Army Corps of Engineers: Budget Requests Included Construction Projects Located in Over 30 States, Selected Using a Multi-level Process

Through its civil works program, the Corps plans, designs, constructs, operates, and maintains a range of water resources projects for purposes such as aquatic ecosystem restoration, flood risk management, and navigation. To support these projects, the Corps requests funding through the annual budget and appropriation process. For fiscal year 2017, the President's budget requested $4.6 billion for Corps' water resources projects, of which about $1 billion was for construction projects.

GAO was asked to review budget requests for construction projects under the Corps' civil works program, including the geographic distribution of those projects. This report examines for fiscal years 2008 through 2017 (1) the geographic distribution of the construction projects included in the President's budget requests for the Corps, and (2) how the Corps prioritized such projects for inclusion in the President's budget requests. GAO summarized available budget data for fiscal years 2008 through 2017; reviewed the Corps' budget guidance and documents; mapped locations for construction projects in budget requests for years when sufficient information was available; and interviewed Corps headquarters and division officials.

For fiscal years 2008 through 2017, construction projects included in the President's budget requests to Congress for the U.S. Army Corps of Engineers (Corps) were geographically distributed in 31 states, the District of Columbia, and Puerto Rico. During this 10-year period, the President requested over $12.9 billion for 164 construction projects included in the Corps' three main missions—aquatic ecosystem restoration, flood risk management, and navigation. The Corps provided GAO with detailed information on the location of construction projects included in the budget requests for the 3 most recent fiscal years at the time of its review—2015 through 2017. These projects, shown in the figure below, spanned 26 states and Puerto Rico. They were typically located near sources of water or Corps-constructed water infrastructure.

To prioritize construction projects to include in the President's budget requests for fiscal years 2008 through 2017, the Corps used a process involving each of its three organizational levels—districts, divisions, and headquarters. Districts divided projects into work packages and assigned 1 of 6 priority levels to indicate the order in which work packages from the same project should be completed. Districts grouped these work packages by business line or appropriations account based on the Corps' budget guidance for the fiscal year and then ranked them. Then Corps divisions and headquarters ranked the work packages. To assign rankings, Corps officials applied criteria specific to the business line of each project. These criteria often varied by fiscal year to address changes to policy guidance. Across the organization, Corps officials ranked more than 25,000 packages for fiscal year 2017. After assigning rankings, headquarters developed final budget recommendations to submit to the Assistant Secretary of the Army for Civil Works, who in turn provided the recommendations to the Office of Management and Budget for review and potential inclusion in the President's budget requests.

GAO is not making recommendations in this report. The Department of Defense stated that they had no comments on the draft report.

The U.S. Army Corps of Engineers (Corps) is one of the world’s largest  public engineering, design, and construction management agencies. The  Corps provides public engineering services across the nation and the  world to strengthen the nation’s security, protect and manage aquatic  ecosystems, reduce risks from disasters, and support commerce. More  specifically, through its civil works program, the Corps plans, designs,  constructs, operates, and maintains water resources projects to address  the three primary missions of the program: (1) restoration, protection, and  management of aquatic ecosystems; (2) flood risk management; and (3)  support of commercial navigation.

The Corps seeks funding for these water resources projects through the  annual budget and appropriations process. Under this process, the Corps  prioritizes projects to recommend for inclusion in the President’s annual  budget request to Congress. The Assistant Secretary of the Army for Civil  Works reviews the Corps’ requested funding amounts and selected  projects before submitting the finalized recommendation to the Office of  Management and Budget (OMB). OMB reviews the recommendation  before submitting the Corps’ budget request to the President for review  and approval. The fiscal year 2017 budget presentation for the Corps  stated that the President’s budget requested $4.62 billion in discretionary  funding for water resources projects under the Corps’ civil works  program. Of this total, the President’s budget request included $1.09  billion for the Corps’ construction account; the remainder was largely for  operations and maintenance of existing infrastructure. In fiscal year  2017, Congress appropriated $1.88 billion for the Corps’ construction  account, of which $985.6 million was to be used for to specific projects.

You asked that we review the budget requests for construction projects  under the Corps’ civil works program, including the geographic  distribution of those projects. This report examines, for fiscal years 2008  through 2017, (1) the geographic distribution of the construction projects  included in the President’s budget requests for the Corps and (2) how the  Corps prioritized construction projects for inclusion in the President’s  budget requests.

To examine the geographic distribution of the construction projects  included in the President’s budget requests for the Corps, we obtained  and summarized descriptive data on construction projects—such as  project name, state, business line, and requested funding amount— included in the budget requests from the Corps’ annual Press Books and  Congressional Budget Justifications for fiscal years 2008 through 2017.  Our work focused on the projects that the Corps prioritized within the  construction appropriations account’s three main business lines, which  correspond to the three primary missions of the civil works program.  These three main business lines are aquatic ecosystem restoration, flood  risk management, and navigation. We also obtained detailed data from  the Corps on the locations of the construction projects included in the  budget requests. The detailed data we obtained was limited to fiscal  years 2015 through 2017 because the Corps did not maintain the data for  earlier years in its current database for budget development—the Civil  Works Integrated Funding Database—and did not maintain the historic  data in an accessible form. We analyzed the detailed data to map the  locations of projects within states and Corps regional divisions. To assess the reliability of the detailed data and the descriptive data, we  conducted electronic testing and compared the descriptive data with  information from the annual Press Books; we found that they were  sufficiently reliable for the purposes of our reporting objectives. We also  interviewed Corps headquarters and division officials about the  geographic distribution of the projects included in the President’s budget  requests.

To examine how the Corps prioritized construction projects for inclusion in  the President’s budget requests for fiscal years 2008 through 2017, we  reviewed federal and Corps guidance on methods for evaluating  construction projects. We reviewed and summarized the Corps’ policy  guidance for budget development (budget guidance) from fiscal year  2008 through fiscal year 2017, along with the guidance’s annexes and  business-line-specific appendixes, on the process and criteria for  evaluating and prioritizing construction projects in the Corps’ three main  business lines for inclusion in the budget requests. We also reviewed  additional guidance from the Assistant Secretary of the Army for Civil  Works on how to prepare the Corps’ budget requests. We compared the  Corps’ budget guidance across fiscal years 2008 through 2017 and  tracked differences in the eligibility criteria and business-line-specific  criteria. We interviewed Corps headquarters officials to gain perspective  on any significant changes in the guidance, process, or criteria used. We  interviewed and obtained information from Corps headquarters and  division officials responsible for prioritizing projects for the budget  requests, as well as from officials in the Assistant Secretary’s office,  about the application of the criteria and factors to consider when  preparing the budget requests for fiscal years 2008 through 2017.

We conducted this performance audit from April 2017 to December 2018  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

Headquartered in Washington, D.C., the Corps has eight regional  divisions and 38 districts that carry out its domestic civil works’ program  (see fig. 1). Corps headquarters primarily develops policies based on  administration guidance; plans the direction of the organization; and  approves projects to recommend for inclusion in the President’s annual  budget request to Congress. The divisions approve projects for  submission to headquarters and coordinate projects within their districts,  while the districts plan and implement the projects. The Corps’  construction appropriations account has three main business lines— aquatic ecosystem restoration, flood risk management, and navigation— that correspond to the three primary missions of its civil works program.  Some projects may be multipurpose and fit into more than one business  line within the program.

