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...on Substance Use
--Policy Issues--

www.ProjectCork.org

Summer 2002

Safer injection facilities in North America: Their place in public policy and health initiatives.

Broadhead RS; Kerr TH; Grund JPC; Altice FL. Journal of Drug Issues 32(1): 329-355, 2002. (61 refs.)
The continuing threat posed by HIV, HCV, drug overdose, and other injection-related health problems in both the United States and Canada indicates the need for further development of innovative interventions for drug injectors, for reducing disease and mortality rates, and for enrolling injectors into drug treatment and other health care programs. Governmentally sanctioned "safer injection facilities" (SlFs) are a service that many countries around the world have added to the array of public health programs they offer injectors. In addition to needle exchange programs, street-outreach and other services, SlFs are clearly additions to much larger comprehensive public health initiatives that municipalities pursue in many countries. A survey of the existing research literature, plus the authors' ethnographic observations of 18 SlFs operating in western Europe and one SIF that was recently opened in Sydney, Australia, suggest that SlFs target several problems that needle exchange, street-outreach, and other conventional services fall short in addressing: (1) reducing rates of drug injection and related-risks in public spaces; (2) placing injectors in more direct and timely contact with medical care, drug treatment, counseling, and other social services; (3) reducing the volume of injectors' discarded litter in, and expropriation of, public spaces. In light of the evidence, the time has come for more municipalities within North America to begin considering the place of SlFs in public policy and health initiatives, and to provide support for controlled field trials and demonstration projects of SIFs operating in injection drug-using communities.

A nationwide survey of hepatitis C services provided by drug treatment programs.

Strauss SM; Falkin GP; Vassilev Z; Des Jarlais DC; Astone J. Journal of Substance Abuse Treatment 22(2): 55-62, 2002. (43 refs.)
Drug treatment programs are a site of opportunity for the delivery of primary and secondary hepatitis C (HCV) prevention services to drug users, a population at great risk for contracting and transmitting the virus. Using data collected from a random nationwide sample (N = 439) of drug treatment programs in the United States, this study examines the extent to which various types of HCV services are provided to their patients. Findings indicate that the majority of drug treatment programs educate at least some of their patients about HCV, and provide some type of support for patients who are infected with the virus. Only 29 of the programs in the sample test all of their patients for HCV, however, and 99 programs test none of them. For the most part, residential treatment programs offer more HCV related services than outpatient drug-free programs.

Alcohol marketing on the internet: New challenges for harm reduction.

Carroll TE; Donovan RJ. Drug and Alcohol Review 21(1): 83-91, 2002. (42 refs.)
While much has been made of the problems of regulating alcohol and other drug promotion in the traditional media of print, radio and newspapers, the 'new media' and in particular the world wide web, provides new fertile ground for alcohol advertisers. In this Harm Reduction Digest Tom Carroll and Rob Donovan apply the voluntary standards of the Alcohol Beverages Advertising Code to six websites for alcohol products available in Australia. They conclude that the internet provides an opportunity for alcohol marketing targeted at underage consumers, that some alcohol-related web pages would be in breach of the Code if it applied to the internet, and suggest that web marketing practices of alcohol beverage companies should be monitored and a code of practice developed to regulate alcohol promotion on the web.

Health care utilization of chronic inebriates.

Thornquist L; Biros M; Olander R; Sterner S. Academic Emergency Medicine 9(4): 300-308, 2002. (18 refs.)
Chronic inebriates often use emergency services, including the emergency department (ED), because they lack other resources or access to primary care. Because of their complicated medical needs, which are often exacerbated by acute intoxication and related illness or injury, a relatively small number of acutely intoxicated chronic inebriates can stretch ED resources and contribute to ED overcrowding. Objective: In order to address this, as well as over-utilization of other county services, three county programs were developed (ethnic-and gender-specific supportive housing; intensive street ease management) to reduce emergency resource utilization while still providing a safe environment. This study determined the effectiveness of these programs. The authors hypothesized that program enrollment would reduce medical and detoxification (detox) expenditures for this patient population. Methods: Pre-and post-program comparisons were made on the number of detox and medical visits, insured days, and charges. Data were retrieved (with patients' written informed consent) from hospital and health plan billings and county databases. Descriptive statistics compared groups pre and post enrollment. Least-squares regression predicted total and non-inpatient medical charges. Results: Complete data were available for 92 of 122 patients (mean age = 47 years; 60% Native American; 93% male); seven had severe illnesses or injuries, skewing the mean. However, there were significant overall reductions in the median numbers of yearly detox visits (10 to 1) and medical visits (11 to 8), and in median medical charges ($5,436 to $2,770) and total health care charges ($9,297 to $5,218). The median number of days insured increased (284 to 353). By regression analysis, injury was the most important preprogram predictor of medical charges; illness drives charges post-entry. Alcohol-related visits added to the model before entry but disappeared post-entry. Conclusions: These programs reduced health care use for most patients. however, serious medical illness or injury in a small number of patients contributed heavily to resource utilization.

