Cork Newsletter. Policy Issues. Winter 2003

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...on Substance Abuse - Policy Issues

www.ProjectCork.org

Winter 2002/03

Achieving effective supervision.

Kavanagh DJ; Spence SH; Wilson J; Crow N. Drug and Alcohol Review 21(3): 247-252, 2002. (46 refs.)
Supervision probably does have benefits both for the maintenance and improvement of clinical skills and for job satisfaction, but the data are very thin and almost non-existent in the area of alcohol and other drugs services. Because of the potential complexity of objectives and roles in super vision, a structured agreement appears to be an important part of the effective super-vision relationship. Because sessions can degenerate easily into unstructured socialization, agendas and session objectives may also be important. While a working alliance based on mutual respect and trust is an essential base for the supervision relationship, procedures for direct observation of clinical skills, demonstration of new procedures and skills practice with detailed feedback appear critical to supervision's impact on practice. To ensure effective supervision, there needs not only to be a minimum of personnel and resources, but also a compatibility with the values and procedures of management and staff, access to supervision training and consultation and sufficient incentives to ensure it continues.

Alcohol, drug abuse, and mental health care for uninsured and insured adults.

Wells KB; Sherbourne CD; Sturm R; Young AS; Burnam MA. Health Services Research 37(4): 1055-1066, 2002. (32 refs.)
Objective. To compare adults with different insurance coverage in care for alcohol, drug abuse, and mental health (ADM) problems.Data Sources/Study Setting. From a national telephone survey of 9,585 respondents. Design. Follow-up of adult participants in the Community Tracking Study. Data Collection. Self-report survey of insurance plan (Medicare, Medicaid, unmanaged, fully, or partially man-aged private, or uninsured), ADM need, rise of ADM services and treatments, and satisfaction with care in the last 12 months. Principal Methods. Logistic and linear regressions were used to compare persons by insurance type in ADM use. Principal Findings. The likelihood of ADM care was highest under Medicaid and lowest for the uninsured and those under Medicare. Perceived unmet need was highest for the uninsured and lowest under Medicare. Persons in fully rather than partially managed private plans tend to be more likely to have ADM care and ADM treatments given need. Satisfaction with care was high in public plans and low for the uninsured. Conclusions. The uninsured have the most problems with access to and quality of ADM care, relative to the somewhat comparable Medicaid population. Persons in fully managed plans had better rather than worse access and quality compared to partially managed plans, but findings are exploratory. Despite low ADM rise, those with Medicare tend to be satisfied. Across plans, unmet need for ADM care was high, suggesting changes are needed in policy and practice.

Bridging the gap between substance abuse practice and research: The National Treatment Plan Initiative.

Clark HW. Journal of Drug Issues 32(3): 757-768, 2002. (9 refs.)
The abuse of alcohol and other drugs leads to serious health problems, criminal activity, automobile crashes, and lost productivity in the workplace. As we advocate treatment for those who suffer from alcohol or drug addiction, we must advocate treatment that is proven effective for the drug and populace involved. However, due to background, cultural, and language differences between substance abuse researchers, treatment providers, and policy makers, empirically tested treatments are not being put into widespread practice. To bridge this gap, the Center for Substance Abuse Treatment sponsored the National Treatment Plan Initiative, a two-year effort to listen to multiple segments of the treatment field. This led to the formation of the Practice Improvement Collaborative (PIC) Program, whose purpose is to foster community-based partnerships that are committed to the identification, adoption, and evaluation of evidence-based practices that address locally defined needs. The PIC and the overall goals of the National Treatment Plan are discussed.

Can the United Nations support "objective" and unhampered illicit drug policy research? A testimony of a UN funded researcher.

Thoumi FE. Crime, Law & Social Change 38(2): 161-183, 2002. (15 refs.)
Policies towards mind-altering drugs are controversial and vary among countries and cultures. Many nations feel that the United Nations should be a forum where anti-drug issues can be discussed openly and `objectively'. During the 1990s I participated frequently in U.N. sponsored research projects. This essay summarize what has been a challenging and exciting experience and raises many questions about the U.N.'s capacity to do and or fund `objective' drug research. This is so because of pressures on the U.N. from drug-policy setting countries, lack of independent funds for the U.N. drug policy agencies, the structure and internal dynamics of the U.N. bureaucracies, and the background of the involved U.N. staff. As a result of these factors, the U.N. has promoted a repressive anti-drug agenda and does not allow open debate of many of key anti-drug issues currently discussed in many countries. This is unfortunate because the UN. has the largest amount of information about illicit drugs anywhere in the world and can play a key role improving anti-drug policies that currently are unsatisfactory to both, drug hawks and doves.