For fiscal years 2008 through 2017, the President’s budgets requested  about $4.78 billion per year, on average, in discretionary funding for the  Corps’ civil works program to plan, construct, operate, and maintain a  wide range of water resources projects (see fig. 2). Of this total, the  budget requested an average of about $1.39 billion total per year for  construction projects in the aquatic ecosystem restoration, flood risk  management, and navigation business lines.

The total construction amounts in Corps budget documents include  funding for the hydropower business line; hydropower funding is  represented in the other discretionary funding in this figure. We excluded  those funding amounts from our business line totals, in part because  these projects are now mainly funded through the operations and  maintenance account. They represented less than 4 percent of the  construction account requests from fiscal years 2008 through 2017.

Discretionary funding refers to the level of budget authority, outlays, or  other budgetary resources (other than those for mandatory programs)  that is provided in, and controlled by, appropriation acts.

Construction Projects Included in the President’s Budget Requests for the Corps Located In Over Half of the States

For fiscal years 2008 through 2017, the President’s budget requests for  the Corps included 164 construction projects located in 31 states, the  District of Columbia, and Puerto Rico. The five states for which the most  funds were requested in this period were:

Florida, with $2.4 billion requested for 15 construction projects,  Illinois, with $2.3 billion requested for 15 construction projects,

California, with $1.6 billion requested for 24 construction projects,

Washington, with $924 million requested for 9 construction projects,

Kentucky, with $646 million requested for 6 construction projects.

The projects in these five states accounted for 61 percent of the $12.9  billion that the President requested for Corps construction projects in  these years. Figure 3 shows the total number of construction projects and  funds included in the President’s budget requests for fiscal years 2008  through 2017, by state, within the Corps’ three main business lines— aquatic ecosystem restoration, flood risk management, and navigation.  See appendix I for the number of construction projects and funds  requested for each fiscal year during this period, by state. See appendix II  for a list of the names of construction projects, locations, business lines,  and funds requested per year during this period.

For fiscal years 2015 through 2017, the Corps provided us with detailed  data for the construction projects included in the President’s budget  requests. This information included latitudinal and longitudinal  coordinates to locate projects within states and divisions, as well as  business-line-specific data. A total of 71 projects were included in the  budget requests for these business lines during this period. Construction  projects included in the President’s budget requests for the Corps’ three  main business lines for fiscal years 2015 through 2017 were  geographically distributed in 26 states and Puerto Rico. According to our  analysis of Corps budget data, most of the projects were near either  water sources or Corps-constructed water infrastructure. Figure 4, which  is an interactive map, identifies the locations and describes budget data  for each construction project (see interactive instructions). See appendix  III for a list of these construction projects by Corps division, state,  business line, and funds requested for each fiscal year.

Corps headquarters officials said that the Corps does not specifically use  geographic locations to select construction projects to recommend for  inclusion in the President’s budget requests. However, Corps officials  explained that geographic characteristics, such as population, might have  affected how they considered including construction projects within  specific business lines. For example, Corps officials within the flood risk  management business line may have considered a construction project  located in a population center that could be severely impacted by a  flooding event to be a higher priority over other projects in less populated  areas.

For fiscal years 2015 through 2017, the Corps requested more than $3  billion for the 71 construction projects that fell within the three main  business lines:

Aquatic ecosystem restoration. The President’s budget requested  $618 million for 15 Corps construction projects in the aquatic  ecosystem restoration business line, which were located in California,  Florida, Georgia, Illinois, Louisiana, Maryland, Minnesota, Oregon,  and Washington. According to the Corps budget guidance, these  projects were located in areas of federal significance that have some  degree of habitat scarcity, connectivity, and special-status species,  among other characteristics. Moreover, according to the Corps  budget guidance, construction projects in this business line  emphasize the restoration of nationally or regionally significant  habitats where the solution primarily involves modifying the hydrology  and geomorphology. For example, the goals of the South Florida  Ecosystem Restoration program—a collection of several projects— includes improving the health of over 2.4 million acres of the south  Florida ecosystem (including Everglades National Park), enhancing  water supply, and maintaining flood mitigation, according to a Corps  document and Corps officials. According to a Corps document,  since 2000, the Corps has invested a total of $2.4 billion in the  program including other initiatives, such as the Comprehensive  Everglades Restoration Plan and Central and Southern Florida.

Flood risk management. The President’s budget requested $1.33  billion for 33 Corps construction projects in the flood risk management  business line, which were located in California, Florida, Illinois,  Kansas, Kentucky, Massachusetts, Missouri, New Jersey, Ohio,  Oklahoma, Pennsylvania, Tennessee, Texas, Virginia, and West  Virginia. According to the Corps’ budget guidance and strategic plan,  these projects are located in areas that may experience riverine and  coastal flooding, and they are to provide water supply storage. For  example, the Bluestone Lake project, in West Virginia, is to address  deficiencies that could lead to a breach of a dam built by the Corps in  the 1940s. According to the Corps, the dam’s spillway cannot  discharge enough water without substantially increasing the potential  for a breach of the dam. According to the Corps, a breach could  cause catastrophic flooding along the largest river valleys in West  Virginia, including locations of major manufacturing and chemical  industries, and put 165,000 lives at risk. The Corps started the project  in 1998, and plans to award the next phase of the project in 2022. A  draft supplementary study has been completed to identify a plan to  address this additional deficiency, according to the Corps. The Corps  is planning for a 10-year construction period, with an estimated cost of  $575 million, according to a Corps document and a headquarters  official.

Navigation. The President’s budget requested $908 million for 20  Corps construction projects in the navigation business line, which  were located in coastal, inland, and intracoastal navigation systems in  California, Georgia, Illinois, Louisiana, Missouri, New Jersey, New  York, Ohio, Oregon, South Carolina, Texas, Virginia, Washington, and  Wisconsin. According to Corps’ budget guidance, these projects are  intended to provide safe, reliable, cost-effective and environmentally  sustainable waterborne transportation systems for the movement of  commercial goods. For example, the Corps’ Olmsted Locks and Dam  project is located on the Ohio River, which connects to the  Tennessee, Cumberland, and Mississippi rivers and is considered  critical for commercial navigation. According to the Corps, the project  consists of two 110-foot by 1,200-foot locks, which are located  adjacent to the Illinois bank, and a dam comprising of five tainter  gates, which control the amount of water that flows downstream.  According to a Corps document, over the last several years,  approximately 80 million tons of bulk commodities (for example, coal,  grain, rock, and sand) per year, on average, have passed through  navigation structures that are part of the project. The Corps estimates  that this project has been under construction for nearly 30 years.

According to Corps documents and headquarters officials, the project  became operational as of September 2018, with a total estimated cost  of $3 billion by the time of project completion.