A synthesis of welfare reform policy and its impact on substance users.

Montoya ID; Atkinson JS. American Journal of Drug and Alcohol Abuse 28(1): 133-146, 2002. (23 refs.)
Objectives: The purpose of this study was to provide an overview of welfare reform and its impact on the substance-abusing recipient. Methods: The data for this paper were derived from sources including the US Department of Health and Human Services and the National Institute on Drug Abuse. Results: The number of individuals on public assistance has decreased in the years following implementation of welfare reform legislation. Factors relevant to transitioning welfare recipients into the workplace, such as transportation and childcare, have special ramifications for the drug using population. Additionally, these individuals require treatment for their addictions in order to be employable. The issue of concern is that recipients may be deterred from seeking benefits by various provisions of welfare reform legislation and turn instead to other sources (including illicit activities) for sustenance. Conclusions: Welfare caseloads have been dropping over the past two years. However, the number of substance abusers continues to rise. It is not known in what ways welfare reform will affect substance abusers who are welfare recipients. Important policy issues arise from this nexus; it is argued that these issues will require careful investigation.

Drugs and alcohol: US prohibition and the origins of the drug trade in Mexico, 1910-1930.

Recio G. Journal of Latin American Studies 34(Part 1): 21-42, 2002. (22 refs.)
Even though Mexico has been an important player in the international drug trade, this country's history in such illegal ventures has been insufficiently studied. In an effort to begin to understand how and when the country began to be an active participant in such illicit markets, this article first analyses regulations introduced in the United States regarding drug and alcohol consumption, marketing and production and assesses their impact on the Mexican side. Secondly, it argues that Mexico's participation in the narcotics trade, the routes that have developed and the Mexican states involved in this traffic have roots that can be traced to the beginning of the twentieth century at least.

Illicit drug use and reliance on welfare.

Lehrer EL; Crittenden K; Norr KF. Journal of Drug Issues 32(1): 179-207, 2002. (37 refs.)
This paper uses longitudinal data on nearly 500 minority mothers living in an innercity neighborhood of Chicago to study the role of illicit drugs as a potential barrier to economic self-sufficiency. The analysis employs information collected during the last trimester of pregnancy and one year after the birth of the child. Logit regressions that control for a rich set of human capital and demographic characteristics reveal that illicit drug use in the months before the pregnancy is associated with a large increase in the likelihood of welfare reliance one year later. Other models, focusing on a drug addiction problem as measured by very frequent drug use before the pregnancy or any use during the pregnancy, yield even more pronounced effects, a result that is robust to a different specification that treats this variable as endogenous.

Substance use and labor force participation among homeless adults.

Zlotnick C; Robertson MJ; Tam T. American Journal of Drug and Alcohol Abuse 28(1): 37-53, 2002. (39 refs.)
Objectives: We measured the proportion of homeless adults in the labor force and examined the impact of substance use on labor force participation. Methods: A county-wide probability sample of 397 homeless adults was interviewed three times in a 15-month period. Results: Almost 80% of homeless adults were employed or looking for work at one point in time; however, only 47.7% remained in the labor force over the 15-month study period. Recent drug users were only 5% as likely as other homeless adults to be in the labor force; and consistent public entitlement recipients were only 18% as likely as other homeless adults to be in the labor force. Conclusions: Recent illicit drug use posed a deterrent to labor force participation among homeless adults, but heavy alcohol use did not. Most homeless adults were not consistently in the labor force and those who were, did not receive public entitlement benefits. This finding poses an interesting dilemma since previous studies indicated that homeless adults, who are consistent public entitlement recipients, were more likely to get housed than those who are not.

The economics of alcohol abuse and alcohol-control policies.

Cook PJ; Moore MJ. Health Affairs 21(2): 120-133, 2002. (62 refs.)
Economic research has contributed to the evaluation of alcohol policy through empirical analysis of the effects of alcohol-control measures on alcohol consumption and its consequences. It has also provided an accounting framework for defining and comparing costs and benefits of alcohol consumption and related policy interventions, including excise taxes. The most important finding from the economics literature is that consumers tend to drink less ethanol, and have fewer alcohol-related problems, when alcoholic beverage prices are increased or alcohol availability is restricted. That set of findings is relevant for policy purposes because alcohol abuse imposes large "external" costs on others. Important challenges remain, including developing a better understanding of the effects of drinking on labor-market productivity.

The effects of obesity, smoking, and drinking on medical problems and costs.

Sturm R. Health Affairs 21(2): 245-253, 2002. (33 refs.)
This paper compares the effects of obesity, overweight, smoking, and problem drinking on health care use and health status based on national survey data. Obesity has roughly the same association with chronic health conditions as does twenty years' aging; this greatly exceeds the associations of smoking or problem drinking. Utilization effects mirrors the health effects. Obesity is associated with a 36 percent increase in inpatient and outpatient spending and a 77 percent increase in medications, compared with a 21 percent increase in inpatient and outpatient spending and a 28 percent increase in medications for current smokers and smaller effects for problem drinkers. Nevertheless, the latter two groups have received more consistent attention in recent decades in clinical practice and public health policy.