Addiction and the Americans with Disabilities Act.

Westreich LM. Journal of the American Academy of Psychiatry and the Law 30(3): 355-363, 2002. (14 refs.)
On July 26, 1990, the U.S. Congress enacted the Americans with Disabilities Act (ADA), which was intended as a broad, national, civil rights-oriented mandate "for the elimination of discrimination against individuals with disabilities," both physical and mental. ADA protection is extended, in limited form, to those with addiction disorders. However, many addicted individuals are denied ADA protection because of exclusionary criteria in the ADA itself and because of increaseingly restrictive interpretations of the ADA in recent cases. The benefit to the addicted persons, and to the larger society, is lost when unfair discriminatory practices preclude employment of otherwise qualified, though stigmatized, individuals. The ADA currently falls short, in many respects, of preventing such discrimination against those with addictions. .

Cost-effectiveness of pharmacological interventions for smoking cessation: A literature review and a decision analytic analysis.

Song FJ; Raftery J; Aveyard P; Hyde C; Barton P; Woolacott N. Medical Decision Making 22(5 Supplement): S26-S37, 2002. (39 refs.)
To evaluate the relative cost-effectiveness of nicotine replacement therapy (NTRT) and bupropion SR for smoking cessation, the authors reviewed published studies and devel-oped a decision analytic model from the UK National Health Services perspective. Irrespective of the methods or assumptions involved, the results of published studies consistently indicated that NRT for smoking cessation is cost- effective. No published studies have evaluated the relative cost- effectiveness of bupropion SR for smoking cessation. The results of the decision analyses indicated that, as compared with advice or counseling alone, the incremental cost per life-years saved is about $1,441similar to $3,455 for NRT, $920 similar to $2,150 for bupropion SR, and $1,282 similar to $2,836 for NRT plus bupropion SR. The cost- effectiveness of adding NRT and bupropion SR to advice or counseling for smoking cessation is better than many other accepted health care interventions.

Dutch coffee shops and trends in cannabis use.

Korf DJ. Addictive Behaviors 27(6): 851-866, 2002. (51 refs.)
Conflicting predictions have been made to the influence of decriminalization on cannabis use. Prohibitionists forecast that decriminalization will lead to an increase in consumption of cannabis, while their opponents hypothesise that cannabis use will decline after decriminalization. Most probably cannabis use in the Netherlands so far evolved in two waves, with a first peak around 1970, a low during the late 1970s and early 1980s, and a second peak in the mid-1990s. It is striking that this trend in cannabis use among youth in the Netherlands rather parallels four identified stages in the availability of cannabis. The number of cannabis users peaked when the cannabis was distributed through an underground market (late 1960s and early 1970s). Then the number decreased as house dealers were superseding the under-ground market (1970s), and went up again after coffee shops took over the sale of cannabis (1980s), and stabilised or slightly decreased by the end of the 1990s when the number of coffee shops was reduced. Although changes in cannabis policy went along with changes in availability of cannabis and prevalence of cannabis use, it is questionable whether changes in cannabis policy were causally related to trends in cannabis use. Cannabis use also developed in waves in other European countries that did not decriminalize cannabis, as well as in the US. Consequently, trends in cannabis use seem to develop rather independently of cannabis policy.

Heroin-assisted treatment as a response to the public health problem of opiate dependence.

Fischer B; Rehm J; Kirst M; Casas M; Hall W; Krausz M et al. European Journal of Public Health 12(3): 228-234, 2002. (68 refs.)
Injection drug use (involving the injection of illicit opiates) poses serious public health problems in many countries. Research has indicated that injection drug users are at higher risk for morbidity in the form of HIV/AIDS and Hepatitis B and C, and drug-related mortality, as well as increased criminal activity. Methadone maintenance treatment is the most prominent form of pharmacotherapy treatment for illicit opiate dependence in several countries, and its application varies internationally with respect to treatment regulations and delivery modes. In order to effectively treat those patients who have previously been resistant to methadone maintenance treatment, several countries have been studying and/or considering heroin-assisted treatment as a complementary form of opiate pharmacotherapy treatment. This paper provides an overview of the prevalence of injection drug use and the opiate dependence problem internationally, the current opiate dependence treatment landscape in several countries, and the status of ongoing or planned heroin-assisted treatment trials in Australia, Canada and certain European countries.

