Library Watch - On Policy Issues

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Last Update: 21.3.09

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...on Policy Issues

www.ProjectCork.org

Spring 2009

Benefit limits for behavioral health care in private health plans.

Hodgkin D; Horgan CM; Garnick DW; Merrick EL. Administration and Policy in Mental Health Services Research 36(1): 15-23, 2009. (36 refs.)
Data from a nationally representative sample of private health plans reveal that special lifetime limits on behavioral health care are rare (used by 16% of products). However, most plans have special annual limits on behavioral health utilization; for example, 90% limit outpatient mental health and 93% limit outpatient substance abuse treatment. As a result, enrollees in the average plan face substantial out-of-pocket costs for long-lasting treatment: a median of $2,710 for 50 mental health visits, or $2,400 for 50 substance abuse visits. Plans' access to new managed care tools has not led them to stop using benefit limits for cost containment purposes.

Treatment Cost Analysis Tool (TCAT) for estimating costs of outpatient treatment services.

Flynn PM; Broome KM; Beaston-Blaakman A; Knight DK; Horgan CM; Shepard DS. Drug and Alcohol Dependence 100(1-2): 47-53, 2009. (28 refs.)
A Microsoft (R) Excel-based workbook designed for research analysts to use in a national study was retooled for treatment program directors and financial officers to allocate, analyze, and estimate outpatient treatment costs in the U.S. This instrument can also be used as a planning and management tool to optimize resources and forecast the impact of future changes in staffing, client flow, program design, and other resources. The Treatment Cost Analysis Tool (TCAT) automatically provides feedback and generates summaries and charts using comparative data from a national sample of non-methadone outpatient providers. TCAT is being used by program staff to capture and allocate both economic and accounting costs, and outpatient service costs are reported for a sample of 70 programs. Costs for an episode of treatment in regular, intensive, and mixed types of outpatient treatment were $882, $1310, and $1381 respectively (based on 20% trimmed means and 2006 dollars). An hour of counseling cost $64 in regular, $85 intensive, and $86 mixed. Group counseling hourly costs per client were $8, $11, and $10 respectively for regular, intensive, and mixed. Future directions include use of a web-based interview version, much like some of the commercially available tax preparation software tools; and extensions for use in other modalities of treatment.

Alcohol research and the alcoholic beverage industry: Issues, concerns and conflicts of interest. (review).

Babor TF. Addiction 104(Supplement 1): 34-47, 2009. (59 refs.)
Using terms of justification such as 'corporate social responsibility' and 'partnerships with the public health community', the alcoholic beverage industry (mainly large producers, trade associations and 'social aspects' organizations) funds a variety of scientific activities that involve or overlap with the work of independent scientists. The aim of this paper is to evaluate the ethical, professional and scientific challenges that have emerged from industry involvement in alcohol science. Source material came from an extensive review of organizational websites, newspaper articles, journal papers, letters to the editor, editorials, books, book chapters and unpublished documents. Industry involvement in alcohol science was identified in seven areas: (i) sponsorship of research funding organizations; (ii) direct financing of university-based scientists and centers; (iii) studies conducted through contract research organizations; (iv) research conducted by trade organizations and social aspects/public relations organizations; (v) efforts to influence public perceptions of research, research findings and alcohol policies; (vi) publication of scientific documents and support of scientific journals; and (vii) sponsorship of scientific conferences and presentations at conferences. While industry involvement in research activities is increasing, it constitutes currently a rather small direct investment in scientific research, one that is unlikely to contribute to alcohol science, lead to scientific breakthroughs or reduce the burden of alcohol-related illness. At best, the scientific activities funded by the alcoholic beverage industry provide financial support and small consulting fees for basic and behavioral scientists engaged in alcohol research; at worst, the industry's scientific activities confuse public discussion of health issues and policy options, raise questions about the objectivity of industry-supported alcohol scientists and provide industry with a convenient way to demonstrate 'corporate responsibility' in its attempts to avoid taxation and regulation.

Closing the revolving door? Substance abuse treatment as an alternative to traditional sentencing for drug-dependent offenders.

Warner TD; Kramer JH. Criminal Justice and Behavior 36(1): 89-109, 2009. (37 refs.)
The criminal justice system is often viewed as a revolving door for drug-dependent offenders due to its failure to recognize the association between addiction and offending, and repeated incarceration of drug-dependent offenders has contributed to prison overcrowding. The authors evaluated the effectiveness of Pennsylvania's drug and alcohol treatment-based intermediate punishment, Restrictive Intermediate Punishments (RIP/D&A), at reducing the risk of rearrest. Rearrest was compared at 12, 24, and 36 months postrelease. Offenders who successfully completed treatment had a lower risk of rearrest than traditionally sentenced offenders in general and county jail and probation offenders specifically. However, offenders sentenced to RIP/D&A who did not successfully complete treatment were more at risk for rearrest than traditionally sentenced offenders in general. Also, offenders sentenced to state incarceration had a lower risk of rearrest than RIP/ D&A participants, regardless of program completion.

Harm reduction product distribution in British Columbia.

