CORK Library Watch Policy Issues, Summer 2004

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Summer 2004

Benign neglect or neglected abuse: Drug and alcohol withdrawal in US jails.

Fiscella K; Pless N; Meldrum S; Fiscella P. Journal of Law, Medicine & Ethics 32(1): 129+, 2004. (50 refs.)
Untreated drug and alcohol withdrawal can result in significant pain, trauma, morbidity, and even death. Despite national guidelines for detoxification, including those developed specifically for jails and prisons, most U.S. jails don't detoxify arrestees. Forcing detained persons, presumed innocent under law, to undergo acute drug or alcohol withdrawal without adequate treatment may constitute a human rights abuse and a violation of constitutional protections. Greater public awareness of the inhumane treatment afforded drug and alcohol dependent arrestees is a prerequisite to correctional health care reform, particularly mandatory accreditation of health care services in jails. Copyright 2004, American Society of Law, Medicine & Ethics

Criminality in drug addicts: A follow-up study over 25 years.

Gjeruldsen SR; Myrvang B; Opjordsmoen S. European Addiction Research 10(2): 49-55, 2004. (16 refs.)
Background/Aims/Method: 214 drug addicts were included in a 25-year study on criminality using data from the National Register of Convictions, and 84% of those still living in Oslo attended a follow-up examination. Results: 89% of the 214 had committed offences, compared to 25% in a control group without drug use. 83% had been imprisoned. Males showed more criminal behavior than females and committed the most serious crimes. Male gender and more than two convictions were risk factors for reduced survival. At the follow-up examination 65% had abandoned illegal drugs and the majority had simultaneously stopped their criminal activities. There were significantly less drug offenders, thieves and people committing fraud or violations of traffic laws among the former drug addicts, but not less violent criminals. Criminality diminished with increasing age. Conclusions: Drug addicts were heavily involved in criminal affairs. Abandonment of illegal drugs and increasing age were associated with discontinuation of criminality.

Duty of Care to the Intoxicated: "The Irish Approach?".

Drennan M. San Diego International Law Journal 4: 423-436, 2003. (96 legal refs.)
Traditionally the common law has been loathe to impose a duty of care on a third party to help another individual in danger, even where such assistance would not be a source of inconvenience to the helper. Although there is no general duty to act, certain relationships may give rise to a duty of care. Under Irish common law and statute, a publican is under a duty of care to look after the safety of all his customers, intoxicated and sober alike. This Article examines whether the relationship between publican and patron should or should not produce such an obligation. It also addresses the possible defenses to such a claim in the tort of negligence. Finally, as the matter is not a settled point of Irish law, this article also attempts to assess the potential approach of its courts, in view of the approach taken by the English courts to the issue and the flurry of academic comment in the wake of a recent Irish settlement. n4 These issues are certain to surface in litigation again. Regardless of the approach taken by the Irish courts, the impact of any resolution will have dramatic consequences on Irish society and culture.

Collateral sanctions and civil disabilities: The secret barrier to true sentencing reform for legislatures and sentencing commissions.

Barnett SM. Alabama Law Review 55: 375-391, 2004. (109 refs.)
While it is debatable whether we should have collateral sanctions--some may serve an important purpose and some may not--the goal of this Comment is to provide lawmakers with evidence that these sanctions exist and that they impact the goals of sentencing policy through ways that, if left alone, will continue to hinder Alabama's ability to achieve truth-in-sentencing and successful reintegration of prior offenders. ... Filler argued that sex offender statutes requiring registration upon conviction, a collateral sanction to the criminal penalties involved in sex crimes, has caused offenders to plead to offenses carrying longer prison sentences over sex offenses carrying shorter sentences but requiring the significant and permanent civil disability of registration. ... In recognizing these problems, the Alabama Legislature commissioned the Sentencing Commission to study Alabama's current sentencing structure and provide a series of recommendations that would assist in the relief of prison overcrowding, requiring the Sentencing Commission to develop a process whereby Alabama would move toward truth-in-sentencing, while increasing the number of community correction alternatives. [Note: Among the invisible sanctions for those convicted of drug crimes after 1996 is the possible denial of welfare benefits, public housing, the ability to gain appropriate skills and training, and the right to vote.]

Heroin diffusion in the mid-Hudson region of New York State.