Hospital initiatives in promoting smoking cessation: A survey of internet and hospital-based programs targeted at consumers.

Denny JT; Ginsberg S; Papp D; Browne G; Morgan S; Kushins L; Solina A. Chest 122(2): 692-698, 2002. (27 refs.)
Study objectives: This study assesses how often local US hospitals provide smoking cessation information in the following two ways: via hospital Web sites; and via routing incoming phone calls to their hospital switch-boards to an in-house smoking cessation clinic. Design: Random survey of US hospitals. Setting: US hospital Web pages and telephone switchboards. Patients or participants: One hundred two randomly selected US hospitals. Interventions: One hundred two hospital Web sites were randomly selected across the United. States. The site was searched for the topic of smoking cessation. In the second phase of the survey the main switchboard number of the same 102 hospitals was anonymously called and the "stop smoking clinic" was asked for. Measurements and results: The overall results indicate that among the hospital Web sites surveyed, only, 30% contained information relating to smoking cessation programs. The phone survey of hospital switchboards showed that 47% had a smoking cessation program available via phone inquiry, while 53% did not. Conclusions: Of the US hospital Web sites visited, only 30% contained information on smoking cessation. The yield of finding the desired information was increased by the presence of an intrasite search option, which is a low-cost enhancement to any complex Web site. The relatively low cost of promoting healthy behaviors such as smoking cessation on a hospital Web site should be used more widely. Surprisingly, the phone survey of hospitals showed that the lower technology, route of providing smoking cessation information to patients via a patient-initiated phone call is only available in 47% of hospitals. Both the Internet and phone-based switchboard referrals could be more widely and effectively used. Joint Commission on Accreditation of Healthcare Organizations guidelines would be on avenue of increasing the availability of smoking cessation information at hospital switchboards and Web sites. .

Integration and its discontents: Substance abuse treatment in the Oregon health plan.

Laws KE; Gabriel RM; McFarland BH. Health Affairs 21(4): 284-289, 2002. (13 refs.)
With the creation of the Oregon Health Plan (OHP) in 1994, Oregon placed its Medicaid program under a managed care system. This paper examines the managed care practices of seven health plans serving OHP enroll-ees between 1996 and 1998. Results indicated that the original vision of integrating substance abuse treatment services with physical care for OHP enrollees evolved into a multilayered, carved- out approach. Factors work-ing against integration included changes in the administration and management of the chemical dependency benefit, financial losses by health plans, and lack of training and incentives for physicians to refer clients to substance abuse treatment.

Health promotion practices of restaurants and cafes in Australia: Changes from 1997 to 2000 using an annual telemarketing intervention.

Licata M; Gillham K; Campbell E. Health Promotion International 17(3): 255-262, 2002. (17 refs.)
This study looked at whether rates of health promotion practices among restaurants and cafes in the Hunter Region of New South Wales (NSW), Australia, in-creased between 1997 and 2000. During the project period all restaurants and cafes in the region were offered an annual direct marketing telephone interview (1997, 1998 and 1999), during which resources were offered to assist in the adoption of health promotion practices. Owners or managers of restaurants and cafes completed phone interviews that assessed 18 health promotion practices relating to: environmental tobacco smoke (two practices); responsible service of alcohol (five practices); healthy food choices (one practice); food safety (four practices); occupational health and safety (three practices); and the prevention of infectious diseases (three practices). Changes in practices were examined by comparing data from cross-sectional samples in 1997 (before any offers of resources) and 2000 (after zip to three annual telemarketing calls), and among a cohort interviewed in both 1997 and 2000. Ninety-one per cent of restaurants and cafes (321) participated in the 1997 survey and 239 (81%) participated in the 2000 survey, A cohort of 122 restaurants and cafes participated in both surveys. Significant increases were present for 14 of the 18 health promotion initiatives in the cross-sectional sample and for 10 of the 18 health promotion initiatives in the cohort. For both cross-sectional and cohort samples, a change in at least one practice in each area was evident, with the exception of nutrition. The proportion of restaurants and cafes in the project region that undertake health promotion initiatives is increasing. A telephone-based intervention may contribute to such an increase, The suggestion that the prevalence of health promotion initiatives in restaurants and cafes can be increased highlights the potential for health promotion to be more actively involved in this setting..

Origins and consequences of child neglect in substance abuse families. (review).