The origins of commitment for substance abuse in the United States.

(review).
Hall KT; Appelbaum PS. Journal of the American Academy of Psychiatry and the Law 30(1): 33-45, 2002. (109 refs.)
Policymakers in the United States have long been perplexed by how to deal with substance abuse. As attitudes shifted in the 19th century toward viewing substance abuse as a medical problem akin to insanity rather than as a moral failing, greater emphasis was given to the potential for treatment. Thus, by the middle of the 19th century, states began developing substance abuse commitment codes and institutions to which substance abusers could be committed. Public ambivalence over whether substance abusers should be seen as having an illness or a weakness of will, however, was reflected in the lack of sustained support forthese efforts, in contrast to support accorded systems for commitment of the mentally ill. Contemporary policy-makers are faced with the same ambivalence, as they struggle with the extent to which substance abusers ought to be subjected to involuntary treatment. The legacy of the early years of substance abuse commitment lives on.

Untreated addiction imposes an ethical bar to recruiting addicts for non-therapeutic studies of addictive drugs.

Cohen PJ. Journal of Law, Medicine & Ethics 30(1): 73-3, 2002. (45 refs.)
Many American research centers allow only addicts who do not seek treatment to volunteer as subjects, arguing that since they will continue to use addictive drugs, participation in such studies will impose no additional burdens on them. However, non-treatment-seeking addicts manifest compulsive use even in situations when their use is physically hazardous or associated with legal problems. This denial of disease and rejection of treatment under these circumstances demonstrate a lack of independent decision-making capacity regarding their use of addictive drugs. Thus, non-treatment-seeking addicts are incapable of giving autonomous consent and their recruitment raises significant ethical questions.

The experience and acceptability of drug testing: Poll trends.

Fendrich M; Kim JYS. Journal of Drug Issues 32(1): 81-95, 2002. (12 refs.)
With a growing interest in using drug testing as part of standard survey procedures for drug use prevalence estimation, we undertook an examination of national surveys of attitudes towards and experience with employment-related drug testing. After identifying 102 questions from 20 different surveys administered from the mid 1980s to the late 1990s, we found a trend suggesting that the population has become increasingly favorable toward drug testing. Although drug-testing policies are highly prevalent, personal experience with drug testing is not normative. Personal experience also varies with race, gender, age, and occupational group. Implications for epidemiological research incorporating testing are addressed.

Hospital use of ethanol survey (HUES): Preliminary results.

Smoger SH; Looney SW; Blondell RD; Wieland LS; Sexton L; Rhodes SB et al. Journal of Addictive Diseases 21(2): 65-73, 2002. (32 refs.)
Little information exists about alcohol use within health facilities. We sought to determine alcohol use and control in acute-care hospitals by mailing a questionnaire to a convenience sample of Pharmacy Directors of 24 hospitals in two regions. Of 23 responders, inpatient alcohol was dispensed by 21 (91%) within the last 5 years. Of these 21, both beverage and intravenous alcohol were dispensed by 13 (62%), only beverage alcohol by seven (33%), and only intravenous alcohol by one (5%). No institutional policies regarding alcohol dispensing existed in 16 (70%) hospitals. Alcohol was frequently used as a patient courtesy (14/20, 70%), and to prevent withdrawal (7/20, 35%). All pharmacies procured intravenous alcohol in a formal process, but 60% (12/20) obtained beverage alcohol informally. Alcohol is widely dispensed with few guidelines in this sample of acute-care hospitals. Additional research on therapeutic efficacy, consequences, and institutional oversight of alcohol in hospitals is needed.

State laws mandating or promoting training programs for alcohol servers and establishment managers: An assessment of statutory and administrative procedures.

Mosher JF; Toomey TL; Good C; Harwood E; Wagenaar AC. Journal of Public Health Policy 23(1): 90-113, 2002. (36 refs.)
We conducted a qualitative analysis of 23 state Responsible Beverage Service (RBS) laws to determine how effective the laws are in mandating or encouraging high-quality RBS programs. As of January, 2001, 12 states at least partially mandate RBS training for alcohol establishments and 11 states offer incentives to encourage participation in RBS training. We collected information regarding state RBS laws from two sources: (1) RBS statutes and associated regulatory provisions, and (2) telephone surveys of Alcoholic Beverage Control agency staff. We identified and evaluated five components of RBS laws: program requirements, administrative requirements, enforcement provisions, penalties for lack of compliance with law, and benefits for participation in training programs. Comprehensiveness of RBS laws varied by state; however, RBS legislation was weak across all states overall. While some states were strong in one or two of the RBS components, almost all states were weak in at least one component.

...on Substance Use --Policy Issues--