Library Watch - On Policy Issues

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...on policy issues

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Winter 2008

Aggressive crime, alcohol and drug use, and concentrated poverty in 24 U.S. urban areas.

Valdez A; Kaplan CD; Curtis RL. American Journal of Drug and Alcohol Abuse 33(4): 595-603, 2007. (22 refs.)
The nexus between substance use and aggressive crime involves a complex interrelationship among mediating individual and community- level variables. Using multilevel logistic regression models, we investigate how community level concentration of poverty variables mediate the predictive relationships among individual level social attachment variables and substance use on aggressive crime in a large national sample of male arrestees (N 20,602) drawn from 24 U. S. urban areas. The findings support our hypothesis that individual social attachments to marriage and the labor force (education and employment) are the principal individual- level pathway mediating the substance abuse-aggression nexus. In the random intercept model, 3.17% of the variation not explained by the individual level predictor variables is attributable to community level variation in urban area female- headed households and households receiving welfare. This confirms our hypothesis that social structural conditions of an urban environment differentially expose persons to conditions that predict being arrested for an aggressive crime. Our findings tend to counter the cultural theorists who argue for an indigenous culture of violence in inner- city ghettos and barrios.

Alcohol and environmental justice: The density of liquor stores and bars in urban neighborhoods in the United States.

Romley JA; Cohen D; Ringel J; Sturm R. Journal of Studies on Alcohol and Drugs 68(1): 48-55, 2007. (36 refs.)
Objective: This study had two purposes: (1) to characterize the density of liquor stores and bars that individuals face according to race, economic status, and age in the urban United States and (2) to assess alternative measures of retailer density based on the road network and population. Method: We used census data on business counts and sociodemographic characteristics to compute the densities facing individuals in 9,361 urban zip codes. Results: Blacks face higher densities of liquor stores than do whites. The density of liquor stores is greater among nonwhites in lower-income areas than among whites in lower- and higher-income areas and nonwhites in higher-income areas. Nonwhite youths face higher densities of liquor stores than white youths. The density of liquor stores and bars is lower in higher-income areas, especially for nonwhites. Conclusions: Mismatches between alcohol demand and the supply of liquor stores within urban neighborhoods constitute an environmental injustice for minorities and lower-income persons, with potential adverse consequences for drinking behavior and other social ills. Our results for bars are sensitive to the measure of outlet density as well as population density. Although neither measure is clearly superior, a measure that accounts for roadway miles may reflect proximity to alcohol retailers and thus serve as a useful refinement to the per-capita measure. If so, alcohol policy might also focus on density per roadway mile. Further research on the existence, causes, and consequences of environmental injustice in alcohol retailing is warranted.

Alcohol as a 'drug': A moral revolution. (editorial).

Kleiman MAR. Addiction102(8): 1189-1189, 2007. (2 refs.)
'In terms of its effects on the human body and psyche, alcohol is simply another psychoactive substance'. This sentence may well be regarded as a fallacy, an outrage and an insult by many, if not most, ordinary citizens. Why is that claim controversial, and why does the rejection of that claim matter? It is controversial, I would submit, because the mood in which the public, its elected representatives and their appointed officials consider drugs, drug-taking and drug policy has little to do with the calm, evidence-based, policy-analytical tone taken by Cook and Reuter. In contrast with any of the controlled drugs, alcohol use is neither statistically nor legally deviant. In particular, those who discuss drug policy (outside Islamic societies) have no obligation to pretend that they themselves, nor any right to assume that their audiences, are abstinent from alcohol. Thus courtesy forbids even those who themselves do not drink, and disapprove of drinking, from referring to alcohol users generically as 'drunkards' or 'degenerates' or 'slaves of the Demon Rum'. Problems with alcohol must therefore be treated, in Abraham Lincoln's formulation, as 'the abuse of a good thing', not 'the use of a bad thing'. However, if alcohol is a drug then 'drug use' is normal, and not all drug use is abuse. That undercuts the entire project of stigmatization underlying much of what passes for 'drug abuse prevention'.

An exploratory study of drug abuse and dependence information in package inserts.

Phipps LB; Balster RL; Slattum PW; Kirkwood CK. Journal of Addictive Diseases 26(2): 25-34, 2007. (21 refs.)
Information about drug abuse and dependence from package inserts of centrally acting drugs was evaluated for content. Of the 77 labels reviewed, 40 were opiate agonists, 18 were stimulants, and the remainder fell into other selected categories. The amount of information ranged from 0-66 sentences, with greatest variability found in the opiate agonists (range 9-66). Information amount was significantly correlated with the year of drug approval (p < 0.001) but not with the latest label revision (p = 0.749). Information amount did not differ significantly with warning strength or schedule. While most package inserts explain physical dependence, tolerance, and withdrawal, there is a lack of information about psychological dependence. Variability in information about abuse and dependence potential is high and can affect prescribing by physicians and counseling by pharmacists, underscoring the need for further studies.

