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...Policy

www.ProjectCork.org

Summer 2003

Crossing the Bridge: An Evaluation of the Drug Treatment Alternative-to-Prison (DTAP) Program.

New York: National Center on Addiction and Substance Abuse at Columbia University, 2003. (60 refs.)
This report is the evaluation of a program established in Brooklyn NY as an alternative to prison for drug addicted, non-violent felony offenders. Those enroll-ed, with an average of five prior drug arrests and an average of four years behind bars achieved signifi-cantly lower recidivism rates and higher employment rates through a drug treatment program than comparable offenders who were sent to prison. Among the findings were that the rearrest rates for DTAP participants were 26% lower and reconviction rates 36% lower at two years after leaving the pro-gram, compared to a matched comparison group. The DTAP participants were 67% less likely to return to prison two years after leaving the program. Fifty-two percent of participants completed the program. Also they were three and a half times more likely to be employed, stayed in treatment 6 times longer. With program changes the retention rate increased to 81% at one year and 62% at year two. The costs was half that of incarceration. The average cost, including cost of residential drug treatment, vocational training, and supportive services was about $33,000.

Feasibility of screening and intervention for alcohol problems among young adults in the ED.

Hungerford DW; Williams JM; Furbee PM; Manley WG; Helmkamp RC; Horn K. American Journal of Emergency Medicine 21(1): 14-22, 2003. (41 refs.)
This study evaluates the feasibility of screening and brief intervention (SBI) for alcohol problems among young adults (18- 39 years) in a rural, university ED. Research staff screened a convenience sample of patients waiting for medical treatment with the Alcohol Use Disorders Identification Test (AUDIT), used motivational interviewing techniques to counsel screen-positive patients (AUDIT greater than or equal to 6) during the ED visit, and referred patients to off-site alcohol treatment as appropriate. Patients were interviewed again at 3 months. Eighty-seven percent of age-eligible drinkers (2,067 of 2,371) consented to participate. Forty-three percent (894 of 2,067) screened positive, of which 94% were counseled. Forty percent of those counseled set a goal to decrease or stop drinking and 4% were referred for further treatment. Median times for obtaining consent, screening, and intervention were 4, 4, and 14 minutes, respectively. Project staff reported that 3% of patients screened or counseled were uncooperative. Seventy percent of 519 patients who participated in follow-up interviews agreed the ED is a good place to help patients with alcohol problems. High rates of informed consent and acceptance of counseling confirmed this protocol's acceptability to patients and indicated patients were comfortable divulging alcohol-related risk behavior. The modest times required for the process enhanced acceptability to patients as well as ED staff. The high prevalence of alcohol problems and the broad acceptance of SBI in this sample provide evidence of the ED's promise as a venue for this clinical preventive service.

Financial costs of alcoholism treatment programs: A longitudinal and comparative evaluation among four specialized centers.

Nalpas B; Combescure C; Pierre B; Ledent T; Gillet C; Playoust D et al. Alcoholism: Clinical and Experimental Research 27(1): 51-56, 2003. (14 refs.)
Background: Alcoholism is a worldwide problem. Many strategies for alcohol detoxification and relapse prevention exist, but each alcohol treatment center has its own program. The objective of this study was to analyze and compare the financial cost and effectiveness of alcohol treatment pro-grams from inpatient stay to follow-up 1 year later. This was a prospective, open, nonrandomized study of 4 specialized alcohol treatment centers and 267 patients admitted for alcohol detoxification. Methods: We recorded all medical and nonmedical interventions related to the program during patient stay in the hospital and every 3 months after disc-harge for 1 year and recorded the occurrence of alcohol relapse. Financial evaluation was based on the prices of refund from the French national health insurance service. Results: The mean cost of hospitalization ranged from euro1326 to euro1917 (p = 0.001), a variation mainly due to the difference in the length of hospital stay but also to the cost of the inpatient program, routine medical checkups, and drugs administered. The mean cost of 1 year of follow-up per patient ranged from euro419 to euro1704 (p = 0.001). The efficiency, corresponding to the money spent to prevent the relapse of one patient during 1 month, was approx-imately euro500/month in three centers and euro658 in the fourth. However, for a similar efficiency, the effectiveness, assessed by the mean time without relapse, was significantly (p = 0.001) different; center 1, which had the highest total cost, had an effectiveness 1.56 times higher than center 3, which had the lowest cost. Conclusions: This work emphasizes the heterogeneity of the costs and effectiveness of alcoholism treatment programs and suggests that research should be conducted to determine which program is the most rational, cost-efficient, and beneficial for patients and the public health office economy.

Impact of supply-side policies for control of illicit drugs in the face of the AIDS and overdose epidemics: investigation of a massive heroin seizure.

