SAMHSA FY Budget for 2005
Substance Abuse and Mental Health Services Administration
Significant Items for the House, Senate and Conference Appropriations Committee Reports - Senate Report No. 108-81

[Adolescent mental health screening public awareness campaign] - Between 7 million to 10 million teenagers suffer from a mental health condition which, for many, may lead to serious behavioral problems including dropping out of school, substance abuse, violence, and suicide. The Committee is aware that some school districts, juvenile justice facilities, and community-based clinics have taken advantage of relatively simple screening tools now available to detect depression, the risk of suicide, and other mental disorders in teenagers. The Committee believes that screening should occur with the consent of the adolescent and his or her parents or guardian, and with a commitment by the screener to make counseling and treatment for those found to be at-risk. The Committee strongly urges SAMHSA to make the availability of these screening programs more widely known, and to collaborate with the Department of Education, Department of Justice, CDC, HRSA, and other pertinent agencies to encourage implementation of similar teenage screening programs. The Committee expects to receive a report on steps being taken to promote this effort prior to the fiscal year 2005 appropriations hearings. (Pages 179-180).

Action taken or to be taken
The Committee requested a report on the steps being taken to promote this activity before the 2005 appropriations hearings. The information is provided below.

SAMHSA is currently supporting the development of school-based suicide prevention guidelines in response to a set of objectives given by the National Strategy for Suicide Prevention. These guidelines provide information on how to create comprehensive, suicide prevention programs. The guide also offers descriptions of over 30 exemplary, school-based suicide prevention programs, including several screening programs utilizing evidence-based screening tools. SAMHSA plans to work in collaboration with the Department of Education, the Department of Justice, CDC and other pertinent agencies to promote dissemination of these guidelines.

SAMHSA will meet with NIMH, CDC, and other Federal partners, to discuss the requirements, feasibility, advisability, and necessary next steps to promote widespread implementation of screening programs for teenagers.

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[Resources required to establish State infrastructure supporting transition to performance partnership] The Committee is concerned that SAMHSA has not yet provided Congress information detailing the resources each State will need for data infrastructure and other needs to support a transition to a performance partnership grant as called for in the Children's Health Act of 2000. The Committee expects SAMHSA to work with the State and local substance abuse community in order to accurately determine the resources needed for the new and expanded data collection requirements and to report this information to Congress expeditiously. (Pages 186-187)

Action taken or to be taken
SAMHSA is planning to assess individual State needs in this area. For example, it plans to use technical assistance funds of the Center for Substance Abuse Treatment (CSAT) to assess State capacity to report substance abuse treatment data. In general, however, over the past several years, SAMHSA and the States have prepared for performance measurement and management. SAMHSA's block grant set-asides are the key source of funding available to both SAMHSA and the States for consensus building, data collection, data analysis, technology support, technical assistance, and evaluation. Activities funded by the set-aside sustain and advance the action steps identified in the PPG implementation plan described in the next section of this report.

Another key source of support that will enable States to transition more easily to PPGs comes through SAMHSA's State Incentive Grants (SIG). Because they are designed to give the States the ability to plan comprehensively, leverage funds across systems and departments to address certain priorities and use evidence-based practices, SAMHSA SIGs work in much the same way as the proposed PPGs. At a minimum, they work in tandem with PPGs. The CSAT Access To Recovery initiative, a SIG, is also consistent and supportive of developing the state data infrastructure essential in measuring and monitoring PPG activities.

SAMHSA will continue its specific support to the States for data collection and reporting through grant and contract programs. CMHS is providing support for States through the Data Infrastructure Grants (DIG) program to report on the URS measures, supporting web-based reporting, and refining measures and methodologies for recording and reporting. It is also providing support to National Association of State Mental Health Directors (NASMHPD) to synthesize this data into state specific and national reports. In addition to the general support for performance measurement like activities through the SIG program, CSAP's SIG Enhancement grants will enable States to strengthen their data infrastructure for gathering and reporting performance data. This program is funded from SAMHSA discretionary funding. CSAT has been funding State Data Infrastructure and State Treatment Needs Assessment program from block grant set-aside funds.