Corps Used a Multi- level Process to Prioritize Construction Projects

To prioritize construction projects to recommend for inclusion in the  President’s budget requests for fiscal years 2008 through 2017, the Corps  used a process involving the three levels of its organization—districts,  divisions, and headquarters.

Districts Prepared Work Packages for Ranking

To begin the process, Corps district officials divided projects into work  packages—increments of work that can be considered for inclusion in the  budget. According to Corps policy guidance for budget development  (budget guidance), these work packages should contribute to the overall  project and be executed without being dependent on the funding of  additional work packages. According to a district official, district officials  then assigned one of six priority levels to indicate the order in which work  packages for the same project should be completed for that fiscal year.  Priority levels are categories used to differentiate work packages within  the same project. Corps budget guidance instructed district officials to  assign priority levels based on criteria including whether a project is new  or continuing and where a work package falls within a project’s overall  work plan. Corps budget guidance also instructed officials to group work  packages either by business line or appropriations account, depending on  the fiscal year, based on the budget guidance for that fiscal year.

Districts, Divisions, and Headquarters Ranked Work Packages

Corps districts, divisions, and headquarters consecutively ranked the  work packages, as shown in figure 5. In doing so, they established criteria  specific to the business line for each project. Corps budget guidance  provided instructions on which criteria to use for each business line to  determine rankings in a particular year. The ranking criteria in the  guidance—such as the rate of economic return, populations at risk, or the  environmental impact—varied nearly every year from fiscal years 2008 to  2017 for two of the three main business lines: flood risk management and  navigation (see appendix IV for the criteria used, by business line and  fiscal year). Corps officials said they routinely revised the criteria while  developing the annual budget guidance, for reasons such as addressing  changes in the policy guidance from the Assistant Secretary of the Army  for Civil Works or OMB, or improving the ranking process.

Corps officials we interviewed noted that although each level used the  same criteria to rank work packages, the districts, divisions and  headquarters had different focuses and increasing numbers of work  packages to rank and compare. Specifically, officials at each level  considered the overall needs of their respective jurisdictions when making  ranking decisions: districts had a local focus; divisions had a regional or  watershed focus; and headquarters had a national focus. The number of  work packages to be ranked increased at each level according to Corps  officials: districts ranked local work packages; divisions re-ranked work  packages from four to seven districts; and headquarters re-ranked work  packages from all of the divisions nationwide.

After ranking all work packages within their respective jurisdictions by  business line or appropriations account, officials from all three levels  entered the rankings into the database for use in the budget review  process. According to information from the Civil Works Integrated  Funding Database, the Corps ranked more than 25,000 work packages  for the fiscal year 2017 budget recommendation.

Headquarters Developed Final Recommendations for Budget Requests

According to one headquarters official, Corps officials in the Program  Development Branch at headquarters facilitated discussions among  business line and account managers to develop the final rankings of all  work packages. As part of this process, headquarters officials noted that  business line managers compared work packages with different  characteristics across business lines or accounts. According to Corps  budget guidance and headquarters officials, business line managers and  account managers are instructed to consider two key factors when  determining their final rankings each fiscal year. Specifically, those  managers are instructed to give top priority to work packages that  significantly impact the risk to human life posed by potential disasters. In  addition, the managers are to prioritize work packages that address a  legal requirement to mitigate potential negative effects caused by  construction, such as adverse environmental effects.

Using the final rankings, Corps headquarters officials said they developed  the final budget recommendations for each fiscal year, including a  recommended funding amount for each project, with input from various  levels of the organization. More specifically, to determine the budget  recommendations, Corps headquarters officials obtained feedback from  district commanders, generals, directors, and the Chief of Engineers. In  fiscal year 2017, the Corps used its final rankings to determine  recommended funding amounts for 89 construction projects, each of  which included one or more work packages; ultimately, these projects  comprised about 298 work packages. Once the Corps headquarters  officials developed these recommendations, they briefed the Assistant  Secretary of the Army for Civil Works on their recommendations. An  official from the Assistant Secretary’s office said they reviewed the Corps  recommendations and compared them with the Assistant Secretary’s  priorities, after which they developed the final recommendations to send  to OMB for review and potential inclusion in the President’s budget  requests. According to a Corps official, 34 percent of construction projects  included in the fiscal year 2017 President’s budget request received  funding.

We provided a draft of this report for review and comment to the  Department of Defense. The department told us they had no comments  on the draft report.

We are sending copies of this report to the appropriate congressional  committees, the Secretary of Defense, the Chief of Engineers and  Commanding General of the U.S. Army Corps of Engineers, and other  interested parties. In addition, the report is available at no charge on the  GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (202) 512-3841 or fennella@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last   page of this report. GAO staff who made key contributions to this report  are listed in appendix V.

Appendix I: Corps Construction Projects Included in the President’s Budget Requests, by State, Fiscal Years 2008 through 2017

Table 1 lists the 164 construction projects and funds requested, by state,  within the U.S. Army Corps of Engineers’ (Corps) three main business  lines—aquatic ecosystem restoration, flood risk management, and  navigation—for fiscal years 2008 through 2017.

Appendix II: Corps Construction Projects Included in the President’s Budget Requests, Fiscal Years 2008 through 2017

Table 2 lists the names and locations of the 164 construction projects the  U.S. Army Corps of Engineers (Corps) identified as included in the  President’s budget requests for its three main business lines for fiscal  years 2008 through 2017. The Corps’ three main business lines are  aquatic ecosystem restoration, flood risk management, and navigation.

Appendix III: Corps Construction Projects Included in the President’s Budget Requests, by Division, Fiscal Years 2015 through 2017

Table 3 lists the names of the 71 construction projects, their locations,  and the agency divisions that manage them, as shown in interactive  figure 4 of this report, and includes the figure’s rollover information. The  U.S. Army Corps of Engineers (Corps) identified these projects as  included in the President’s budget requests for its three main business  lines for fiscal years 2015 through 2017. The Corps’ three main business  lines are aquatic ecosystem restoration, flood risk management, and  navigation.

Appendix IV: U.S. Army Corps of Engineers’ Criteria Used to Rank Construction Projects in Main Business Lines

Table 4 lists the criteria included in the U.S. Army Corps of Engineers’  (Corps) annual budget guidance for its three main business lines for fiscal  years 2008 through 2017. The Corps’ three main business lines are  aquatic ecosystem restoration, flood risk management, and navigation.

Appendix V: GAO Contact and Staff Acknowledgments

Anne-Marie Fennell, (202) 512-3841 or fennella@gao.gov.

In addition to the contact named above, Vondalee R. Hunt (Assistant  Director), Leah E. English, Kerstin Hudon, Susan Malone, and Cynthia  Norris made significant contributions to this report. Important contributions  were also made by Melinda Cordero, Justin Fisher, Juan Garay, Patricia  Moye, and Danny Royer.

Army Corps of Engineers: Factors Contributing to Cost Increases and  Schedule Delays in the Olmsted Locks and Dam Project. GAO-17-147.  Washington, D.C.: February 16, 2017.

Standards for Internal Control in the Federal Government. GAO-14-704G.  Washington, D.C.: September 2014.