Dunn MG; Tarter RE; Mezzich AC; Vanyukov M; Kirisci L; Kirillova G. Clinical Psychology Review 22(7): 1063-1090, 2002. (154 refs.)
The empirical literature pertaining to the prevalence, origins, and consequences of neglectful parenting as it relates to substance abuse is critically reviewed. Available evidence indicates that children who experience parental neglect, with or without parental alcohol or drug abuse, are at high risk for substance use disorder (SUD). The effects of parental substance abuse on substance abuse outcome of their children appear to be partly mediated by their neglectful parenting. The discussion concludes with presentation of a developmental multifactorial model in which neglect, in conjunction with other individual and environmental factors, can be integratively investigated to quantify the child's overall liability across successive stages of development as well as to map the trajectory toward good and poor outcomes.

Migration and substance use: Evidence from the US National Health Interview Survey.

Johnson TP; VanGeest JB; Cho YI. Substance Use & Misuse 37(8/10): 941-972, 2002. (48 refs.)
Representative data from the U.S. National Health Interview Survey are used to investigate the substance use patterns of immigrants and compare them to those of the native born populations. The information examined is from the 1991 supplementary Drug and Alcohol Use Data File, which examined the self-reported substance use behaviors of approximately 21,000 adults aged 18-44. Findings indicate that immigrants to the U.S. in the late twentieth century are less likely to use alcohol and other drugs than are native born citizens. Additional findings suggest assimilation processes by which exposure to mainstream American society leads to patterns of alcohol and illicit drug use among long term immigrants that approximates that of the native born population. The patterns of substance use observed among immigrants, however, are not consistent with acculturative stress mechanisms. These findings provide an important and representative profile of the substance use patterns of one of the largest international migration streams of the past one hundred years.

Needle exchange programs - Delivery and access issues.

Strike CJ; Challacombe L; Myers T; Millson M. Canadian Journal of Public Health 93(5): 339-343, 2002. (32 refs.)
Objective: Examine the challenges of four service delivery models (i.e., fixed, mobile, satellite and home visits) and how service delivery may impact on NEP HIV prevention efforts. Methods: Using a modified ethnographic approach, semi-structured interviews concerning policies and procedures were conducted with staff (n=59) of NEPs (n=15) in Ontario. An iterative, inductive analytic process was used. Results: According to workers and managers, effectiveness of NEP prevention efforts depend on client development and retention and service design. Fixed and satellite sites, home visits and mobile services provide varied levels of temporal and spatial accessibility. Combining modes of delivery can offset the disadvantages of individual modes. Discussion: NEP evaluations that do not consider service and resource factors run the risk of concluding that NEPs are ineffective when it may be that the program works for a small proportion of IDUs whom the NEP has the resources to serve.

Programs and policies to discourage the use of tobacco products. (review).

Cummings KM. Oncogene 21(48): 7349-7364, 2002. (107 refs.)
The past 50 years has witnessed a dramatic change in attitudes toward and use of tobacco by Americans that has resulted in recent declines in the incidence of lung cancer. Most public health scholars believe that this change has been accelerated by public policy interventions to reduce tobacco use. The research literature suggests that the most potent demand reducing influences on tobacco use have been efforts to increase the financial cost of using tobacco products primarily through taxation, smoke-free policies, comprehensive advertising bans, and paid counter-advertising campaigns. New therapies for treating nicotine dependence and measures to liberalize access to medicinal forms of nicotine have the potential to revolutionize the way societies address the problem of tobacco use in the future. Unfortunately, the economic reality of the tobacco business has hindered public health efforts to curb the use of tobacco products. While government regulation of tobacco products is a worthy goal, capitalism, and not government regulation, most likely holds the greatest potential to rapidly alter the worldwide epidemic of tobacco caused disease. It is up to the public health community to harness the powers of capitalism to speed the development of less dangerous alternatives to the conventional cigarette.

Staff beliefs about drug abuse clinical trials.

Forman RF; Bovasso G; Woody G; McNicholas L; Clark C; Royer-Malvestuto C; Weinstein S. Journal of Substance Abuse Treatment 23(1): 55-60, 2002. (18 refs.)
Staff from 10 community-based addiction treatment organizations in the National Drug Abuse Clinical Trials Network participated in an educational session about addiction research practices and human subject protections. This 1.5-hour presentation addressed "informed consent," "confidentiality of research information," "inclusion and exclusion criteria," "random assignment," "patient protections," and "patient payments." Pre- and post-session surveys were administered to 115 staff members measuring their beliefs about clinical trials. At baseline, 52% of staff believed patients could transfer out of a study even if they were doing poorly, and 55% believed staff had this right; 44% agreed that patients could participate in a clinical trial without understanding what would take place in the study. After the educational session, staff beliefs about patient protections were significantly increased in five of the seven items. A fourth of staff continued to believe patient payments were harmful, and 37% did not believe participation in a clinical trial would increase a patient's chances at recovery.