Assessing the long-term impact of drug court participation on recidivism with generalized estimating equations.

Krebs CP; Lindquist CH; Koetse W; Lattimore PK. Drug and Alcohol Dependence 91(1): 57-68, 2007. (31 refs.)
Drug courts are one of the most common strategies for dealing with the large proportion of criminal offenders who are drug-involved, yet methodological limitations limit the conclusions that can be drawn from many existing evaluations of their effectiveness. The current study 41 examined the long-term impact of drug court participation compared to regular probation on the recidivism of 475 drug-involved offenders under supervision in Hillsborough County, Florida. Using a combination of self-reported data (collected through in-person interviews at baseline, i.e., the beginning of supervision) and administrative records, the study employed a repeated measures framework (examining five 6-month time periods from baseline to 30 months post-baseline) and generalized estimating equations to compare the likelihood of being arrested between drug court participants and a matched sample of comparison offenders. The results indicate that participation in drug court was associated with a significant decrease in the likelihood of being arrested in the 12-18 months post-baseline time period. Although the drug court effect was somewhat delayed (it was not significant prior to 12 months) and short-lived (it was not significant after 18 months), the fact that significant program effects were observed during a time period that coincides with the conclusion of drug court participation for graduates and a time period well beyond initial program exposure, suggests that drug court participants are more likely than comparable offenders not exposed to drug court to remain arrest free when no longer under community supervision.

Alcohol-attributable morbidity and resulting health care costs in Canada in 2002: Recommendations for policy and prevention.

Taylor B; Rehm J; Patra J; Popova S; Baliunas D. Journal of Studies on Alcohol and Drugs 68(1): 36-47, 2007. (43 refs.)
Objective: Alcohol is one of the most important risk factors for burden of disease, particularly in high-income countries such as Canada. The purpose of this article was to estimate the number of hospitalizations, hospital days, and the resulting costs attributable to alcohol for Canada in 2002. Method: Exposure distribution was taken from the Canadian Addiction Survey and corrected for per capita consumption from production and sales. For chronic disease, risk relations were taken from the published literature and combined with exposure to calculate age- and gender-specific alcohol -attributable fractions. For injury, alcohol -attributable fractions were taken directly from available statistics. Data on the most responsible diagnosis, length of stay for hospitalizations, and costs were obtained front the national Canadian databases. Results: For Canada in 2002, there were 195,970 alcohol-related diagnoses among acute care hospitalizations, 2,058 alcohol-attributable psychiatric hospitalizations, and 183,589 alcohol-attributable admissions to specialized treatment centers. These accounted for 1,246,945 hospital days in acute care facilities, 54,114 hospital days in psychiatric hospitals, and 3,018,688 hospital days in specialized treatment centers (inpatient and outpatient). The main causes of alcohol-attributable morbidity were neuropsychiatric conditions, cardiovascular disease, and unintentional injuries. In total, Can. $2.29 billion were spent on alcohol-related health care. Conclusions: Alcohol poses a heavy burden of disease as well as a financial strain on Canadian society. However, there are evidence-based effective and cost-effective policy and legislative interventions as well as measures to better enforce these laws.

Burnout among corrections-based drug treatment staff - Impact of individual and organizational factors.

Garner BR; Knight K; Simpson DD. International Journal of Offender Therapy and Comparative Criminology 51(5): 510-522, 2007. (33 refs.)
As a result of limited budgets, many treatment programs are forced to operate for extended periods at or beyond their capacity. The resulting pressure and stress on treatment staff can be taxing and lead to serious problems, including job burnout. Although the concept of burnout within other social service professions has been broadly researched, less attention has been given to burnout among drug abuse treatment staff, especially among corrections-based drug treatment staff. The goal of this article is to extend this area of research by exploring the impact of individual factors and organizational factors on burnout. Findings revealed that although a number of factors were related to staff burnout, younger counselor age, lower adaptability, poorer clarity of agency mission, and higher stress were most significant. Ways in which treatment programs might address these issues affecting staff burnout are discussed.

Community pharmacies and the provision of opioid substitution services for drug misusers: Changes in activity and attitudes of community pharmacists across England 1995-2005.