Furst RT; Herrmann C; Leung R; Galea J; Hunt K. Addiction 99(4): 431-441, 2004. (44 refs.)
Aims: Prompted by the history of heroin diffusion in the United States, press reports and building on previous research into retail heroin distribution, ethnographic research was undertaken identifying and describing retail distribution and diffusion of heroin in and into medium- and small-sized towns in the mid-Hudson region of New York State. Methods: In conjunction with fieldwork, in-depth tape-recorded interviews were conducted with recent admissions (30 days) at 28 different drug treatment facilities located in the region. Interviews were also conducted with drug counselors, narcotic officers, drug treatment administrators and the county commissioners of mental hygiene. Findings: Heroin-dependent individuals who have access to cheaper heroin in urban areas, such as New York City, Newark, and Patterson, New Jersey, drive retail heroin distribution in the mid-Hudson region. They travel to these cities, purchase heroin in quantity (costing $8-10 per bag), return to the region and sell premium-priced heroin ($20-$25 per bag) mostly to irregular users who do not have access to retail drug sellers in urban areas. Conclusion: Price disparity contributes to a recurrent process whereby irregular users who are able to gain access to cheaper heroin in urban areas, return to the mid-Hudson and sell premium-priced heroin to other users who do not have access to cheaper heroin. This process contributes to the diffusion of heroin abuse.

Statistical definition of relapse: Case of family drug court.

Alemi F; Haack M; Nemes S. Addictive Behaviors 29(4): 685-698, 2004. (23 refs.)
At any point in time, a patient's return to drug use can be seen either as a temporary event or as a return to persistent use. There is no formal standard for distinguishing persistent drug use from an occasional relapse. This lack of standardization persists although the consequences of either interpretation can be life altering. In a drug court or regulatory situation, for example, misinterpreting relapse as return to drug use could lead to incarceration, loss of child custody, or loss of employment. A clinician who mistakes a client's relapse for persistent drug use may fail to adjust treatment intensity to client's needs. An empirical and standardized method for distinguishing relapse from persistent drug use is needed. This paper provides a tool for clinicians and judges to distinguish relapse from persistent use based on statistical analyses of patterns of client's drug use. To accomplish this, a control chart is created for time-in-between relapses. This paper shows how a statistical limit can be calculated by examining either the client's history or other clients in the same program. If client's time-in-between relapse exceeds the statistical limit, then the client has returned to persistent use. Otherwise, the drug use is temporary. To illustrate the method, it is applied to data from three family drug courts. The approach allows the estimation of control limits based on the client's as well as the court's historical patterns. The approach also allows comparison of courts based on recovery rates.

National health insurance and health-based drug policy: An examination of policy linkages in the USA and Canada.

Benoit E. Journal of Social Policy 33(Part 1): 133-151, 2004. (40 refs.)
For more than 50 years the United States and Canada maintained illegal-drug policies that followed the same course: a long period of punitive prohibition followed by moderation and an emphasis on drug abuse as a public health problem. Then in the 1980s, the USA reverted to a punitive model while Canada increased its commitment to a health-based approach. Why this divergence after following the same path for so long? In this paper I argue that one factor was Canada's adoption of national health insurance, which guaranteed universal access to health care, including addiction treatment. As the country's most popular policy it was protected against budget cuts during a period of welfare-state retrenchment in the 1980s. In the USA, on the other hand, public health insurance was limited to the elderly and the poor, and addiction treatment services were isolated and stigmatized. Thus the public health side of drug policy was poorly positioned to resist welfare cutbacks and ascendant criminal-justice interests. The experiences of the USA and Canada have implications for policy reformers and for the study of how institutional interests cross policy domains.

New Mexico's 1998 drive-up liquor window closure. Study I: Effect on alcohol-involved crashes.

