Background Federal Grant Programs 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. Agency Comments 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 GAO Contact 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.
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.