Sheridan J; Manning V; Ridge G; Mayet S; Strang J. Addiction102(11): 1824-1830, 2007. (25 refs.)
Aims: In England, the role of community pharmacy in service provision to drug misusers was studied in 1995. Extensive involvement was identified, and considerable underused capacity was noted. This study explores these and potential new roles 10 years on. Design: Cross-sectional national study. Postal survey (three mailshots), plus a fourth telephone follow-up using a structured questionnaire based on the 1995 questionnaire. Setting: Community pharmacies in England. Measurements: Involvement in opioid substitution therapy services (e.g. methadone, buprenorphine) and related activities. Attitudes towards service provision and novel services. Findings A 95% response rate was obtained. This was higher than in 1995, due largely to the use of a telephone follow-up. There had been an increase in the proportion providing substitution therapy dispensing services from 51% to 63% and in the average current case-load (from 5.9 to 9.2); and consequently a large increase in the numbers being treated (approximately x 1.9). Similarly, supervised consumption of methadone and buprenorphine was being provided more widely (increasing from 0 to 59% of all responding pharmacists). Attitudes towards existing roles were more positive than in 1995, and providers tended to be more positive than non-providers. For newer roles (e.g. supervise medications for comorbidity; provide hepatitis B vaccination), there was support from around one-quarter of respondents. Conclusion: Community pharmacy continues to play an important role in delivering treatment, including prescribing services, to drug misusers. There still appears to be untapped capacity, and moderate support for newer roles.

Core undergraduate psychiatry: What do non-specialists need to know?

Wilson S; Eagles JM; Platt JE; McKenzie H. Medical Education 41(7): 698-702, 2007. (17 refs.)
Objective: The purpose of this study is to define the most relevant topics for inclusion in an undergraduate psychiatric curriculum by asking non-psychiatrists what knowledge, skills and attitudes related to psychiatry they need in their day-to-day practice. Methods: A questionnaire study involving non-psychiatric doctors (based both in hospitals and general practice) was carried out using Delphi methodology in 2 waves. In the first wave, 408 doctors described the psychiatric competencies they required in their current posts. From this, a list of 101 psychiatric topics was generated. In the second wave, 867 doctors rated these topics according to the relevance of each topic to their practice. Results: Depression, alcohol misuse and drug misuse were rated as most relevant. General practitioners found more topics relevant to their practice than did hospital doctors, and there were disparities in the relative importance that the 2 groups gave to topics. Conclusions: This study demonstrates a systematic method for developing core curricular undergraduate learning objectives in a specialty area by asking doctors outside that specialty to identify topics that are relevant to their practice. Similar methods could be used for a range of specialties other than psychiatry and could provide a rational and transparent means of developing a core curriculum for medical students, when combined with perspectives from other sources.

Detection of cocaine in the airborne particles of the Italian cities Rome and Taranto.

Cecinato A; Balducci C. Journal of Separation Science 30(12): 1930-1935, 2007. (34 refs.)
Cocaine was first detected in the air of two Italian cities, Rome and Taranto, where it reached concentrations sometimes exceeding 100 pg/m(3), by HRGC-MS analysis of carbonaceous aerosol samples. By contrast, the drug was virtually absent in Algiers (Algeria). In Italy, atmospheric concentrations of cocaine were, on average, similar to those of other toxic pollutants like polychlorobiphenyls or nitrated polynuclear aromatic hydrocarbons, and higher than those of polychlorodibenzo-p-dioxins/polychloro-dibenzofurans. The cocaine concentrations seemed to correlate with regional consumption of the drug in Rome and Taranto. By contrast, it correlated neither with nicotine or caffeine, nor with benzo[a]pyrene, the sole organic compound associated with aerosols that is quoted according to Italian legislation.

Industrial epidemics, public health advocacy and the alcohol industry: Lessons from other fields. (editorial).

Jahiel RI; Babor TF. Addiction102(9): 1335-1339, 2007. (55 refs.)
This is a very provocative editorial that considers the role of the beverage industry in promoting a public health "epidemic." Drawing upon the public health framework, rather than considering the host (the individual beset by alcohol problems) or the agent (beverage alcohol), this editorial considers the disease vector, i.e, the beverage industry which is seen as behaving irresponsibly at times by increasing the exposure of vulnerable populations to alcohol. Parallels are made to the consumption of other products, including guns, fast foods, tobacco. As environmental interventions were key to the marked strides in public health made in the last 19th and early 20th century, it is suggested that such efforts are again required.

Health plan requirements for mental health and substance use screening in primary care.