Army Corps of Engineers: The Corps Needs to Take Steps to Identify All  Projects and Studies Eligible for Deauthorization. GAO-14-699.  Washington, D.C.: August 21, 2014.

Army Corps of Engineers: Cost Increases in Flood Control Projects and  Improving Communication with Nonfederal Sponsors. GAO-14-35.  Washington, D.C.: December 20, 2013.

Army Corps of Engineers: Budget Formulation Process Emphasizes  Agencywide Priorities, but Transparency of Budget Presentation Could be  Improved. GAO-10-453. Washington, D.C.: April 2, 2010.

A Glossary of Terms Used in the Federal Budget Process. GAO-05- 734SP. Washington, D.C.: September 2005.

The President's annual budget request to Congress usually includes more than a billion dollars for U.S. Army Corps of Engineers water resource construction projects. These projects help protect people from flooding, improve navigation, and restore ecosystems.

In fiscal years 2008-2017, there were 164 such projects in 31 states. Florida, Illinois, California, Washington, and Kentucky accounted for 61% of requested funds.

To prioritize the work outlined in its 2017 request, Corps officials ranked more than 25,000 discrete sets of tasks that make up its projects. They did so using criteria such as population at risk and benefits vs. cost.


Adolescent and Young Adult Substance Use: Federal Grants for Prevention, Treatment, and Recovery Services and for Research

According to the Surgeon General, adolescence and young adulthood are critical at-risk periods for illicit substance use, and such use can harm the developing brain. Congress included a provision in law for GAO to review how federal agencies, through grants, are addressing substance use prevention, treatment, and recovery among adolescents and young adults.

Related to prevention, treatment, and recovery targeting adolescents (aged 12 to 17) and young adults (aged 18 to 25), this report describes (1) grant programs to provide services; (2) NIDA grant-funded research, and (3) gaps stakeholders identified in related services or research.

GAO selected four agencies to review—HHS, ONDCP, DOJ, and Education—the key agencies that fund grant programs for services for adolescents and young adults. GAO analyzed documents on grant programs and on research funded by NIDA. GAO interviewed officials from the four agencies and 20 stakeholder groups (including advocacy and education, and research organizations, as well as a non-generalizable selection of state substance abuse, education, and judicial agencies in four states) about gaps in services or research and agency efforts to help address them. States were selected for variation in geography and overdose rates.

HHS, DOJ, and ONDCP provided technical comments on a draft of this report, which GAO incorporated as appropriate.

GAO identified 12 federal grant programs within three federal agencies that funded substance use prevention, treatment, and recovery services in fiscal year 2017 and targeted adolescents' and young adults' use of illicit substances such as marijuana and nonmedical use of prescription opioids. The three agencies included the Department of Health and Human Services (HHS), the Office of National Drug Control Policy (ONDCP), and the Department of Justice (DOJ). While the Department of Education (Education) has grant programs that can fund prevention services for adolescents, they do not specifically target such services.

Eight programs targeted substance use prevention. In total, they had 1,146 active grantees in fiscal year 2017 and provided about $266 million in awards that year.

Four programs targeted treatment and recovery services. In total, they had 57 active grantees in fiscal year 2017. Two of the 4 grant programs awarded about $23 million in funding in that year (the other two awarded funding in prior years).

In addition, other grant programs beyond these 12 also fund substance use prevention, treatment, and recovery services across age groups, but are not specifically targeted to adolescents and young adults.

HHS's National Institute on Drug Abuse (NIDA)—the agency that is the primary funder of research on illicit substance use—also had 186 active grant-funded research projects focused on substance use prevention, treatment, and recovery among adolescents and young adults as of October and November 2017.

Most of these research projects—126—were examining prevention, 45 were examining treatment, 4 were examining recovery, and 11 were examining a combination of research categories.

In total, these 186 research projects received about $61 million from NIDA in fiscal year 2017.

Most of the 20 stakeholders GAO interviewed identified gaps in services for adolescents and young adults, including insufficient access to recovery services and a shortage of treatment providers, and described financial and other reasons that likely contribute to these gaps. Federal agency officials GAO interviewed agreed that these gaps exist, and described grant programs and other efforts to help address them, such as a grant program that HHS established in 2018 to expand recovery services for these age groups. Stakeholders also identified gaps in research, such as too few treatment studies with adolescent participants, and described reasons for these gaps, including too few federal grants focused on adolescent research. NIDA officials agreed that these gaps exist, and stated that NIDA had eight grant opportunities (as of May 2018) that focused on these age groups or included them as a population of interest, three of which were new in 2018.

According to the Surgeon General, adolescence and young adulthood are  critical at-risk periods for the misuse of substances, including the use of  illicit substances such as marijuana and opioids. In 2016, about 4 million  adolescents aged 12 to 17 in the United States had used illicit substances  within the past year, representing about 16 percent of all adolescents in  the country. That same year, an estimated 13 million young adults aged  18 to 25 used illicit substances—about 38 percent of all young adults.  The repeated use of illicit substances among adolescents and young  adults can result in substance use disorders, which are characterized by  symptoms such as the inability to fulfill work, school, and family  obligations. According to the Surgeon General, most people who develop  a substance use disorder begin using substances during adolescence  and develop a disorder by young adulthood, and the use of illicit  substances can adversely affect the developing brain. In addition, the  use of illicit substances can lead to death. In 2016 about 5,400  adolescents and young adults between the ages of 15 and 24 died as a  result of a drug overdose—a rate that has increased nearly 300 percent  since 1999.

In fiscal year 2016 the federal government spent $11.3 billion on  substance use prevention, treatment, and recovery services and  research. Out of this total amount, $1.5 billion supported prevention  services and research—for example, to help discourage the first-time use  of substances, to educate individuals about the negative effects of  substance use and to test the effectiveness of prevention interventions.  Federal agencies used the remaining $9.8 billion to support treatment and  recovery services and research—for example, to help individuals  discontinue the use of substances and improve health and wellness, and  to test new strategies to effectively treat individuals with substance use  disorders. Various federal agencies provide funding for such services or  research through grant programs, including the Department of Health and  Human Services (HHS), Department of Justice (DOJ), Department of  Education (Education), and the Office of National Drug Control Policy  (ONDCP). HHS funds the majority of substance use research through the  National Institute on Drug Abuse (NIDA), an Institute within HHS’s  National Institutes of Health (NIH).

The Comprehensive Addiction and Recovery Act of 2016 included a  provision for us to review federal grant programs that support substance  use prevention, treatment, and recovery services and research  specifically for adolescents and young adults; and any gaps in such  services and research. This report describes  1.  federal grant programs that fund substance use prevention, treatment,  or recovery services targeting adolescents and young adults;  2.  NIDA grant-funded research projects focused on substance use  prevention, treatment, or recovery among adolescents and young  adults; and  3.  gaps stakeholders identified related to services or research for  substance use prevention, treatment, or recovery among adolescents  and young adults.

