. When implemented
in combination with other drug abuse prevention measures, this non-punitive
public health tool can reduce the number of youth using drugs illicitly
and, by preventing or deterring early-initiation, can also decrease
the likelihood of adult drug use. Testing can be used to screen for
the abuse of prescription drugs. If a student tests positive, the
parents can be notified of the result and can take action if they
determine the student should not be taking the drug.
Student drug testing is also an important screening tool that can
identify youth who have initiated prescription substance use so that
parents and counselors can intervene at an early stage as well as
those with a drug dependency so that they can be referred to appropriate
treatment. The Office of National Drug Control Policy works closely
with the Department of Education to help interested schools and communities
learn more about how to develop and implement a comprehensive, considerate,
and safe random student drug testing policy. Regional and State summits
with experts in the field and other outreach activities help spread
model program elements and increase awareness about this prevention
program.
Grants from the Department of Education in 2003 and 2004 in the amount
of $2 million and in 2005 in the amount of $9.9 million have afforded
373 schools around the nation the opportunity to enhance and implement
student drug testing programs. All grantees screen for opioids and
amphetamines. Once a screen shows an opioid positive, the screen is
broken down to determine which drug is present. If it is determined
to be a prescription drug, then the parent is notified to verify that
the student has been prescribed that particular drug. Many more schools
have added this strategy to their existing drug prevention programs.
These schools recognize the benefits of stopping drug use before it
starts and in promoting a safe and drug-free community.
Established Programs: Screening, Brief Intervention, Referral and
Treatment (SBIRT). A key component of expanding the Nation's treatment
capacity lies in early detection and engaging health professionals
in the identification, counseling, referral, and ongoing medical management
of persons with substance use disorders. The Department of Health
and Human Services offers grants through the Screening, Brief Intervention,
Referral and Treatment (SBIRT) program to States, territories, and
tribal organizations to provide effective early identification and
intervention in general medical settings. This program is based on
research showing that by simply asking questions regarding unhealthy
behaviors and conducting brief interventions, patients are more likely
to avoid the behavior in the future and seek help if they believe
they have problem. The programs are based in clinical settings, a
location that has a high propensity to attract higher-risk populations,
who through violence, accidents or health-related problems, are seen
by medical professionals.
SBIRT expands the continuum of care available for treatment of substance
use disorders by matching an individual's stage of illness to the
initial treatment experience and improves linkages among general community-health
related services and specialized substance abuse treatment agencies.
Universal screening of patients in a general medical setting can significantly
reduce drug and alcohol use among non-dependent users, even without
accompanying intervention.
SBIRT could help identify a cohort of prescription drug abusers who
enter hospital or clinical environments seeking treatment for reasons
other than for prescription drug abuse. This cohort would have the
opportunity to be shepherded into interventions or treatment programs.
Awards for the program were made in September 2003 to six States and
one Tribal Council. In addition to these grants, 12 universities and
colleges have received funding to develop a screening and intervention
model to be used on campuses. These programs will identify drug problems
at an early stage and help reduce drug dependency and addiction in
this vulnerable age cohort. The Office of National Drug Control Policy
works closely with the Substance Abuse and Mental Health Administration
to monitor the success of these programs and to highlight the benefits
of early screening and intervention. As part of the FY07 budget, approximately
$31.2 million is requested for this initiative.
Established Treatment Programs. Stopping use before it starts is a
priority of the Office of National Drug Control Policy, but treating
drug users is critical to demand reduction efforts. From extensive
work in the field of addiction science, we know that treatment for
drug dependency and addiction - including to methamphetamine - can
be effective. The programs we support make significant contributions
to closing the treatment gap. At present 8.1 million of the 34.8 million
past year drug users in the United States meet the clinical definition
of abuse or dependency. Of these, 1.4 million received treatment at
a specialty treatment facility. Continued success in healing America's
drug users is predicated on the availability of treatment for the
remaining 6.6 million.
Treatment for prescription drug abuse is available. For example, for
those who abuse methamphetamine, the Matrix Model is an evidence-based
intensive outpatient treatment program created by The Matrix Institute
in Los Angeles. It has been tested through research, showing favorable
outcomes. It is a manual-based treatment that uses cognitive behavioral
therapy, relapse prevention and skill training, all presented in Motivational
Interviewing style. Treatment includes educational sessions for client
families and other support people. Skill training groups focus on
recovery and relapse prevention. The main objective of the program
is to provide clients with a behavioral structure and daily skills
enabling the eventual development of a clean and sober lifestyle.
Matrix clients were 38 percent more likely to stay in treatment compared
with other treatment modalities and were 27 percent more likely to
complete treatment. In some sites of the research clinical trail (total
of 8 sites), the Matrix condition was associated with significantly
longer periods of abstinence. Treatment completion was about 41 percent.