In addition, because PPGs will need to rely on an IT architecture that will enable easy access and use of performance data, SAMHSA will continue its efforts to develop web-based systems. Efforts developing three separate systems are currently supported through contracts and funded through the block grant set-side funds, but will need to be reassessed in terms of whether one or multiple systems are needed, within the broader agency-wide Data Strategy. CMHS is funding the Decision Support System 2000+ (DSS 2000+). CSAP supports the development of State Management Information Systems through its state Data Systems contracts, including specific funding for MIS development. CSAT supports the Web Information for Treatment Services program (WITS).

With respect to staff training, CSAT has been funding the PPG Technical Assistance Coordinating Center (PPG TACC) to provide trainings and materials for States on performance measurement and performance management. In addition, CSAT is working with its ATTCs on various aspects of PPG implementation, including the identification of State workforce and training needs related to PPGs. CMHS is supporting technical assistance for the States through its National Treatment Assistance Center and held a conference on performance data issues for the States in late May 2003. Analytic and TA support to CSAP staff is provided through CSAP's SPAS and Performance Partnership Models (PPM) projects. CSAP provides TA to the States primarily through its Centers for the Advancement of Prevention Technology.

Information on these activities and estimates of funding needed to continue them have been provided to SAMHSA's Data Strategy Group and will be addressed as the Administrator finalizes and implements SAMHSA's Data Strategy.

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[Substance abuse in rural and Native American communities] -- The Committee remains concerned by the disproportionate presence of substance abuse in rural and native communities, particularly for American Indian, Alaska Native and Native Hawaiian communities. The Committee reiterates its belief that funds for prevention and treatment programs should be targeted to those persons and communities most in need of service. Therefore, the Committee has provided sufficient funds to fund projects to increase knowledge about effective ways to deliver services to rural and native communities. (Page 176)

Action taken or to be taken
Through collaborative efforts of SAMHSA's Centers for Substance Abuse Prevention (CSAP) and Substance Abuse Treatment (CSAT), SAMHSA is addressing the substance abuse prevention and treatment issues of rural and Native American Communities. Both Centers recognize the need for funding to increase knowledge about effective ways to deliver services to rural and native communities, and are committed to providing culturally competent services to members of all communities, including rural communities, American Indian, Alaska Native (AI/AN), and Native Hawaiian communities. In response to this issue, CSAP and CSAT fund alcohol and drug abuse service programs under Programs of Regional and National Significance (PRNS) and Substance Abuse Prevention and Treatment Block Grant (SAPTBG) allocations.

Specific examples of activities focusing on rural and Native American Communities include:

· During FY 2003, CSAP supported approximately $24,262,000 American Indian/Alaska Native grant activities through its PRNS and SAPT BG programs.

· For several fiscal years, CSAT has targeted funding for treatment services in rural, native, and tribal communities where little or no treatment capability exists. In FY 2003, CSAT provided approximately $35 million, or almost 11% of its total Programs of Regional and

National Significance (PRNS) discretionary funds, to support services for American Indian, Alaskan Native, and Hawaiian Native populations.

· The 20 percent prevention set-aside of the Substance Abuse Prevention and Treatment Block Grant (SABG) substantially increases states' capacity to build and enhance their prevention and treatment services and systems to address the needs of rural communities and Native American/Alaskan Native populations.

· CSAP is continuing to implement the Fetal Alcohol Syndrome Disorder (FASD) project in Alaska to prevent alcohol-related birth defects and improve services to individuals throughout the State.

· In FY 2003, a $3 million, three-year award, with equal contributions from CSAT and CSAP, established a National American Indian/Alaska Native Resource Center, built on the concepts of CSAT's Addiction Technology Transfer Centers (ATTCs) and CSAP's Centers for the Application of Prevention Technology (CAPTs). The focus of the AI/AN Resource Center is identification and dissemination of effective evidence-based and traditional prevention and treatment services and to enhance communication, technical assistance, and other information sharing among rural and native populations nationwide.

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[SAMHSA and NIH collaboration] - The Committee continues to strongly support the ongoing collaboration between SAMHSA and the National Institutes of Health, specifically the National Institute of Mental Health, the National Institute on Drug Abuse, and the National Institute on Alcohol Abuse and Alcoholism. The Committee urges SAMHSA to make concerted efforts to reduce the current 15- to 20-year lag between the discovery of an effective treatment or intervention and its availability at the community level. (Page 176)

Action taken or to be taken
In FY 2002 and 2003, SAMHSA's Administrator took the first step to advance the SAMHSA/NIH collaboration by prioritizing Science to Services as a SAMHSA effort; articulating a vision for the collaboration; and identifying a senior level staff person to serve as a focal point for the initiative. The following additional steps have been taken:

· The SAMHSA Administrator, the Center Directors and the Acting Institute Directors met to formally launch the Science to Services initiative.