To describe federal grant programs that fund substance use prevention,  treatment, or recovery services targeting adolescents and young adults,  we reviewed information about grant programs funded by four federal  agencies—HHS, DOJ, Education, and ONDCP. We selected these  agencies because our prior work and consultations with ONDCP  identified them as key federal agencies that provide prevention,  treatment, or recovery grant programs that support services for  adolescents or young adults. We included in our review grant programs  identified by these federal agencies that met the following criteria: (1)  substance use prevention, treatment, or recovery was a primary purpose  or goal; (2) adolescents and young adults ranging from anywhere  between 12 to 25 years of age were the targeted population; (3) all or part  of the grants were used for direct services (rather than only for  infrastructure development, for example); and (4) the program addressed  the use of illicit substances (including nonmedical use of prescription  opioids). We excluded grant programs that focused solely on tobacco,  alcohol, or e-cigarettes because the use of these substances is legal for  certain young adults. We reviewed documentation and interviewed  officials from each of the four agencies to obtain information about each  of the grant programs, including the number of grantees, award amounts,  and any planned evaluations. We did not identify grant programs  administered by Education that met all of our criteria. While several of  Education’s grant programs allow grantees to use funds for prevention  services, they do not specifically target such services.

In addition to the grant programs targeting adolescents and young adults,  we analyzed data on HHS’s Substance Abuse Prevention and Treatment  Block Grant, which is the largest federal grant program that funds  prevention, treatment, and recovery services across age groups.  Specifically, we analyzed the Substance Abuse Prevention and  Treatment Block Grant data included in HHS’s 2017 annual report, which  were the most current data available and reflected data pertaining to its  2014 grants. We analyzed these data nationally and by grantee—which  included states, territories, and one federally recognized tribe—to  determine the percentages of all persons provided prevention, treatment,  and recovery services with grants who were adolescents and young  adults. To assess the reliability of these data, we reviewed  documentation about the data and interviewed knowledgeable agency  officials and determined the data were sufficiently reliable for the  purposes of our reporting objective.

To describe NIDA grant-funded research projects focused on substance  use prevention, treatment, or recovery among adolescents and young  adults, we examined applicable project information, which included  research project abstracts and the 2017 funding received. The research  projects were identified by NIDA through searches conducted in October  and November of 2017 of active projects in the NIH RePORTER  database. We included in our review research projects that (1) primarily  focused on adolescent and young adult substance use prevention,  treatment, or recovery research; (2) were not animal research; and (3) did  not focus exclusively on tobacco, alcohol, or e-cigarettes. We reviewed  the individual research abstracts for reference to brain imaging to count  how many of those prevention, treatment, and recovery studies involved  research on the physical brain. We also obtained from NIDA grant  information for the Adolescent Brain Cognitive Development study, a  large longitudinal study examining the effects of substance use and other  factors on development of the adolescent brain. To verify the reliability of  the information obtained from NIDA, we interviewed knowledgeable  officials and reviewed relevant documentation. We determined that the  data were sufficiently reliable for the purposes of our reporting objective.

To describe gaps stakeholders identified related to services or research  for substance use prevention, treatment, or recovery among adolescents  and young adults, we interviewed 20 stakeholder organizations and  agencies, in total, to obtain their perspectives on these topics. The  organizations included 5 national advocacy and education organizations  and 3 research organizations. We selected advocacy and education  organizations that broadly represented the views of state substance  abuse agencies, community coalitions, juvenile drug treatment courts,  private foundations that fund substance use related services, and  recovery community organizations. We selected stakeholders from the 3  research organizations because they had expertise in research in  substance use prevention, treatment, or recovery among adolescents and  young adults. We also interviewed 12 state substance abuse, education,  and judicial agencies from four states. The four states included New  Hampshire, West Virginia, Oregon, and Michigan, and were selected to  achieve variation in geography, median family income, opioid overdose  rates, and the percentage of all persons provided treatment and recovery  services (funded by the Substance Abuse Prevention and Treatment  Block Grant) that were adolescents and young adults. Finally, we  interviewed federal officials from HHS’s Substance Abuse and Mental  Health Services Administration (SAMHSA), Indian Health Service (IHS),  and NIDA; DOJ’s Office of Juvenile Justice and Delinquency Prevention  (OJJDP), within DOJ’s Office of Justice Programs; ONDCP; and  Education about any ongoing efforts they have to help address the gaps  that stakeholders identified.

We conducted this performance audit from August 2017 to September  2018 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.

The federal government uses grants to address national priorities—such  as substance use prevention, treatment, and recovery—through  nonfederal parties, including state and local governments, federally  recognized tribes, educational institutions, and nonprofit organizations.  While there is variation among different grant program goals and grant  types, most federal grants follow a common life cycle that includes an  award, implementation, and closeout stage for administering the grants.  During the award stage, the federal awarding agency enters into an  agreement with the grantee stipulating the terms and conditions for the  use of grant funds including the period that funds are available for the  grantee’s use. During the implementation stage, the grantee carries out  the requirements of the agreement and requests payments, while the  awarding agency monitors the grantee and approves or denies payments.  The grantee and the awarding agency close the grant once the grantee  has completed all the work associated with a grant agreement, the grant  period of performance end date (or grant expiration date) has arrived, or  both.

Federal grant programs may fund various types of grants, including  discretionary grants, formula grants, and cooperative agreements.  Discretionary grants are generally awarded on a competitive basis for  specified projects that meet eligibility and program requirements. Formula  grants are noncompetitive awards based on a predetermined formula,  typically established in statute, and are provided to eligible applicants that  meet specified criteria outlined by statute or regulation, such as a state. A  cooperative agreement is a type of federal financial assistance similar to  a grant, except the federal government is more substantially involved with  the implementation.

Substance Use Prevention, Treatment, and Recovery Services

Substance use prevention programs and services (which we refer to  collectively as “prevention services” in this report) are designed to prevent  or delay the early use of substances and stop the progression from use to  problematic use or to a substance use disorder. Prevention services  generally focus on reducing a variety of risk factors and promoting a  broad range of protective factors through various activities that include,  for example, setting policies that reduce the availability of substances in a  community, teaching adolescents how to resist negative social influences,  and communicating the harms of substances such as the nonmedical use  of prescription opioids and marijuana through media campaigns. In  addition, prevention services can be targeted at all members of a given  population without regard for risk factors, such as all adolescents, or to  particular subgroups of individuals or families, such as those who are at  increased risk of substance use due to their exposure to risk factors.  Targeted audiences for such services may include families living in  poverty or children of substance-using parents.

When substance use progresses to a point that it is clinically diagnosed  as causing significant impairments in health and social functioning, it is  characterized as a substance use disorder. Treatment services for  substance use disorders are designed to enable an individual to reduce  or discontinue substance use and to address health problems, and  typically include behavioral therapy. Behavioral therapies use various  techniques to modify an individual’s behaviors and improve coping skills,  such as incentives and reinforcements to reward individuals who reduce  their substance use. For opioid use disorders, treatment may involve  combining behavioral therapy with medications—an approach commonly  referred to as medication-assisted treatment. Some of these treatment  services may be paid for by private insurers, public health coverage  programs, nonprofit organizations, or consumers (out-of-pocket), but  federal grant programs and various state and local programs also provide  funding for these services.