Horgan CM; Garnick DW; Merrick EL; Hoyt A. Journal of General Internal Medicine 22(7): 930-936, 2007. (31 refs.)
Background: Screening for substance abuse and mental health in primary care can improve detection. One way to advance screening is for health plans to require it. Objectives: We developed national estimates of the prevalence and type of mental and substance-use condition screening health plans require of primary care practitioners. Design: In 1999 (N = 434, response rate = 92%) and 2003 (N = 368, response rate = 83%), we conducted a nationally representative health plan survey regarding alcohol, drug, and mental health services, including screening requirements. Participants: Health plans reported on screening requirements of their top three private insurance products. Products were categorized by type (HMO, POS, or PPO), behavioral health contracting arrangements, tax status, market area population, and region. Measurements: We asked whether primary care practitioners are required to use a general health screening questionnaire (including mental health, alcohol, or drugs items) and/or a screening questionnaire focused on mental health, alcohol, or drug problems. Results: By 2003, 34% of products had any behavioral health screening requirements. Although there was no increase from 1999 to 2003 in requirements for any kind of behavioral health screening, requirements for using a standard screening instrument declined for mental health but increased for alcohol and drug screening. PPOs showed the largest increase in prevalence of behavioral health screening requirements. Products contracting with managed behavioral health organizations were more likely to require screening. Conclusions: Most products do not require behavioral health screening in primary care. More screening could help to improve identification of behavioral health conditions, a first step towards effective treatment.

Methamphetamine and the changing face of child welfare: Practice principles for child welfare workers.

Connell-Carrick K. Child Welfare 86(3): 125-144, 2007. (50 refs.)
Methamphetamine use and production is changing child welfare practice. Methamphetamine is a significant public health threat (National Institute of justice, 1999) reaching epidemic proportions (Anglin, Burke, Perrochet, Stamper, & Dawud-Nouris, 2000). The manufacturing of methamphetamine is a serious problem for the child welfare system, yet child welfare has not addressed the needs of children living in homes where methamphetamine is manufactured (U.S. Department of justice, 2002; DOJ, 2003; Altshuler, 2005). This article presents key issues for child welfare workers related to the use, production, and effects of methamphetamine on children and families, and identifies practice principles for child welfare workers in order to ensure safety for victims, parents, and workers themselves.

The effectiveness of nationally implemented smoking interventions in Denmark.

Kjaer NT; Evald T; Rasmussen M; Juhl HH; Mosbech H; Olsen KR. Preventive Medicine 45(1): 12-14, 2007. (9 refs.)
Objective. The present study aimed to investigate the effectiveness of smoking cessation interventions at a national level. Method. A systematic follow-up was made of 3628 adults who participated in smoking cessation groups or in individual interventions in different settings in Denmark from January 2001 to March 2002. Results. The rates of continued abstinence from smoking were estimated as 18% and 16% after 6 and 12 months, respectively, for the 3628 participants from 101 smoking cessation units. Among participants, who accomplished at least 75% of the intervention, the rates of non-smokers after six and twelve months were 23% and 19%, respectively. Five of the investigated factors influenced continued abstinence after 12 months: gender, age, degree of nicotine dependence, the format and the setting of the cessation service. Conclusions. The study shows that it is possible to implement uniform smoking cessation interventions at a national level keeping the same abstinence rates as previously achieved in randomized clinical trials. The successful cessation interventions were run by nurses and equivalent staff that had received only 3 days of training and had no other particular therapeutic skills.

Do licensing and accreditation matter in outpatient substance abuse treatment programs?

Wells R; Lemak CH; Alexander JA; Nahra TA; Ye YN; Campbell CI. Journal of Substance Abuse Treatment 33(1): 43-50, 2007. (17 refs.)
Licensing and accreditation are widely used to improve and convey organizational quality. The objective of this study was to provide substance abuse treatment stakeholders with better evidence about how well licensing and accreditation actually correlate with staffing and treatment practices. Regressions using data from national surveys of outpatient substance abuse treatment facilities indicated that no form of licensing or accreditation was associated with better staff-to-client ratios or with one important aspect of comprehensive treatment -- the percentage of clients receiving routine medical care. There were several positive associations between licensing/accreditation and other aspects of treatment comprehensiveness. Three categories of licensure/accreditation were also positively associated with use of after treatment plans. Post hoc analyses revealed that accreditation was associated with units' organizational contexts and referral sources as well as the nature of the competitive environment. Licensing/accreditation may reveal as much about units' institutional environments as about the quality of treatment provided.

Substance dependence and level of treatment need among recently-incarcerated prisoners.

Rounds-Bryant JL; Baker L. American Journal of Drug and Alcohol Abuse 33(4): 557-561, 2007. (7 refs.)
This study assessed both prevalence rates of substance dependence and level of treatment need among recently- incarcerated prisoners in a southeastern state. Participants were 752 consecutive admissions to the state prison system in 2002. They were administered the 93 item Substance Abuse Subtle Screening Inventory (SASSI). The results indicated that approximately 72% of participants met criteria for substance dependence and 46% of participants met criteria for prison-based residential treatment. The results of this study can be used to inform allocation of prison-based treatment resources.