· SAMHSA established and filled a Science to Services Coordination position.

· A Science to Service Implementation Work Group was established, and has been meeting regularly. Membership includes representatives from the NIAAA, NIDA, NIMH and each of SAMHSA's Centers. An internal SAMHSA Science to Services work group was also organized to coordinate SAMHSA efforts.

· Each of SAMHSA's three Centers (Center for Mental Health Services [CMHS], Center for Substance Abuse Treatment [CSAT], and Center for Substance Abuse Prevention [CSAP]) has identified appropriate Science to Services activities that support the larger NIH/SAMHSA initiative.

· To implement the vision of the Science to Services initiative, the Work Group has conceptualized a Science to Services cycle that identifies specific inter-related steps of the process.

· In July 2002, a training and technical assistance session on the Science to Services Initiative was held for SAMHSA staff. The purpose of the session was to provide SAMHSA project officers with information and tools to help their grantees to apply for Institute grants. Senior staff from the three Institutes provided the training. The session was well received by SAMHSA staff.

· In April 2003, a training and technical assistance session on the Science to Services Initiative was held for current SAMHSA grantees. The purpose of the session was to provide these grantees with information and tools to help them apply for Institute grants. Senior staff from the three Institutes provided the training, which was well received by participants.

· In an effort to reach consensus on mechanisms for collaboration, the Implementation Work Group is sharing information related to the Institutes effective clinical interventions, SAMHSA's effective program interventions and an inventory of current SAMHSA/NIH collaborations.

· Transition of research responsibilities in FY 2004 and FY 2005 will continue, and additional steps within SAMHSA will accelerate the translation of research findings into the delivery of services, as evidenced by the following:

· Expansion of SAMHSA's National Registry of Effective Programs (NREP) is underway and will involve the review and identification of effective or evidence-based programs in the core areas of mental health treatment and prevention, and substance abuse treatment, to add to programs already identified in substance abuse prevention. Many of the current NREP model programs began as NIH-funded interventions, and it is likely that NREP expansion will identify additional NIH-funded interventions for recognition as model, effective and promising programs.

· SAMHSA's efforts to create standardized discretionary grant mechanisms will enable targeted investments in services, infrastructure, best practices, and service-to-science grants that will promote the expansion and adoption of evidence-based practices.

· Exploration with NIH to identify how existing Institute grant mechanisms may be aligned with SAMHSA's new standard grant mechanisms to promote coordinated or collaborative funding of research and services in specific priority areas.

· Planning efforts to reach out and engage mental health and substance abuse providers and training institutions to develop curriculum and educational programs that will reinforce the use of effective and evidence-based practices.

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[Review of report on underage drinking] - The Committee is troubled by SAMHSA's letter to the National Academy of Sciences Institute of Medicine recommending that it include traditional advocacy groups and the alcoholic beverage industry as peer reviewers for the NAS/IOM report on a national strategy to reduce and prevent underage drinking prior to the report's release. The Committee provided funding to the NAS for this report in fiscal year 2002 because it values the NAS's reputation for objectivity, independence, and competence, and it has confidence that the NAS will offer the most appropriate science-based findings and recommendations. SAMHSA should not recommend the involvement of groups with potential conflicts of interest in the peer review process. The Committee believes the NAS has developed appropriate policies for the conduct of the peer review process that will ensure a balanced, objective and science-based report. (Pages 176-177)

Action taken or to be taken
The NAS report has been issued, and it is SAMHSA's understanding that no groups with potential conflicts of interest were involved in the peer review process. Consistent with the conference report, SAMHSA looks forward to having a key role in establishing an interagency committee on the prevention of underage drinking, issuing an annual report summarizing all Federal agency activities concerning this issue, and coordinating with NIAAA on a plan for combating underage drinking,

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[Mental health counselors] - The Committee continues to support funding for mental health counselors for school-age children, as part of an effort to reduce the incidence of youth violence.