Substance use recovery services are designed to help engage and  support individuals with substance use disorders in treatment and provide  ongoing support after treatment. There are a variety of recovery services  such as peer recovery coaching, which involves the use of coaches— peers who identify as being in recovery and use their knowledge and  experience to inform their work—to help individuals who are transitioning  out of treatment to connect with community services and address barriers  that may hinder the recovery process. Other examples include recovery  housing, which provides a substance-free environment and support from  fellow recovering residents, and recovery high schools, which help  students recovering from substance use disorders focus on academic  learning. Some recovery services may be paid for through various  sources, including Medicaid programs in certain states, some private  insurers, and federal grant programs. In addition, some recovery services  may be offered by member-led, voluntary associations that charge no  fees, such as 12-step groups.

Three Federal Agencies Operated 12 Grant Programs That Funded Services Specifically Targeting Adolescents and Young Adults in Fiscal Year 2017

Eight of the 12 Federal Grant Programs for Adolescents and Young Adults Funded Substance Use Prevention Services

We identified 12 federal grant programs within three of the four agencies  in our review that funded substance use prevention, treatment, and  recovery services in fiscal year 2017 and targeted adolescents’ and  young adults’ use of illicit substances. Eight of these programs focused  on prevention, and all 8 remain active in fiscal year 2018. The 8 grant  programs have varying purposes and were administered by two entities  within HHS—SAMHSA or IHS—or by ONDCP. For example, the Drug- Free Communities Support Program is funded and directed by ONDCP to  support community coalitions in preventing and reducing substance  abuse among youth aged 18 and younger. As another example, the  Strategic Prevention Framework for Prescription Drugs program,  administered by SAMHSA, is designed to raise awareness about the  dangers of sharing prescription medications such as opioids, and to  promote collaboration between states and pharmaceutical and medical  communities to understand the risks of overprescribing to youth (aged 12  to 17) and adults (aged 18 and older). In addition, this program is  intended to provide prevention activities and education to schools,  communities, and parents.

In total, the 8 grant programs targeting the prevention of substance use  among adolescents and young adults had 1,146 active grantees in fiscal  year 2017. The Drug-Free Communities Support Program had the  largest number of active grantees—713 community coalitions—and the  other 7 programs had a combined total of 434 that included states and  federally recognized tribes. The total number of active grantees in fiscal  year 2017 includes those that received a single- or multi-year award in  fiscal year 2017, as well as those that received a multi-year award in  fiscal year 2016 for a project that was ongoing in fiscal year 2017.  Grantees were awarded a total amount of about $266 million in fiscal year  2017, with SAMHSA’s Strategic Prevention Framework-Partnerships for  Success program providing the largest amount of funding (about $95  million). (See table 1.)

All 8 prevention grant programs had ongoing or planned evaluations to  assess the effectiveness of their grantees in accomplishing a variety of  program goals, according to agency officials. For example, ONDCP is  overseeing the ongoing evaluation of the Drug-Free Communities  Support Program through semi-annual progress reports and through the  collection of data, such as data on past 30-day substance use, from  coalitions that received awards. A recent evaluation of this program found  that coalitions included about 19,000 community members who were  targeting prevention services to about 20 percent of the population in the  United States (including 2.5 million middle school and 3.5 million high  school youth) in fiscal year 2015. In addition, this evaluation found that  middle and high school youth in communities with a coalition reported a  significant decrease in the past 30-day use of marijuana, prescription  drugs, alcohol, and tobacco, from 2002 to 2016. However, at the same  time, the perceptions of the risk of marijuana use decreased significantly  among high school youth in communities with community coalitions,  according to the evaluation. As another example, IHS’s planned  evaluation of the Methamphetamine and Suicide Prevention Initiative- Generation Indigenous grant program will focus on measures such as the  types of services that grantees implemented to prevent  methamphetamine use and promote positive development among  American Indian and Alaska Native youth, according to agency officials.  For the other 6 prevention grant programs, planned evaluations will  examine the extent to which reductions in substance use are observed  over time among the grantees’ targeted adolescents or young adults.

Four of the 12 Federal Grant Programs for Adolescents and Young Adults Funded Substance Use Treatment and Recovery Services

Of the 12 federal grant programs targeting adolescents’ and young adults’  use of illicit substances, we identified 4 that focused on the provision of  substance use treatment and recovery services and had active grantees  in fiscal year 2017. Two of the 4 programs ended at the close of fiscal  year 2017 and the other 2 remained active in fiscal year 2018. The 4  programs had different purposes and were administered by OJJDP or  SAMHSA, within DOJ and HHS, respectively. For example, the  Cooperative Agreements for Adolescent and Transitional Aged Youth  Treatment Implementation, administered by SAMHSA, is still active, and  intends to increase the capacity of states to provide treatment and  recovery services to adolescents (aged 12 to 18) and transitional-aged  youth (aged 16 to 25) that have substance use disorders or co-occurring  substance use disorders and mental disorders. This program aims to  increase states’ capacity by increasing the number of qualified treatment  providers. The other 3 grant programs were designed to improve different  aspects of the existing juvenile drug treatment courts, which DOJ defines  as a court calendar or docket that provides specialized treatment and  services for youth with substance use or co-occurring mental health  disorders. As an example, the Fiscal Year 2017 Juvenile Drug Treatment  Court Program, which is still active and administered by OJJDP, aims to  deliver services that are consistent with DOJ’s Juvenile Drug Treatment  Court Guidelines—a set of best practices for effective juvenile drug  treatment courts.

In total, the 4 grant programs that targeted substance use treatment and  recovery services among adolescents and young adults had 57 active  grantees in fiscal year 2017. SAMHSA’s Cooperative Agreements for  Adolescent and Transitional Aged Youth Treatment Implementation had  the largest number of active grantees (36), which included state  substance abuse agencies and federally recognized tribes. The three  juvenile drug treatment court programs had a total of 21 active grantees  that included, for example, county juvenile drug treatment courts and a  state judicial department. The total number of active grantees in fiscal  year 2017 included those that received a single- or multi-year award in  fiscal year 2017 as well as active grantees that received multi-year  awards in prior years. In total, active grantees from 2 of the 4 programs  were awarded about $23 million in fiscal year 2017. (See table 2.)

Two of the 4 treatment and recovery grant programs had ongoing or  planned evaluations to assess the effectiveness of their grantees in  accomplishing a variety of program goals, according to agency officials.  SAMHSA officials told us that its ongoing evaluation of the Cooperative  Agreements for Adolescent and Transitional Aged Youth Treatment  Implementation is assessing the types of treatment services provided to  adolescents and young adults as well as the extent to which they  abstained from substance use. Officials added that the evaluation is  examining grantees’ efforts to expand the qualified workforce of treatment  providers for adolescents and young adults. A recent evaluation that was  completed for this program found that most grantees provided training to  treatment providers on evidence-based treatment services and other  topics, and about one-third of grantees identified additional training needs  such as training on co-occurring disorders and trauma-informed services.  This evaluation also found a decrease in substance use among  adolescents and young adults who received treatment services after 6  months and that enhanced provider training was associated with this  decrease. OJJDP’s Fiscal Year 2017 Juvenile Drug Treatment Court  Program includes a planned evaluation of the impact of the DOJ juvenile  drug treatment court guidelines on participant outcomes. That is, OJJDP  plans to compare the outcomes of participants in courts aligned with the  guidelines to participants in other court programs that will serve as  “comparison courts.” OJJDP officials told us that the evaluation plans to  assess youth outcomes such as recidivism in substance use, quality of  relationships with parents and peers, and mental wellbeing. OJJDP  officials stated that while they are not evaluating their fiscal year 2015 and  2014 juvenile drug treatment court grant programs, grantees must report  on various performance measures related to substance use to assist DOJ  with fulfilling its responsibilities under the Government Performance and  Results Act of 1993 and the GPRA Modernization Act of 2010. For  example, grantees must report on a semiannual basis the number of drug  and alcohol tests performed on juveniles and the number of positive tests  recorded.