Lapham SC; Gruenwald PJ; Remer L; Layne L. Addiction 99(5): 598-606, 2004. (21 refs.)
Aims: To determine the spatial relationship between drive-up liquor window locations and alcohol-related traffic crashes for 2 years before and after New Mexico banned drive-through alcohol sales. Design: Current liquor licenses, crash data, roadway information and US Census data were used in this analysis. Cross-sectional and longitudinal regression analyses were applied to the entire state, and to Albuquerque only. Findings: Of all NM liquor licenses, 189 (9%) included drive-up sales, which co-occurred with on- or off-premise licenses (94%). The rate of non-pedestrian alcohol-related crashes relative to non-pedestrian total crashes showed an increasing trend prior to closure and a decreasing trend after the closure. Cross-sectional analyses in Albuquerque revealed that the percentage of alcohol-involved crashes was not related to densities of on- or off-premise outlets per kilometer of roadway, or to percentage of drive-up outlets. Statewide, the percentage of drive-up outlets was not significantly related to the percentage of alcohol-related crashes within census tracts but was associated positively with the percentage of alcohol-related crashes in surrounding census tracts. There was no statistically significant relationship between number of drive-ups and percentage of alcohol-related crashes in either longitudinal model. Conclusions: Despite the declining rate of alcohol-related crashes following closure of drive-up liquor windows, both in Albuquerque and statewide, regression models using spatial data do not demonstrate definitively an association between the decline and the closure of the drive-up liquor windows.

The contribution of research to Australian policy responses to heroin dependence 1990-2001: A personal retrospection.

Hall W. Addiction 99(5): 560 -569, 2004. (58 refs.)
Periodic public concern about heroin use has been a major driver of Australian drug policy in the four decades since heroin use was first reported. The number of heroin-dependent people in Australia has increased from several hundreds in the late 1960s to around 100 000 by the end of the 1990s. In this paper I do the following: (1) describe collaborative research on heroin dependence that was undertaken between 1991 and 2001 by researchers at the National Drug and Alcohol Research Centre; (2) discuss the contribution that this research may have made to the formulation of policies towards the treatment of heroin dependence during a period when the policy debate crystallized around the issue of whether or not Australia should conduct a controlled trial of heroin prescription; and (3) reflect on the relationships between research and policy-making in the addictions field, specifically on the roles of investigator-initiated and commissioned research, the interface between researchers, funders and policy-makers; and the need to be realistic about the likely impact of research on policy and practice.

The moral relevance of addiction.

Husak DN. Substance Use & Misuse 39(3): 399-436, 2004. (85 refs.)
I attempt to understand and assess, the widespread, belief that addiction is relevant to morality. I examine several accounts of how addiction might be significant from a moral point of view. Although I briefly discuss theories of virtue, I focus on three possible ways addiction might be relevant to moral blame. First, blame might be imposed for the act of using addictive drugs. Second, blame might be imposed for the condition of being addicted. Third, blame might be imposed for further risks persons are likely to undertake once they have become addicts. I conclude that each of-these accounts has some plausibility, but none is entirely unproblematic. Addiction probably is relevant to morality, although its degree of importance is not as great as some commentators appear to believe. The moral relevance of addiction does not appear to rise to whatever level would justify a punitive response to addictive drug users.

Does a health plan effort to increase smokers' awareness of cessation medication coverage increase utilization and cessation?

Alesci NL; Boyle RG; Davidson G; Solberg LI; Magnan S. American Journal of Health Promotion 18(5): 366-369, 2004. (14 refs.)
Purpose. To test whether a mailing describing new coverage for smoking cessation medications increases benefit knowledge, utilization, and quitting. Methods. This randomized controlled trial assigned participants to benefit communication via (1) standard contract changes or (2) enhanced communication with direct-to-member postcards. A sample of 1930 self-identified smokers from two Minnesota health plans took surveys before and I year after the benefit's introduction. The follow-up response rate was 80%. A multilevel logistic estimator tested for differences in benefit knowledge and smoking behavior from baseline. Results. More enhanced than standard communication respondents knew about the benefit (39.0% vs. 22.2%, p < .0001) at follow-up. Groups did not differ on bupropion utilization (24.6% vs. 23.1%, p = .92); nicotine replacement therapy utilization (26.9% vs. 25.9%, p = .26), or cessation (12.8% vs. 15.6%, p = .32).Conclusion. Although limited by the low intervention intensity and potential social desirability bias, information about new coverage alone does not appear to increase quitting behaviors.

Treatment need and utilization among youth entering the juvenile corrections system.

Johnson TP; Cho YI; Fendrich M; Graf I; Kelly-Wilson L; Pickup L. Journal of Substance Abuse Treatment 26(2): 117-128, 2004. (44 refs.)
Relatively little is known about the substance abuse treatment need patterns and experiences of youth incarcerated in the United States juvenile justice system. To address this issue, four analytic questions concerned with understanding the predictors of treatment need and utilization patterns among adolescents entering the juvenile corrections system are examined. Data analyzed were collected as part of a face-to-face survey of 401 youth who entered the Illinois juvenile correctional system in mid-2000. Overall, need for treatment and treatment utilization each were predicted by sets of social environmental and personal characteristics, in addition to several sociodemographic variables. Less than half of youth with an identified need for treatment reported receiving treatment. Considerable variability in the effects of demographic and social environmental indicators on treatment need and utilization across race groups also was observed. These findings underscore the need for the continual development of the cultural competence of treatment providers and the expansion of onsite provision of substance abuse treatment services to incarcerated juveniles.

