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...on Policy Issues
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www.ProjectCork.org
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Spring 2006
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Witch-hunt. (editorial).
Drucker E. Harm Reduction Journal 2: e-article 3, 2005. (6 refs.)
Beginning two years ago, the US Dept of Health and Human Services began "special reviews" of all current research grants that involved harm reduction, sex and drugs, and continues its ban on funding of needle exchange. With Bush's second term, the campaign was extended to all US funded international programs that dealt with these issues and populations. And, most recently, the US has again undertaken to dominate the discourse within international organizations charged with drug control and AIDS policies - especially those of the UN. But the international harm reduction and human rights community is fighting back in several important ways, including "An Open Letter to the delegates of the Forty-eighth session of the Commission on Narcotic Drugs (CND) of the UN" prepared by a group of 334 well respected public health experts and human rights advocates, protesting U.S. pressure on the U.N. to withdraw its support from harm reduction. This editorial includes the letter and signatures as well as French, Spanish, and Russian versions of the letter as additional files. Copyright 2005, Biomed Central, Ltd.
Who let the dogs in? The use of drug sniffer dogs in mental health settings.
Rolfe G; Cutcliffe J; Nash M. Journal of Psychiatric and Mental Health Nursing12(6): 745-749, 2005. (35 refs.)
A Home Affairs Select Committee (HASC 2002) report estimates that around four million people use illicit drugs each year in the UK. There is understandable concern about the prevalence of substance use by people with mental illness, especially in hospital settings. Compelling evidence exists that indicates how substance misuse, including alcohol use, is widespread in mental health services. Dogs have a more developed sense of smell than humans. The olfactory lobe of a dog is four times that of a human which makes the dog's sense of smell 1000-10 000 times better. Dogs have been trained to detect a range of substances including large sums of money, tobacco, meat and meat products, firearms and ammunition. In more recent times dogs have been trained to locate people trapped in buildings as the result of earthquakes, escaped prisoners and in some reported cases detecting bladder cancer by sniffing urine. Some commentators (Gordon & Haider 2004, p. 197) believe that the issue of rights and consent is secondary. The use of DSDs suggests that other detection methods have failed yet we should be cautious of putting our faith into a system that is not foolproof. Copyright 2005, Blackwell Publishing.
Enforcing the minimum drinking age: State, local and agency characteristics associated with compliance checks and Cops in Shops programs.
Montgomery JM; Foley KL; Wolfson M. Addiction 101(2): 223-231, 2006. (32 refs.)
Aims: To identify state, local and organizational characteristics associated with local law enforcement agencies' implementation of two dramatically different approaches to enforcement of underage drinking laws: compliance checks and Cops in Shops programs. Compliance checks use underage decoys to attempt to purchase alcohol from retail merchants, while Cops in Shops programs deploy undercover law enforcement officers in alcohol outlets to detect and cite persons under the age of 21 who attempt to purchase alcohol. Design: Cross-sectional telephone interview conducted as part of the Tobacco Enforcement Study (TES), which examined enforcement of laws related to youth access to tobacco. Setting Data were collected in 1999 among law enforcement agencies in all 50 states of the United States. Participants: Representatives of city police departments, departments of public safety, sheriffs or county police were included (n = 920 local agencies). Measurements: Alcohol compliance checks and Cops in Shops programs were the primary outcomes. Covariates included state level policies (e. g. beer tax), agency resources (e. g. number of sworn officers) and community demographics (e. g. college dormitory population). Findings Local enforcement agencies were more likely to perform alcohol compliance checks than to have a Cops in Shops program (73.9% compared to 41.1% in cities > 25000 and 55.7% compared to 23.9% in cities <= 25000). Conducting compliance checks for tobacco age-of-sale laws was positively associated with alcohol compliance checks and Cops in Shops (OR 3.30, P < 0.001; OR 1.84, P = 0.001, respectively). Having a Drug Abuse Resistance Education (DARE) officer was negatively related to conducting compliance checks (OR 0.67, P = 0.03). Special community policing units were associated with departments having Cops in Shops programs (OR 1.80, P = 0.006). Conclusions: This study used a nationally representative sample of communities to better understand state and local factors that shape local law enforcement agencies' use of two distinct approaches to underage drinking enforcement. The strong link observed between tobacco and alcohol compliance checks may indicate a culture within some law enforcement agencies supporting strict enforcement of age-of-sale laws. Copyright 2006, Society for the Study of Addiction to Alcohol and Other Drugs.