Other Federal Grant Programs Fund Prevention, Treatment, and Recovery Services, but Do Not Specifically Target Adolescents and Young Adults

Other federal grant programs beyond the 12 we identified provide funds  for substance use prevention, treatment, and recovery services across  age groups but do not specifically target adolescents and young adults.  The Substance Abuse Prevention and Treatment Block Grant is the  largest of such grant programs that fund prevention, treatment, and  recovery services across age groups. SAMHSA, which administers this  grant, awarded a total of $1.8 billion in fiscal year 2017 to grantees which  included states, the District of Columbia, territories, and one federally  recognized tribe. The amount of awards that states receive is based on a  formula that takes into account a grantee’s: population at risk of  substance abuse; relative costs of providing prevention and treatment  services; and relative ability to pay for prevention and treatment  services.

States have some flexibility in determining how to use their Substance  Abuse Prevention and Treatment Block Grant funds, and our analysis  shows variation in the extent to which grantees used these funds to  provide prevention, treatment, and recovery services to adolescents and  young adults in 2014, the most recent year for which data were available.  For prevention services that target individuals, such as those delivered to  middle school students in the classroom, the percentage of persons  served that grantees could identify as being adolescents and young  adults ranged from 0.1 percent (Oklahoma) to 100 percent (American  Samoa and United States Virgin Islands). However, most of the grantees  reported percentages that fell in the range of 23 to 61 percent. For  prevention services that target populations rather than individuals, such  as media campaigns, grantees similarly reported that the percentage of  adolescents and young adults served ranged from 0.1 percent (Indiana)  to 100 percent (United States Virgin Islands). However, most of the  grantees reported percentages that fell in the range of 18 to 46 percent.

For treatment and recovery services, grantees reported that the  percentage of all persons served who were adolescents and young adults  ranged from 8 percent (District of Columbia) to 100 percent (Red Lake  Band of Chippewa Indians). However, most of the grantees reported  percentages that fell in the range of 17 to 26 percent. (See app. I for the  percentages of persons served that were adolescents and young adults,  by grantee.)

In addition to the Substance Abuse Prevention and Treatment Block  Grant, other federal grant programs provide funds for prevention,  treatment, and recovery services across age groups, but do not  specifically target adolescents and young adults. For example, the State  Targeted Response to the Opioid Crisis grant program, administered by  SAMHSA, aims to help states and others reduce the number of opioid  overdose related deaths by providing funds for prevention, treatment, and  recovery services for opioid use disorders. In fiscal year 2017, SAMHSA  awarded about $485 million in grants to 50 states, the District of  Columbia, and 6 territories through this program. As another example, the  Targeted Capacity Expansion: Medication Assisted Treatment –  Prescription Drug and Opioid Addiction grant program, also administered  by SAMHSA, provides funding to states to expand access to medication- assisted treatment services as well as recovery services among  individuals with opioid use disorders. In fiscal year 2017 SAMHSA  awarded $31 million in additional grants to 6 states through this program.

NIDA Had 186 Active Grant-Funded Research Projects Focused on Substance Use Prevention, Treatment, and Recovery among Adolescents and Young Adults in 2017

Most of NIDA’s 186 Active Grant-Funded Research Projects for Adolescents and Young Adults in 2017 Focused on Substance Use Prevention

Our analysis found that HHS’s NIDA had 186 active grant-funded  research projects focused on illicit substance use prevention, treatment,  or recovery among adolescents and young adults in October and  November 2017, and most of these projects addressed substance use  prevention. Specifically, 126 research projects, or about 68 percent of  NIDA’s ongoing research projects for this population, involved research  related to preventing the use of illicit substances, such as the use of  marijuana or nonmedical use of opioids and other prescription drugs. The  remaining 60 projects, or about 32 percent, involved research related to  treatment for or recovery from the use of illicit substances among  adolescents and young adults, or a combination of categories (e.g.,  substance use prevention, treatment, and recovery). Among the  categories of research projects, the fewest involved research exclusively  about recovery (4 out of 186 projects, or about 2 percent), as shown in  table 3. Our analysis also found that about 12 percent of the ongoing  projects (22 of 186) involved the use of brain imaging in research on  prevention, treatment, or recovery. In total, of the 186 research projects  that were active in October and November 2017, 135 received $61.3  million in grants from NIDA in fiscal year 2017. NIDA did not provide  awards in fiscal year 2017 for the remaining 51 projects that were active  in October and November 2017.

The following examples illustrate the types of research activities funded  by the prevention, treatment, and recovery grants identified in our  review:

Prevention research projects. One research project involved  testing whether a parenting intervention is associated with lower  substance use and other high-risk behaviors among adolescents  in the long term, including how such outcomes relate to genetic  risk factors. The project’s participants included 731 adolescents to  be assessed over multiple years. The project planned to collect  DNA; observations of family interaction; parent, youth, and  teacher reports regarding adolescents’ conduct; and assessments  of their peer environments.

Treatment research projects. One research project involved  testing the effectiveness of the use of the medication naltrexone  (extended release), compared to the use of buprenorphine in  treating adolescents and young adults with opioid use disorders.  The project’s participants included 340 adolescents and young  adults and the project planned to provide counseling to the  participants during the course of the study. The project planned to  assess a variety of outcomes after 3 and 6 months, including the  number of days participants were in treatment, participants’ use of  opioids as well as other drug and alcohol use, and the cost- effectiveness of the treatment.

Recovery research projects. One research project involved  testing the effectiveness of a smartphone application to deliver  recovery services to adolescents after they received treatment for  a substance use disorder, compared to a control group of  adolescents that received recovery services via traditional  methods. Examples of recovery services delivered with a  smartphone application include participating in online recovery  group discussions and receiving motivational messages. The  project’s participants included 400 adolescents to be assessed  over a 9-month period. The project planned to collect a variety of  information, such as how frequently participants used the  smartphone application, how long they abstained from substance  use, and their quality of life.