The Vermont defendant accommodation project: A case study.

Kinsler PJ; Saxman A; Fishman DB. Psychology, Public Policy and Law 10(1-2): 134-161, 2004. (8 refs.)
This article describes the increasing use of the courts and the jails as "institutions of last resort" for multi-problem clients suffering the effects of mental retardation combined with other life challenges, such as mental illness, substance abuse, homelessness, and a history of physical and/or sexual abuse. The authors label these individuals as suffering from "Horrible Life Disorder" (HLD), and characterize them, for the most part, as lacking the comprehension necessary to navigate through the complexities of the court and probation systems. The article describes and evaluates the development of a program, within the Office of the Defender General of the State of Vermont, to (a) identify and accommodate such mentally retarded, HLD clients in the criminal justice system and (b) train public defense attorneys, judges, police, and probation officers to respond more effectively to the special issues of these citizens.

Statistical definition of relapse: Case of family drug court.

Physician and allied health professionals' training and fetal alcohol syndrome.

Sharpe TT; Alexander M; Hutcherson J; Floyd RL; Brimacombe M; Levine R. Journal of Women's Health 13(2): 133-139, 2004. (19 refs.)
Maternal prenatal alcohol use is one of the leading preventable causes of birth defects and developmental disabilities. On the severe end of the spectrum of conditions related to drinking during pregnancy is fetal alcohol syndrome (FAS). Physicians and other health practitioners play a critical role in diagnosing FAS and in screening women of childbearing age for alcohol use during pregnancy. The Fetal Alcohol Syndrome Prevention Team at CDC's National Center on Birth Defects and Developmental Disabilities awarded funds to four medical school partners (Meharry and Morehouse Medical Colleges, St. Louis University, the University of Medicine and Dentistry of New Jersey, and the University of California at Los Angeles) to develop FAS regional training centers (RTCs). The RTCs are developing, implementing, evaluating, and disseminating educational curricula for medical and allied health students and practitioners that incorporate evidence-based diagnostic guidelines for FAS and other prenatal alcohol-related disorders.

The effect of alcoholism treatment on medical care use.

Kane RL; Wall M; Potthoff S; Stromberg K; Dai Y; Meyer ZJ. Medical Care 42(4): 395-402, 2004. (16 refs.)
Objective: The objective of this study was to assess changes in outpatient and inpatient medical care utilization associated with outpatient and inpatient treatment of alcohol abuse by comparing alcoholics who engaged in treatment to alcoholics who presented for, but did not engage in, treatment. Research Design: Claims and encounter data of 29,122 adults receiving benefits from both a behavioral managed care company and its parent medical care insurance company who had a diagnosis of alcoholism were analyzed. The nontreated alcoholics in this sample (n = 13,133) were used for comparison and to control for historical time trend in medical utilization across the study years 1993-1999. A longitudinal over-dispersed Poisson regression model was fit by the generalized estimating equation method to compare differences in medical utilization before and after outpatient and inpatient alcoholism treatment. Results: The pattern of medical utilization before and after alcoholism treatment appears basically symmetric. There is a gradual increase, which accelerates in the year before treatment and then falls off rapidly for the first year after treatment and then falls more gradually. Such a pattern does not suggest any net savings over time. The area under the curve before treatment is basically equivalent to that after treatment. Slopes of medical utilization for both treatment groups before 1 year before treatment were statistically similar to the control groups, but during 1 year before treatment, both treatment groups' outpatient utilization increased 1.25% and inpatient utilization increased 1.8% relative to the nontreated group. The slopes posttreatment showed differential effects over time of inpatient versus outpatient alcoholism treatment on inpatient and outpatient medical utilization. Conclusions: Although a clear increase in medical utilization before treatment and a decrease in utilization after treatment was found, it is not clear if the change is linked to changes in the status of the individuals as they prepare to enter alcoholism treatment or if there is a real causal effect of the alcoholism treatment.

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