Matching judicial supervision to clients' risk status in drug court.
Marlowe DB; Festinger DS; Lee PA; Dugosh KL; Benasutti KM. Crime & Delinquency 52(1): 52-76, 2006. (47 refs.)
This article reports out comes from a program of experimental research evaluating the risk principle in drug courts. Prior studies revealed that participants who were high risk and had (a)antisocial personality disorder or (b)a prior history of drugabuse treatment performed better in drug court when scheduled to attend biweekly judicial status hearings in court. In contrast, participants who were low risk performed equivalently regardless of the court hearings schedule. This study prospectively matches drug court clients to the optimal schedule of court hearings based on an assessment of their risk status and compares outcomes to clients randomly assigned to the standard hearings schedule. Results confirmed that participants who were high risk and matched to biweekly hearings had better during-treatment outcomes than participants assigned to status hearings as usual. These findings provide confirmation of the risk principle in drug courts and yield practical information for enhancing the efficacy and cost-efficiency of drug courts. Copyright 2006, Sage Publications.
Narcotics on the net: The availability of web sites selling controlled substances. (editorial).
Forman RF. Psychiatric Services 57(1): 24-26, 2006. (13 refs.)
The Internet is not only a vital medium for communication, entertainment, and commerce, but it is also an outlet for illicit drug sales. Although the U. S. Controlled Substances Act regulates access to certain drugs by requiring prescriptions, unique characteristics of the Internet create significant challenges for the enforcement of U. S. drug policies. In the late 1990s "no prescription Web sites" (NPWs) began to emerge, which allow persons to purchase drugs, such as opiates, without a prescription. Given the likely role of NPWs in increasing prescription drug abuse, health care professionals must develop and disseminate strategies for helping patients who are affected by these Web sites. Copyright 2006, Am Psychiatric Association.
Attitude changes among emergency department triage staff after conducting routine alcohol screening.
Nordqvist C; Johansson K; Lindqvist K; Bendtsen P. Addictive Behaviors 31(2): 191-202, 2006. (39 refs.)
Excessive alcohol consumption is common among injury patients, but routine alcohol interventions seem to be difficult to implement in emergency departments. An obstacle seen in previous studies is the limited time available in a real-world setting for staff to participate in routine alcohol screening and interventions. In the present study, ordinary staff participated in a simple alcohol screening procedure. The aim of the study was to evaluate the feasibility of this procedure and if there was any change in attitudes and practices among triage staff after the implementation. We analyzed interviews with six staff members and questionnaires completed by 29 nurses and medical secretaries before and after a period of systematic routine screening. The staff reported that the routine worked well and that few patients reacted negatively. A positive change was seen in attitudes towards alcohol preventive measures in general. However, this seems not to be sufficient for the staff to spontaneously engage more actively. In fact, more of the staff were uncertain after the study period whether the emergency department is an appropriate place for alcohol screening and intervention despite an increased role legitimacy and perceived competence. There is a need for further development of alcohol prevention models that are acceptable for the staff to implement as part of the daily routine. Copyright 2006, Elsevier Science Ltd.
Shelter-based managed alcohol administration to chronically homeless people addicted to alcohol.
Podymow T; Turnbull J; Coyle D; Yetisir E; Wells G. Canadian Medical Association Journal 174(1): 45-49, 2006. (33 refs.)