Wood E; Tyndall MW; Spittal PM; Li K; Anis AH; Hogg RS et al. Canadian Medical Association Journal 168(2): 165-169, 2003. (30 refs.)
Background: More than 93% of the nearly $500 million spent annually on Canada's drug strategy goes toward efforts to reduce the illicit drug supply. However, little is known about the effectiveness of this strategy. On Sept. 2, 2000, Canadian police seized approximately 100 kg of heroin in one of the nation's largest-ever seizures of this drug. An ongoing prospective cohort study of injection drug users afforded an opportunity to evaluate the impact of this seizure. Methods: The Vancouver Injection Drug User Study is a prospective cohort study of injection drug users that began in 1996. The present study relied primarily on data acquired from participants who were seen during the 30-day periods immediately before and after the seizure. We com-pared drug use and behavioural characteristics, heroin and cocaine prices, and participants' reports of whether law enforcement had affected their source of drugs or the types of drugs available on the street, as well as overdoses, in these 2 periods. Results: The 138 participants seen before the seizure were similar to the 123 participants seen after the seizure with respect to age, sex, ethnic background, education, HIV serostatus, neighbourhood residence, instability of housing, employment status, use of methadone maintenance therapy and all other measured potential confounders (all p > 0.10). We found no difference in the extent to which participants in the 2 groups reported daily use of heroin, frequency of nonfatal overdoses, or whether law enforcement had affected their source of drugs or the types of drugs available on the street (all p > 0.10). Although we detected no difference in the price of cocaine, the median reported price of heroin went down after the seizure (p = 0.034), which suggests that other shipments compensated for the seizure. External evaluations of deaths from overdoses and heroin purity indicated that the seizure had no impact, nor was any impact seen when the periods of analysis were extended. Interpretation: The massive heroin seizure appeared to have no measurable public health benefit. Closer scrutiny of enforcement efforts is warranted to ensure that resources are delivered to the most efficient and cost-effective public health programs.

Income distribution and risk of fatal drug overdose in New York City neighborhoods.

Galea S; Ahern J; Vlahov D; Coffin PO; Fuller C; Leon AC; Tardiff K. Drug and Alcohol Dependence 70(2): 139 - 148, 2003. (46 refs.)
Accidental drug overdose is a substantial cause of mortality for drug users. Neighborhood-level factors, such as income distribution, may be important determinants of overdose death independent of individual-level factors. We used data from the Office of the Chief Medical Examiner to identify all cases of accidental deaths in New York City (NYC) in 1996 and individual-level covariates. We used 1990 US Census data to calculate the neighborhood-level income distribution. This multi-level case-control study included 725 accidental overdose deaths (cases) and 453 accidental deaths due to other causes (controls) in 59 neighborhoods in NYC. Overdose deaths were more likely in neighborhoods with higher levels of drug use and with more unequal income distribution. In multi-level models, income maldistribution was significantly associated with risk of overdose independent of individual-level variables (age, race, and sex) and neighborhood-level variables (income, drug use, and racial composition). The odds of death due to drug overdose were 1.63-1.88 in neighbor-hoods in the least equitable decile compared with neighborhoods in the most equitable decile. Disinvest-ment in social and economic resources in unequal neighborhoods may explain this association. Public health interventions related to overdose risk should pay particular attention to highly unequal neighborhoods.

Perinatal substance abuse and human subjects research: Are privacy protections adequate? (review).

Marshall MF; Menikoff J; Paltrow LM. Mental Retardation and Developmental Disabilities Research Reviews 9(1): 54-59, 2003. (9 refs.)
Privacy incursions in the clinical care of substance abusing pregnant women have gained lay and professional attention recently as the result of a high-profile Supreme Court finding in Ferguson vs City of Charleston et al. In March, 2001 the Supreme Court determined that nonconsensual drug screening of pregnant women by clinicians in a public hospital violated the women's Fourth Amendment rights to be secure against unreasonable search and seizure. Coercive or punitive policy approaches to perinatal substance abuse are often based on mistaken assumptions about the nature of addiction and the outcomes of punitive interventions. Much attention has been given to efforts to criminalize pregnancy for drug using women, and civil laws are also coming under increasing scrutiny. Although no state has passed a law criminalizing pregnancy and drug use, an estimated 250 women in more than 30 states have been prosecuted around the country on theories of "fetal abuse." A growing number of states (eighteen to date) have amended their civil child welfare laws to address specifically the subject of a woman's drug use during pregnancy. No one has examined how these laws and social policies could affect research that includes pregnant and parenting women; women (and their families) who stand to lose a great deal should their drug use be brought to the attention of child welfare or criminal justice authorities. We examine the adequacy of current protective mechanisms, such as federal certificates of confidentiality, in protecting research subjects (and investigators) who may be subject to punitive civil or criminal sanctions. We determine that current protective mechanisms may be insufficient to protect research subjects and that investigators and IRB members are often ignorant of the risks imposed by punitive policy approaches to perinatal substance abuse or fall prey to the same mistaken assumptions that inform punitive policies. We conclude that investigators and IRB members have a moral responsibility to understand local, state and national policies and laws governing perinatal substance abuse. Investigators and IRB members should balance the harms of punitive interventions against the protections that may, or may not be afforded to prospective research subjects as well as the prospective benefits, individual and social, of the research. In situations where criminal or punitive policies are in effect, investigators and IRB members should consider whether adequate protections can be achieved. In the context of inadequate protections, potential risks to prospective research subjects and their families may outweigh the individual or. social benefits that accrue from the research. Clinical researchers are professionally obligated to work toward amending laws and policies that 4, are not in. the best interests of prospective research subjects

Point-of-purchase alcohol marketing and promotion by store type. United States, 2000-2001.