Organizational and client determinants of cost in outpatient substance abuse treatment.

Beaston-Blaakman A; Shepard D; Horgan C; Ritter G. Journal of Mental Health Policy & Economics 10(1): 3-13, 2007. (28 refs.)
Background: Understanding variation in the cost of outpatient substance abuse treatment is important for improving the delivery and financing of care. Studies that examine how the cost of treatment relates to treatment program and client characteristics can provide important data about variables that affect unit costs of treatment. Such analyses can inform those who are responsible for setting appropriate reimbursement rates and can give important cost data to program directors responsible for delivering cost-effective treatment. Aims of the Study: The aim of this study is to describe the results from cost function analyses of outpatient substance abuse treatment programs sampled in the Alcohol and Drug Services Study (ADSS). The ADSS is a national study conducted in the late 1990s to collect organizational, client, and cost data of the specialty sector. Methods: The authors examined how organizational and client characteristics affect the cost per episode and the cost per enrollment day of outpatient care. The analysis incorporates organizational variables such ownership, average length of stay, and visits per enrollment day, as well as client characteristics such as gender, age, and primary drug of choice. For further applicability for current treatment policy, the ADSS cost data were inflated from 1997 to 2005 dollars. Mixed model regressions using log-log and log-linear relationships were developed. Results: Several organizational characteristics have statistically significant coefficients in the model estimating cost per episode, including log of point prevalence (-0.53, p <.01), log of average length of stay (0.73, p <.01), log of visits per enrollment day (0.45, p <.01), log of labor index (0.50, p <.01), proportion of counselor time spent in direct counseling (-0.52, p <.01), and location outside a metropolitan area (-0.19. p <.05). None of the client variables are statistically significant in this model. The analysis of cost per enrollment day indicates diseconomies of scope for programs that provide a broader array of ancillary services. Discussion: Findings suggest there exist increasing returns to scale in outpatient substance abuse treatment. Mergers of substance abuse treatment programs may be economically beneficial. Other major determinants of cost include the average length of stay, wage rates, visits per enrollment day, and direct client contact time. Increased efficiency may enable programs to control costs in these areas. In addition, many of the patterns identified in the model represent the way in which outpatient substance abuse treatment facilities are reimbursed for services. As these patterns become more specified for client conditions, client factors may become statistically significant in determining costs. The potential problem of endogencity is addressed. Limitations of the study include possible inaccuracies in non-personnel cost data, changes in the treatment system unaccounted for in the model, and limited market area information with regard to input prices. Implications for further research: If further research indicates economies of scale, policymakers might consider supporting the merging of treatment programs. Also, further research into the optimal-mix of ancillary and treatment services would provide useful data- for treatment programs seeking to balance resource constraints while providing important clinical and support activities. Lastly, research is needed to understand the relationship between treatment costs and service reimbursement.

Private profits and public health: Does advertising of smoking cessation products encourage smokers to quit?

Avery R; Kenkel D; Lillard DR; Mathios A. Journal of Political Economy 115(3): 447-481, 2007. (55 refs.)
We study the impact of smoking cessation product advertising. To measure potential exposure, we link survey data on magazine-reading habits and smoking behavior with an archive of print advertisements. We find that smokers who are exposed to more advertising are more likely to attempt to quit and to successfully quit. While some increased quitting involves product purchases, we find that product advertisements also prompt cold turkey quitting. Identifying the causal impact of advertising is difficult because advertisers target consumers. Although reverse causality could bias our estimates upward, our baseline results are not sensitive to a series of checks.

Police stress: History contributing factors, symptoms, and interventions.

Waters JA; Ussery W. Policing 30(2): 169-188, 2007. (33 refs.)
Purpose - The purpose of this paper is to highlight the stressors involved in an occupation at potential risk - the profession of law enforcement. Design/methodology/approach - The paper reviews the history of police stress studies. It describes prevention and treatment programs that have unfortunately not been sufficiently utilized because of the police culture. Findings - The documented symptoms of stress include digestive orders, cardiovascular diseas, alcoholism, domestic violence, post-traumatic stress disorder, depression and suicide. While some police officers start their careers in excellent physical health, some retire early or even die from job-related stress disorders if the cumulative impact of stress exacts its toll. Originality/value - The paper offers a description of COP.2.COP a confidential hotline for officers and their families staffed by retired officers and licensed professionals.