The Committee intends that $95,000,000 be used for counseling services for school-age youth. Among other things, the Committee believes that mental health counseling for troubled youth can help prevent violent acts, and therefore is providing continued funding to help schools in that
effort. It is again expected that SAMHSA will collaborate with the Departments of Education and Justice to continue a coordinated approach. (Page 178)

Action taken or to be taken
The goals of the SAMHSA's Safe Schools/Healthy Students initiative include interagency collaboration with the Departments of Education and Justice as well as within communities to address issues related to violence prevention. In FY 2004, SAMHSA will continue support for the interagency collaboration through a new competition for grant awards.

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[Jail diversion grant program] - The Committee supports $6,059,000 for the jail diversion grant program. The Committee recognizes that up to 1 million individuals with mental illnesses will spend time either in jail or prison during the current year. This is a most unfortunate statistic, when individuals could be more appropriately treated in a community health setting. Therefore, the Committee urges SAMHSA to work with the Department of Justice, the law enforcement community, the court system and other appropriate agencies and associations to ensure that funding is utilized to divert inappropriate incarcerations and link individuals with mental illnesses with the support they need to avoid future contact with the criminal justice system. (Page 179)

Action taken or to be taken
In FY 2002, CMHS funded a new Jail Diversion program in the amount of $4 million. In FY 2003, an additional $2 million supported 7 new grants for a total of $6 million with continued funding expected in FY 2004. This program is coordinated with the Department of Justice solicitation `Mental Health Court Grant Program' to divert individuals with mental illness from the criminal justice system to mental health treatment and other support services.

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[Post-traumatic stress disorder] - The Committee remains concerned about the ongoing problem of post-traumatic stress disorder among the refugee immigrant population in Hawaii, and it urges vigorous attention to the mental health problems of these future citizens. (Page 179)

Action Taken or to be Taken
SAMHSA's Refugee Mental Health Program is gathering information on the status and needs of refugees in Hawaii. This information will be used to complete a white paper on refugees resettled in Hawaii as a support for program planning and development.

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Training minority health professionals -- The Committee also recognizes the urgency of training additional minority mental health professionals, including Native Hawaiians, and it encourages SAMHSA to provide additional resources to the Minority Fellowship Program. (p.179)

Action Taken or to be Taken
In FY 2004, SAMHSA will continue to support the Minority Fellowship Program to facilitate entry of minority students into mental health and substance abuse disorders careers. The target populations for this program as identified in the Request for Applications are ethnic minority groups, including Native Hawaiians. Grantees are encouraged to include all under-represented groups in program activities such as the recently convened National SAMHSA Minority Fellowship Program Conference: Cultural Competence and Reducing Health Disparities.

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[States' eligibility for targeted capacity expansion grants] - The Committee is concerned that States have been declared ineligible to apply for certain targeted capacity expansion grants. The Committee expects SAMHSA to submit to the Committee a plan in the fiscal year 2005 budget request to address this issue for all TCE and other appropriate grants. (Page 184)

Action taken or to be taken
In FY 2004, all new funding announcements for TCE grant programs include States as eligible applicants, unless the statutory authority limits eligibility to entities other than the States (e.g., section 506 of the PHS limits eligibility to community-based organizations) or there is a compelling reason for limiting eligibility in such a way that States are not included. Only the following anticipated FY 2004 TCE grant announcements are expected to limit eligibility to entities that do not include the States:

· Homeless Services Grants - the authorizing statute (section 506 of the PHS Act) limits eligibility to community-based organizations.

· HIV Prevention and Substance Abuse Prevention Planning Grants - this program is part of a larger initiative (the Minority AIDS Initiative) designed to empower community-level organizations in communities of color to respond to the HIV epidemic.

· Testing for Hepatitis C and Rapid HIV Testing in Substance Abuse Treatment Programs - This program will be limited to current HIV and Substance Abuse Treatment grantees because it is intended to give them a small amount of supplemental funding to enhance their programs to include new testing capabilities.

· Drug Addiction Treatment Act of 2000 (DATA) Physician Clinical Support Program - Eligibility will be limited to the national professional organizations authorized to carry out training as specified in the DATA.