Terry-McElrath YN; Harwood EM; Wagenaar AC; Slater S; Chaloupka FJ; Brewer RD et al. MMWR. Morbidity and Mortality Weekly Report 52(14): 310-313, 2003. (10 refs.)
Recent studies have focused on alcohol marketing as a po-tentially important contributor to alcohol consumption, part-icularly among underage drinkers (3). Point-of-purchase (POP) (i.e., on-site) marketing, including alcohol advertising and placement, can increase alcohol sales and consumption substantially, thereby increasing the risk for various alcohol-related health outcomes, including alcohol-impaired driving and interpersonal violence. This report summarizes the results of a study that collected and analyzed store observa-tion data during 2000-2001 from 3,961 alcohol retailers in 329 communities throughout the United States. The data suggest that point of purchase marketing is extensive in certain story types frequented by teenagers and young adults. The majority of stores (94%) had some form of POP alcohol marketing. Exterior alcohol advertise-ments were observed in 39% of stores ; 27% of stores had high-intensity exterior advertising¤. Compared with supermarkets, liquor stores (odds ratio [OR] = 176.8), convenience stores (OR = 48.2), conven-ience/gas stores (OR = 42.3), small grocery stores (OR = 24.5), and drug stores/pharmacies (OR = 15.5) were more likely to have high-intensity exterior alcohol advertising. Interior alcohol advertisements were observed in 92% of stores, and 37% of stores had high-intensity interior advertising. Persons aged 21-27 years are more likely to purchase beer in convenience stores and liquor stores than in supermarkets and drug stores, and 75% of teenagers shop at convenience or convenience/gas stores weekly. Therefore, aggressive POP marketing in convenience and liquor stores might influence young adults, underage persons, and adolescents disproportionately. Public Domain.

The toxic torch of the modern Olympic Games. (review).

Prendergast HM; Bannen T; Erickson TB; Honore KR. Veterinary and Human Toxicology 45(2): 97-102, 2003. (34 refs.)
One of the most enduring symbols of the Olympics is the torch or flame, an icon of peace and sportsmanship that has its roots in Ancient Greece. According to the Creed of the Olympics: "The important thing in the Games is not winning, but taking part. The essential thing is not conquering, but fighting well." The mod-ern Olympic Games (1896-2000) have been heavy laden with controversy, as athletes have abused performance enhancing drugs to thrust themselves into the limelight in search of gold. It was not until 1967 that the International Olympic Medical Commission began banning drugs. Full-scale drug testing was instituted in 1972. Retrospective review of modern summer and winter Olympics Game sources (1896-2002) was done for documentation of drug abuse, drug-related overdoses, and positive drug screens. Data were collected for the type of drug documented, the athlete's name, their country of origin, and Olympic event. Seventy cases were identified. The most common class of agents were steroids (29), followed by stimulants (22), diuretics (7), beta-2 agonists; (2), and beta blockers (1). Alcohol and marijuana, while not historically prohibited, have been outlawed by several individual sport federations. Toxicities of these 2 agents were most liked under reported. Countries of origin of individual athletes included Bulgaria (7), USA (7), Sweden (4), Spain (4), Japan (2), Poland (2), Greece (2), Canada (2), Hungary (2), Russia (2), Austria (2), and Great Britain, Norway, Romania., Armenian, and Latvian, each with I. The most common Olympic events in which drug abuse was documented were weightlifting (25), track and field (12), skiing (5), wrestling (5), volleyball (3), modern pentathlon (3), cycling (2), swimming (2), gymnastics (1), and rowing (1). As athletic pressures and financial gains of the Olympic Games heighten, more toxicities are liked to occur despite attempts at restricting performance-enhancing drugs.

Unit cost of counseling and patients' length of stay in a residential drug treatment setting.

Alemi F; Haack M; Holifield L; Claudio Y; Haqqi K. Journal of Mental Health Policy and Economics 5(3): 103-107, 2002The purpose of this study is to show, by way of an example, how cost of an hour of counseling depends on the nature of the patient, in general, and length of the patient's stay, in particular. Even though the health care professional provides the same hour of work, the cost of the hour is different for short-stay and long-stay patients. The authors identified 5-short and 5 long stay patients in a residential treatment program. For each group, they asked the counselors to review the medical records and measure the patients' utilization of various service units. They estimated the cost of a unit of service by dividing cost of an average patient by the program utilization of short and long-stay patients. Results revealed that the cost of an hour of counseling for long stay patients was 2/3 less than the cost of short-stay patients. Similar large changes in unit cost of treatment were observed for cost of group counseling or other components of substance abuse treatment. Our data was limited to one case study and may not indicate similar patterns in other treatment programs. The paper suggests that methods of studying cost of treatment should be adjusted to reflect case mix of patients and their expected length of stay. Implications for health policies are included.