Specific to opioid addiction, SAMHSA's Center for Substance Abuse
and Treatment has Opioid Treatment Program (OT) accreditation grants
to: (1) reduce the costs of basic accreditation education and accreditation
surveys and ongoing reaccreditation for OTPs; (2) ensure that new
OTPs and OTPs that did not become fully accredited before the May
19, 2004, regulatory date become fully accredited under 42 CFR Part
8; and (3) ensure that OTPs maintain their accreditation by undergoing
the reaccreditation process every three years.
The President's FY 2007 budget request includes $1.76 billion for
the Substance Abuse Prevention and Treatment Block grant, of which
20 percent is set-aside for substance abuse prevention. These funds
are directed to specialty treatment providers, many of whom provide
treatment for abuse and dependence of prescription drugs. The President's
budget also includes nearly $556 million in prevention and treatment
discretionary grants (Programs of Regional and National Significance),
including Access to Recovery.
Administered by SAMHSA, the President's Access to Recovery (ATR) program
is now in 14 States and one Native American organization. Over the
three year grant cycle, ATR will provide services to an estimated
125,000 people who seek treatment, but are not able to obtain it,
in part, because they cannot afford it. To close the treatment gap,
ATR also funds essential recovery support services not generally provided
through conventional Federal treatment resources, such as comprehensive
relapse prevention services, transportation, or child-care. Many providers
are unable to offer "wrap-around" services, even though they are less
costly than services required in the initial stages of recovery, and
are of paramount significance to those in recovery
The President's FY07 request for ATR is $98.2 million, which includes
$24.8 million for an ATR-Methamphetamine initiative. Both the House
and Senate appropriations bills eliminated funding for ATR I'd like
to take this opportunity to encourage the Committee to look more closely
at ATR, and data on outcome measures.
Established Treatment Program: Drug Courts. There are currently in
excess of 1,750 drug courts in operation and another 400 in development.
Using the coercive power of the courts to alter behavior through a
combination of escalating sanctions, mandatory drug sentencing, and
rigorous case management to address the individual's overall needs,
drug courts divert non-violent, low- level offenders whose underlying
problem is drug use away from prison and into supervised treatment
The National Center on Addiction and Substance Abuse (CASA) at Columbia
University reviewed and synthesized over 120 evaluations and determined
that drug courts provide the most comprehensive and effective control
of drug-using offenders criminality and drug usage while under the
courts supervision. A National Institute of Justice report demonstrated
that, within the first year of release, 43.5 percent of drug offenders
are rearrested, whereas only 16.4 percent of drug court graduates
are re-arrested. This ratio of re-arrest rates persists in year two
following graduation from drug court. Drug courts have not traditionally
focused on prescription drug abusers. ONDCP will be working with HHS
and DOJ to assess the current status of prescription drug abuse in
drug courts and will make recommendations based on our findings. There
is strong administration support for drug courts. The President's
FY 2007 budget requests a funding level of $69.2 million for drug
courts programs - an increase of $59.3 million over the 2006 enacted
level.
This increase reflects a commitment to this program.
VII. CONCLUSION
Scheduled prescription drugs are safe, effective, and necessary for
intended patients, when prescribed for legitimate medical purposes.
The diversion of prescription drugs for unintended, non- medical purposes
is a national public health challenge. We are encouraged by increasing
collaboration and cooperation between pharmaceutical companies and
federal agencies, the medical community, and state regulators, which
have instituted surveillance, pharmaceutical tracking, legal strategies,
educational programs, risk management plans, tamper-free formulations
and other procedures and polices to attenuate this escalating problem.
ONDCP is committed to eliminate diversion and abuse of potentially
addictive prescription medications, by engaging Federal, private,
legal and medical sectors in the creation of effective strategies
and policies. The Synthetic Strategy focuses on methamphetamine with
relevant programs applicable to prescription drug abuse. Screening,
brief intervention and referral to treatment (SBIRT), Student Drug
Testing and Drug Courts identify and steer methamphetamine or prescription
drug abusers/addicts into intervention and treatment programs. Access
to recovery (ATR) and State Block grants provide the necessary treatment.
The President's Drug Control Policy is characterized by vigilance,
flexibility, adaptability and innovative strategies to address emerging
drug threats. The Administration is committed to developing an effective
public health strategy that balances the legitimate medical use of
prescription drugs by intended populations, while eliminating diversion
and abuse of these medications by unintended populations. Multidisciplinary
programs that provide surveillance, legal strategies, identification
of prescription drug abusers and treatment capacity are major components
of the Synthetic Strategy.
Thank you. I welcome questions from the Subcommittee.
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