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[Workforce recruitment] - The Committee recognizes the need for a qualified and stable workforce to staff treatment centers. The unmet need for treatment services is exacerbated by a workforce crisis in the field of addictions treatment and prevention. The Committee urges SAMHSA to evaluate workforce recruitment, training shortages and retention. (Page 184)

Action taken or to be taken
SAMHSA has initiated several actions to address the unmet need for treatment services due to workforce crisis in the addictions treatment and prevention fields. To begin to define the appropriate role for the federal government in workforce development for the addictions field, in the second and third quarters of FY 2004 SAMHSA will sponsor a series of meetings with seasoned leaders in the field, the affiliated trade associations, representatives of colleges and universities offering both degree and certificate programs in addictions, and representatives from other federal agencies. These meetings will result in a list of operational definitions for the personnel comprising the workforce so that the language used in workforce documents is consistent across the field, setting parameters to distinguish between full time clinical and prevention professionals and adjunct professionals who provide intervention and referral services, and treatment professionals who may manage medication assisted treatment, but not provide therapy.

Additionally, it is important to understand how federal resources are used in other professional fields for training, education, management and clinical supervision education, curriculum development, research, and disseminating clinical guidelines, and how in other disciplines the federal government organizes opportunities for health professionals, faculty and trainers. SAMHSA will gather information for dissemination on private and public sector resources currently available for those seeking to enter the addictions field, and explore the barriers preventing the expansion of the addictions workforce.

The National Office of the SAMHSA Addictions Technology Transfer Network is piloting a workforce survey on addictions treatment providers. If determined useful and informative, SAMHSA's intent is to survey the addictions workforce nationwide. In addition, SAMHSA's Partners for Recovery Initiative will join with the ATTC Network to sponsor a series of Leadership Development Institutes to enhance the management and leadership capabilities in the field. It is believed that these activities will result in a greater understanding of the recruitment and retention problems of the field, and also provide a basis for appropriate actions to impact the current workforce crisis, including development of a national workforce improvement plan.

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[Implementation of performance partnership grant (PPG)] -- The Committee wishes to express its strong support for preserving the current block grant and future PPG as the foundation of our publicly funded substance abuse system in every State and territory in the United States. Similarly, the Committee is concerned with any effort that could erode the strength of the current and future block grant. At a time when States are facing fiscal crises, with some cutting substance abuse services, the maintenance of treatment infrastructure and capacity at the local level is extremely important. The Committee encourages SAMHSA to make the implementation of the PPG its number one priority for substance abuse programming and to allocate commensurate resources to support the transition to reflect this priority status. (Pages 184-185)

Action taken or to be taken
SAMHSA's PPG Report to Congress, as well as the Reauthorization proposal that contains the statutory changes needed to implement PPGs, are nearing final preparation for submission to HHS.

Both SAMHSA and the States have made considerable progress toward PPG implementation. With regard to the Mental Health Block Grant, CMHS has been working with the States to establish and implement the "Uniform Reporting System" (URS), which contains all the core PPG Measures proposed for mental health. Regarding the SAPT BG, well over half the States have established performance measurement and reporting systems that will enable them to incorporate and report on the proposed PPG measures for substance abuse in their program management and reporting processes.

In addition, both the FY2005 mental health and substance abuse Block Grant applications are in the final stages of being revised, as follows:

1. CMHS Block Grant Application: The notice that the new FY2005-2007 CMHS Block Grant application is available for review was published in the Federal Register on December 16, 2003. This application contains the core PPG measures "on which States will be expected to report", and incorporates other key features of PPGs, including permission to do a multi-year plan and State flexibility to include their own performance measures. With OMB approval of this application, it will become the CMHS PPG Application.

2. SAPT Block Grant Application: The FY2005 SAPT Block Grant application is being revised to become a "uniform application" for both prevention and treatment. It will include, as voluntary, the PPG Core Measures for substance abuse. However, because there are existing regulations implementing current statutory provisions, SAMHSA's Reauthorization proposal will need to be enacted before full implementation of PPGs - with multi-year plans and required reporting - can take place. We anticipate that notice of the revised application will be published in the Federal Register shortly after the first of the year. Also, although we will be requesting three-year approval for this application, we plan to submit a subsequent revision - depending upon submission of our Report to Congress and passage of Reauthorization - that will fully become an SAPT PPG Application.