Background: People who are homeless and chronically alcoholic have increased health problems, use of emergency services and police contact, with a low likelihood of rehabilitation. Harm reduction is a policy to decrease the adverse consequences of substance use without requiring abstinence. The shelter-based Managed Alcohol Project ( MAP) was created to deliver health care to homeless adults with alcoholism and to minimize harm; its effect upon consumption of alcohol and use of crisis services is described as proof of principle. Methods: Subjects enrolled in MAP were dispensed alcohol on an hourly basis. Hospital charts were reviewed for all emergency department (ED) visits and admissions during the 3 years before and up to 2 years after program enrolment, and the police database was accessed for all encounters during the same periods. The results of blood tests were analyzed for trends. A questionnaire was administered to MAP participants and staff about alcohol use, health and activities of daily living before and during the program. Direct program costs were also recorded. Results: Seventeen adults with an average age of 51 years and a mean duration of alcoholism of 35 years were enrolled in MAP for an average of 16 months. Their monthly mean group total of ED visits decreased from 13.5 to 8 (p = 0.004); police encounters, from 18.1 to 8.8 (p = 0.018). Changes in blood test findings were nonsignificant. All program participants reported less alcohol consumption during MAP, and subjects and staff alike reported improved hygiene, compliance with medical care and health. Interpretation: A managed alcohol program for homeless people with chronic alcoholism can stabilize alcohol intake and significantly decrease ED visits and police encounters. Copyright 2006, Canadian Medical Association.
Substance abuse and dependence in prisoners: A systematic review. (review).
Fazel S; Bains P; Doll H. Addiction 101(2): 181-191, 2006. (82 refs.)
Aims: To review studies of the prevalence of substance abuse and dependence in prisoners on reception into custody. Design and method: A systematic review of studies measuring the prevalence of drug and alcohol abuse and dependence in male and female prisoners on reception into prison was conducted. Only studies using standardized diagnostic criteria were included. Relevant information, such as mean age, gender and type of prisoner, was recorded for eligible studies. The prevalence estimates were compared with those from large cross-sectional studies of prevalence in prison populations. Findings Thirteen studies with a total of 7563 prisoners met the review criteria. There was substantial heterogeneity among the studies. The estimates of prevalence for alcohol abuse and dependence in male prisoners ranged from 18 to 30% and 10 to 24% in female prisoners. The prevalence estimates of drug abuse and dependence varied from 10 to 48% in male prisoners and 30 to 60% in female prisoners. Conclusions: The prevalence of substance abuse and dependence, although highly variable, is typically many orders of magnitude higher in prisoners than the general population, particularly for women with drug problems. This highlights the need for screening for substance abuse and dependence at reception into prison, effective treatment while in custody, and follow-up on release. Specialist addiction services for prisoners have the potential to make a considerable impact. Copyright 2006, Society for the Study of Addiction to Alcohol and Other Drugs.
The ethics of industry experimentation using employees: The case of taste-testing pesticide-treated tobacco. (review).
McDaniel PA; Solomon G; Malone RE. American Journal of Public Health 96(1): 37-46, 2006. (121 refs.)
In the United States, companies that use their own funds to test consumer products on their employees are subject to few regulations. Using previously undisclosed tobacco industry documents, we reviewed the history of that industry's efforts to create internal guidelines on the conditions to be met before employee taste testers could evaluate cigarettes made from tobacco treated with experimental pesticides. This history highlights 2 potential ethical issues raised by unregulated industrial research: conflict of interest and lack of informed consent. To ensure compliance with accepted ethical standards, an independent federal office should be established to oversee industrial research involving humans exposed to experimental or increased quantities of ingested, inhaled, or absorbed chemical agents. Copyright 2006, American Public Health Association
The extent of the 'prevention paradox' in alcohol problems as a function of population drinking patterns.
Rossow I; Romelsjo A. Addiction 101(1): 84-90, 2006. (24 refs.)