Substance user treatment program quality: Selected topics.

Magura S; Schildhaus S; Rosenblum A; Gastfriend D. Substance Use & Misuse 37(8/10): 1185-1214, 2002. (72 refs.)
This panel explores the "state of the art" in conceptualization and research pertinent to program quality in substance user treatment. First, seven critical questions for program quality are identified and discussed. Second, a recent national evaluation of treatment examines the implications of long-term patient outcomes for treatment quality. Third, a large number of clinical trials of behavioral and pharmacological treatments for cocaine dependence were conducted during the 1990s; this research is synthesized and interpreted. Fourth, progress is reported in improving the quality of treatment through standardized criteria for patient placement matching.

The impact of later trading hours for Australian public houses (hotels) on levels of violence.

Chikritzhs T; Stockwell T. Journal of Studies on Alcohol 63(5): 591-599, 2002. (23 refs.)
Objective: To examine the impact of later trading hours for licensed hotels (Australian public houses are usually known as "hotels") in Perth, Western Australia, on levels of violent assault on or near these premises. Method: Data on assault offenses reported to police between July 1, 1991, and June 30, 1997, were examined to identify those offenses that occurred on or close to hotels. During this period, 45 (24%) of the 188 hotels meeting study criteria were granted an extended trading permit for I AM closing ("ETP hotels"), whereas the rest continued to close at midnight ("non-ETP hotels"). A time-series analysis employing linear regression was used to test whether there was a relationship between the introduction of extended trading and monthly rates of assaults associated with ETP hotels, while controlling for the general trend in assault rates among normally trading hotels. Possible confounders and other variables of interest (e.g., levels of alcohol purchases) were also examined. Results: After controlling for the general trend in assaults occurring throughout Perth hotels, there was a significant increase in monthly assault rates for hotels with late trading following the introduction of extended trading permits. This relationship was largely accounted for by higher volumes of high alcohol content beer, wine and distilled spirits purchased by late trading hotels. Conclusions: Late trading was associated with both increased violence in and around Perth hotels and increased levels of alcohol consumption during the study period. It is suggested that greater numbers of patrons and increased levels of intoxication contributed to the observed increase in violence and that systematic planning and evaluation of late trading licenses is required.

The relationship between liquor outlet density and injury and violence in New Mexico.

Escobedo LG; Ortiz M. Accident Analysis and Prevention 34(5): 689-694, 2002. (24 refs.)
This study used an ecologic design based on data from 1990 to 1994 gathered from forensic, vital statistic, census, law enforcement and liquor licensing agencies to assess the relationship between liquor outlet density and alcohol-related health outcomes in New Mexico. Linear regression models show that suicide, alcohol-related crash, and alcohol-related crash fatality (adjusted for age, sex, and minority status) are significantly associated with liquor outlet density. Data also show that, compared with the first tertile, suicide and alcohol-related crash rates increase about 50% and the alcohol-related crash fatality rate two-fold with the third tertile of liquor outlet density. Greater availability of liquor outlets is associated with higher rates of suicide, alcohol-related crash, and alcohol-related crash fatality.

Strategic marketing in the UK tobacco industry. (review).

Anderson S; Hastings G; MacFadyen L. Lancet Oncology 3(8): 481-486, 2002. (52 refs.)
Tobacco-industry marketing has played a central part in the global spread of tobacco use and addiction. Although the absolute size of the tobacco market has dwindled, the industry is still immensely successful, largely due to sophisticated and manipulative marketing strategies. The UK tobacco industry identifies target groups and builds enduring relationships based on careful brand management. Potential customers are exposed to brands which are likely to appeal to them most. Tobacco companies tailor their products to target markets by altering the content of tar and nicotine, and by adding flavourings to produce a distinctive taste. Market-ng strategies ensure that the products are promoted heavily at the point of sale, and directed advertising and sponsorship agreements are used to increase the visibility of the brand and strengthen its image. Tobacco companies also target non-consumer organisations such as retailers and policy makers with the aim of creating the best possible business environment for tobacco sales. We review published evidence, internal-advertising-agency documents, and observational data about tobacco promotion, and discuss the use of targeted marketing strategies in the UK.