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[Funding to reduce youth drug use] - The Committee is concerned that the trend of the administration to request insufficient funding levels for CSAP not only endangers recent drug prevention efforts, it also hampers the ability of SAMHSA to plan for and fund longer-term grants, especially in critical areas such as emerging drug trends. With the restored funding, the Committee expects CSAP to focus its efforts on identifying and diffusing comprehensive
community-wide strategies to reduce youth drug use, with an emphasis on increasing the age of first use of alcohol and illicit drugs. (Page 185)

Action taken or to be taken
The Committee expressed concern regarding short-term and insufficient funding levels for the Center for Substance Abuse Prevention (CSAP). Discretionary funding levels must be seen within the context of other, larger funding sources such as the SAPT Block Grant and other federal allocations for prevention. Within this larger context SAMHSA/CSAP is using multiple mechanisms to identify effective programs and to communicate that information to States and communities. In this way, effective programming can be identified and disseminated nationwide regardless of funding source.

In previous fiscal years, CSAP has devised and implemented strategies to best utilize available funds, such as funding some1-year planning grants. CSAP is anticipating the advent of 5-year grant programs for selected discretionary grant programs beginning in FY 2004. With this increase in length of discretionary grant programming, CSAP can focus on long-term efforts to identify and disseminate comprehensive community-wide strategies to reduce/prevent drug use. This increased timeframe will also allow CSAP and its grantee partners the opportunity to systematically evaluate programs and identify those that are most effective.

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[Emerging drug use issues] - The Committee notes that over the past 10 years there has been an alarming increase in the use and availability of ecstasy and other club drugs among our Nation's

youth. According to SAMHSA's Drug Abuse Warning Network, ecstasy-related emergency room admissions in the United States increased significantly from 253 in 1994 to 5,542 in 2001. The Committee urges SAMHSA to pay close attention to this and other emerging drug use issues. The Committee has included $5,000,000 to continue and expand on the program funded last year. (Page 186)

Action taken or to be taken
CSAP has focused on responding to the emerging Ecstasy and other club drugs issue since FY 2002, and will continue to fund prevention programs focusing on this issue throughout FY 2004.
As noted in the Committee Report, Ecstasy and other club drugs are powerfully addictive substances whose use can lead to serious health and behavioral problems, including memory loss, aggression, violence, psychotic behavior, and potential heart and neurological damage. Their use also contributes to increased transmission of infectious diseases, especially hepatitis and HIV/AIDS. Use is increasing among young adults who attend "raves" or private clubs; homeless and runaway youth; men who have sex with men and use other drugs; and male and female commercial sex workers.

For the past two years under the Children's Health Act of 2000 (Public law 106-310), SAMHSA/CSAP has funded a number of ecstasy infrastructure development and prevention intervention cooperative agreements addressing these drugs. In FY 2002, 14 one-year ecstasy prevention grants were awarded. These included 7 prevention intervention and 7 ecstasy infrastructure development grants. Program funds are used for planning, establishing, or administering ecstasy and other club drug prevention programs and/or training of State and local law enforcement officials, prevention and education officials, members of community anti-drug coalitions, and parents, especially in traditional and non traditional venues such as clubs where raves are held and for non-traditional populations such as the gay, lesbian, bisexual and questioning community, other young adults and law enforcement personnel.

In FY 2003, 12 additional one-year ecstasy grants were awarded that focused on either or both interventions and infrastructure development. The CSAP FY 2004 budget allocates $5,000,000 to fund additional grants that, for the first time, are proposed for up to 5 years. This change in approach reflects growing recognition that the Ecstasy and other club drug issue requires a sustained, long-term, focused effort of ever-increasing importance.

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[Data system] - In an effort to reach a more accurate assessment of the substance abuse treatment gap, the Committee expects SAMHSA to encourage other Federal agencies that fund substance abuse treatment services to participate in a client level data system administered by SAMHSA. (Page 187)

Action taken or to be taken
SAMHSA estimates 75% of direct service providers participate in our Drug Abuse Services Information System (DASIS) program. SAMHSA has encouraged other federal agencies such as the Department of Justice and the Veterans Administration to participate. Some pilot work has begun; however, relating data from large data sets designated for other purposes to SAMHSA's data set has been a challenging task. Also, data owned by other Federal government contractors would have to be purchased.