Aims: To assess to what extent use of various criteria for high-risk groups and analyses from subpopulations with different drinking patterns may affect the extent of the prevention paradox (that most alcohol-related harm in populations arises within the drinkers at low risk). Data sets Two national surveys of Norwegian adult samples (n = 4321 current drinkers) and one register linkage of Swedish armed forces conscripts (n = 45 839 current drinkers) with inpatient hospital data. Measures High-risk groups were categorized as the upper 10% of drinkers by annual alcohol intake or by intoxication frequency. Acute alcohol-related harms comprised number of quarrels and fights in the Norwegian surveys and number of hospital admissions for attempted suicide and violent injuries over a follow-up period (3 and 25 years) in the Swedish conscript study. Results: The majority of acute alcohol problems were found among the majority of drinkers with low or moderate risk (the lower 90%) by drinking volume, suggesting empirical support for the prevention paradox. By applying frequency of intoxication rather than annual volume of consumption to determine the high-risk group, a somewhat larger proportion of acute alcohol-related harms was found within the high-risk group, and the number of alcohol-related harms tended to be distributed more evenly between high-risk drinkers and other drinkers. The proportion of alcohol-related harms within the risk groups was significantly lower in the younger age group, where the majority drinks to intoxication compared with other drinkers. Conclusion: The extent of the prevention paradox with respect to acute alcohol problems may be more prominent in drinking in subpopulations where intoxication is a common part of the drinking pattern compared with those where intoxication occurs less frequently and among a smaller fraction of the drinkers. Copyright 2006, Society for the Study of Addiction to Alcohol and Other Drugs.
Unmet need for recommended preventive health services among clients of California syringe exchange programs: Implications for quality improvement.
Heinzerling KG; Kral AH; Flynn NM; Anderson RL; Scott A; Gilbert ML et al. Drug and Alcohol Dependence 81(2): 167-178, 2006. (94 refs.)
Background: Comprehensive preventive services are recommended for injection drug users (IDU), including screening tests, vaccinations, risk reduction counseling, and sterile syringes. Syringe exchange programs (SEP) may facilitate receipt of preventive services by IDUs, but whether SEP clients receive recommended preventive care is not known. We examined use of recommended preventive services by clients of 23 SEPs throughout California. Methods: Five hundred and sixty SEP clients were recruited from 23 SEPs throughout California between March and September 2003. Receipt of 10 recommended preventive services and source of care (SEP versus non-SEP providers) was ascertained from client interviews. Results: On average, SEP clients received only 13% of recommended preventive services and 49% of clients received none of the recommended services. Of services that were received, 76% were received from SEPs. In multivariate analysis, use of drug treatment and more frequent SEP visits were associated with receipt of recommended preventive services by clients. Conclusions: SEPs are often the only source of preventive care for their IDU clients. Still, SEP clients fail to receive most recommended preventive services. Interventions to increase use of preventive services and improve the quality of preventive care received by IDUs, such as increased access to drug treatment and SEPs, are needed. Copyright 2006, Elsevier Scientific Publishers Ireland, Ltd.
Benefit-cost in the California treatment outcome project: Does substance abuse treatment "pay for itself"?
Ettner SL; Huang D; Evans E; Ash DR; Hardy M; Jourabchi M et al. Health Services Research 41(1): 192-213, 2006. (57 refs.)
Objective. To examine costs and monetary benefits associated with substance abuse treatment. Data Sources. Primary and administrative data on client outcomes and agency costs from 43 substance abuse treatment providers in 13 counties in California during 2000-2001. Study Design. Using a social planner perspective, the estimated direct cost of treatment was compared with the associated monetary benefits, including the client's costs of medical care, mental health services, criminal activity, earnings, and (from the government's perspective) transfer program payments. Monetary benefits associated with treatment were estimated using a pre-posttreatment admission study design, i.e., each client served as his or her own control. Data Collection. Treatment cost data were collected from providers using the Drug Abuse Treatment Cost Analysis Program instrument. For the main sample of 2,567 clients, information on medical hospitalizations, emergency room visits, earnings, and transfer payments was obtained from baseline and 9-month follow-up interviews, and linked to information on inpatient and outpatient mental health services use and criminal activity from administrative databases. Sensitivity analyses examined administrative data outcomes for a larger cohort (N = 6,545) and longer time period (1 year). Principal Findings. On average, substance abuse treatment costs $1,583 and is associated with a monetary benefit to society of $11,487, representing a greater than 7:1 ratio of benefits to costs. These benefits were primarily because of reduced costs of crime and increased employment earnings. Conclusions. Without considering the direct value to clients, allocating taxpayer dollars to substance abuse treatment may be a wise investment. Copyright 2006, Blackwell Publishing.
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