In Fiscal Year 2017, NIDA and Nine Other HHS Entities Funded a Large Study Examining the Effects of Substance Use on Adolescent Brain Development

In fiscal year 2017, NIDA and nine other entities within HHS provided  grant funding for a large study—the Adolescent Brain Cognitive  Development study—designed to examine the effects of substance use  and other factors on development of the adolescent brain. This study  was established as a result of the collaboration of several federal  agencies that determined such a study was needed because of gaps in  knowledge about how substance use and other factors affect brain  development. This study is a longitudinal study that plans to collect data  from a sample of about 11,000 children across the country for 10 years,  beginning when they are 9 or 10 years old. Twenty-one research sites  across the country were selected to collect information from children  about their brain development, genetics, substance use, mental health,  physical health, environment, and other measures. In addition, this study  is funding a data analysis and informatics center to develop the  procedures for data collection, create and maintain a common database  pooling data from all of the research sites, and conduct data analysis.  According to NIDA officials, data from the Adolescent Brain Cognitive  Development study will be made available to researchers for future use  through a data archive. In fiscal year 2017, 15 federal grants provided  funding for this study, of which NIDA contributed $18.1 million.

Stakeholders Identified Gaps in Services and Research for Adolescents and Young Adults, and Ongoing Federal Efforts Aim to Address Gaps Stakeholders Identified Gaps in Services for Adolescents and Young Adults, and Federal Agencies Have Ongoing Efforts to Address Them

Stakeholders that we interviewed identified various gaps in services, and  among the most frequently cited were a lack of available recovery  services and treatment providers for adolescents and young adults with  substance use disorders. They also identified gaps in substance use  prevention services such as a lack of prevention services tailored for  certain subgroups within these ages. In general, officials from the  agencies in our review agreed that these gaps exist, and described  actions the agencies are taking that may help address them.

Stakeholders Identified Gaps in Research, Such as for Adolescent-Specific Substance Use Treatment Services, and in Recovery Services for both Adolescents and Young Adults

Stakeholders that we interviewed commonly identified gaps in research  concerning adolescent-specific substance use treatment approaches, as  well as in recovery services for both adolescents and young adults. They  also identified other gaps, such as a lack of knowledge about how to  effectively communicate to adolescents and young adults the harms of  substance use. Officials from HHS’s NIDA agreed that such gaps in  research exist.

Gaps in substance use research related to adolescents and young  adults. Stakeholders commonly identified the following gaps in research:

Substance use disorder treatment with adolescents. Four of  the stakeholders we interviewed identified gaps in adolescent- specific substance use disorder treatment research. Officials  from one research organization said that it can be challenging to  recruit a sufficient number of adolescents with a substance use  disorder to participate in research studies focused on substance  use treatment, both because fewer adolescents have such  disorders compared to adults, and because adolescents—or  potentially their parents—may be in denial about the need for  treatment. These officials further stated that having too few  funding announcements that focus on adolescent-specific  research contributes to the gaps in research in this area, because  it is easier for researchers to simply work with adults when  announcements do not specify an age group of interest. An official  from another research organization said there is also a gap in  knowledge about how to deliver treatment services to adolescents  in ways that are developmentally appropriate. The official stated  that adolescents who receive treatment services generally are  less likely to complete substance use disorder treatment, and, as  a result, additional research is needed to identify how to engage  and retain adolescents in a developmentally appropriate way. The  official explained that adolescents often do not believe they need  treatment and are not certain they want to stop using substances.

Recovery services. Three of the stakeholders we interviewed  identified gaps in recovery service research for adolescents and  young adults. Officials from one advocacy and education  organization said there has been little research conducted to  determine the types of recovery services that are most effective  for adolescents in preventing relapse. Officials from one research  organization said that it would be beneficial to develop a variety of  recovery services, since services are likely to vary in effectiveness  for different groups of adolescents and young adults.

Translating research into practice. Three of the stakeholders  we interviewed identified gaps in knowledge about how to  translate evidence-based services from research into sustainable,  real world practices. For example, an official from one research  organization explained that translating evidence-based treatment  services from research into real world settings can be difficult for a  variety of reasons—such as, because services that are grant- funded may have components that are impractical to implement or  are not reimbursable. The official said one example of such an  impractical component would be having an expert observer  periodically rate the fidelity of providers’ implementation of the  service—a component that makes sense when testing the efficacy  of the service under the grant, but which can be disruptive to  workflow and may not be reimbursable by insurers once the grant  ends. Officials from another research organization similarly  commented that more research is needed to identify which  components of services make them effective.

Communicating harms of substance use. Officials from two of  the three research organizations identified a gap in knowledge  about how to effectively communicate the harms of substance use  to adolescents and young adults. They stated that it is particularly  difficult to effectively communicate the harms of cannabis to  adolescents and young adults. One official explained that societal  changes in attitudes towards cannabis have made it more difficult  to convince adolescents of both its harm and of the need for  treatment when its use develops into a substance use disorder.

Federal response to gaps in research. Officials from NIDA agreed that  these gaps in research exist and explained that while additional research  is needed to address them, the process by which NIDA funds research  through grants ultimately relies on researchers to submit proposals for  consideration. While NIDA officials stated that researchers can submit  proposals for research projects addressing adolescent or young adult  substance use prevention, treatment, or recovery under general funding  announcements for grants, NIDA also had eight funding announcements  (as of May 2018) that either focused on these age groups or included  them as a population of interest, three of which were new as of fiscal year  2018.

We provided a draft of this report to HHS, DOJ, ONDCP, and Education  for comment. HHS, DOJ, and ONDCP provided technical comments,  which we incorporated as appropriate. Education did not have comments  on our draft.

We are sending copies of this report to the appropriate congressional  committees; the Secretaries of the Departments of Health and Human  Services, Justice, and Education; the Director of the Office of National  Drug Control Policy; and other interested parties. In addition, the report is  available at no charge on the GAO website at http://www.gao.gov.

If you or your staffs have any questions about this report, please contact  me at (202) 512-7114 or dickenj@gao.gov. Contact points for Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made key contributions to this report are  listed in appendix II.

Appendix I: The Use of Substance Abuse Prevention and Treatment Block Grant Funds for Adolescents and Young Adults

Table 4 shows the percentage of persons who were provided services  with Substance Abuse Prevention and Treatment Block Grant funds in  2014, and who were also identified by grantees as being adolescents or  young adults. Percentages are listed for two broad types of substance  use prevention services (individual and population-based), as well as  substance use disorder treatment and recovery services. Substance  Abuse Prevention and Treatment Block Grant grantees include states,  territories, and one federally recognized tribe.

Appendix II: GAO Contact and Staff Acknowledgments

In addition to the contact named above, Gerardine Brennan, Assistant  Director; Pamela Dooley, Analyst-in-Charge; Spencer Barr; and Brandon  Nakawaki made key contributions to this report. Also contributing were  Kaitlin Farquharson, Derry Henrick, and Laurie Pachter.

About 16 percent of adolescents and 38 percent of young adults used illicit substances in 2016. Most young adults who develop substance use disorders begin using in adolescence.

There are federal grants that fund drug addiction treatment for adolescents and young adults. But most of the stakeholders we talked to believed that there are too few studies about drug addiction treatment for adolescents, too few providers to treat these patients, and too few services to sustain their recovery.

Federal agencies are working to address these shortages, including a new grant to expand access to recovery services for adolescents and young adults.