Harvard SS; Hill WD; Buxton JA. Canadian Journal of Public Health 99(6): 446-450, 2008. (21 refs.)
Objectives: The British Columbia Centre for Disease Control (BCCDC) tracks the distribution of all harm reduction products subsidized by the BC government, including needles and syringes, sterile water vials, alcohol swabs, condoms, and lubricant. This study measures the distribution of harm reduction products in BC, identifies regional variation in distribution, and estimates the supply/demand ratio for needle and syringe units. Methods: Using three years of administrative data (2004-2006) from the BCCDC, the quantity of harm reduction products distributed was calculated by Health Service Delivery Area (HSDA). Regional hepatitis C virus (HCV) case report rates were calculated to reflect potential variation in IDU populations at the HSDA-level and the number of needle and syringe units distributed per reported case of HCV was calculated and ranked by HSDA. To compare the demand for sterile injecting equipment to the distribution, the number of illicit drug injections per year was approximated using established estimates of IDU populations in BC and Vancouver. Results: Marked regional variation exists in the rates of harm reduction product distribution per 100,000 residents aged 15-64. The average number of needle and syringe units distributed annually in BC from 2004-2006 was 5,382,933. The estimated number of injections per year in BC is 24,951,144, suggesting the province distributed 21.5% of the units required to cover all illicit drug injections in the province. Discussion: Harm reduction product distribution is not equitable between BC HSDAs. The current level of distribution of sterile injecting equipment is inadequate to provide a clean needle for every injection.

Impact of US and Canadian precursor regulation on methamphetamine purity in the United States.

Cunningham JK; Liu LM; Callaghan R. Addiction 104(3): 441-453, 2009. (62 refs.)
Reducing drug purity is a major, but largely unstudied, goal of drug suppression. This study examines whether US methamphetamine purity was impacted by the suppression policy of US and Canadian precursor chemical regulation. Autoregressive integrated moving average (ARIMA)-intervention time-series analysis. Continental United States and Hawaii (1985-May 2005). US federal regulations targeting precursors, ephedrine and pseudoephedrine, in forms used by large-scale producers were implemented in November 1989, August 1995 and October 1997. US regulations targeting precursors in forms used by small-scale producers (e.g. over-the-counter medications) were implemented in October 1996 and October 2001. Canada implemented federal precursor regulations in January 2003 and July 2003 and an essential chemical (e.g. acetone) regulation in January 2004. Monthly median methamphetamine purity series. US regulations targeting large-scale producers were associated with purity declines of 16-67 points; those targeting small-scale producers had little or no impact. Canada's precursor regulations were associated with purity increases of 13-15 points, while its essential chemical regulation was associated with a 13-point decrease. Hawaii's purity was consistently high, and appeared to vary little with the 1990s/2000s regulations. US precursor regulations targeting large-scale producers were associated with substantial decreases in continental US methamphetamine purity, while regulations targeting over-the-counter medications had little or no impact. Canada's essential chemical regulation was also associated with a decrease in continental US purity. However, Canada's precursor regulations were associated with purity increases: these regulations may have impacted primarily producers of lower-quality methamphetamine, leaving higher-purity methamphetamine on the market by default. Hawaii's well-known preference for 'ice' (high-purity methamphetamine) may have helped to constrain purity there to a high, attenuated range, possibly limiting its sensitivity to precursor regulation.

Residual methamphetamine in decontaminated clandestine drug laboratories.

Patrick G; Daniell W; Treser C. Journal of Occupational and Environmental Hygiene 6(3): 151-156, 2009. (10 refs.)
This pilot cross-sectional study examined three previously decontaminated residential clandestine drug laboratories (CDLs) in Washington State to determine the distribution and magnitude of residual methamphetamine concentrations relative to the state decontamination standard. A total of 159 discrete random methamphetamine wipe samples were collected from the three CDLs, focusing on the master bedroom, bathroom, living room, and kitchen at each site. Additional samples were collected from specific non-random locations likely to be contacted by future residents (e.g., door knobs and light switches). Samples were analyzed for methamphetamine by EPA method 8270 for semivolatile organic chemicals. Overall, 59% of random samples and 75% of contact point samples contained methamphetamine in excess of the state decontamination standard (0.1 g/100 cm2). At each site, methamphetamine concentrations were generally higher and more variable in rooms where methamphetamine was prepared and used. Even compared with the less stringent standard adopted in Colorado (0.5 g/100cm2), a substantial number of samples at each site still demonstrated excessive residual methamphetamine (random samples, 25%; contact samples, 44%). Independent oversight of CDL decontamination in residential structures is warranted to protect public health. Further research on the efficacy of CDL decontamination procedures and subsequent verification of methods is needed.

Litigation and alcohol policy: Lessons from the US tobacco wars. (review).

Mosher JF. Addiction 104(Supplement 1): 27-33, 2009. (19 refs.)
This paper explores the role of litigation in preventing alcohol-related harms, identifying lessons from the use of litigation in tobacco control policy in the United States. It analyzes the key components of litigation in an international context, provides a case study of its potential use in addressing the marketing of alcopops to youth and offers recommendations for pursuing litigation strategies in future alcohol policy efforts. The paper's analyses are based on both original and secondary legal research. State and federal case law and secondary sources are reviewed in assessing lessons learned from tobacco litigation in the United States and the potential role of litigation in alcohol policy, both in the United States and internationally. Assessment of alcohol litigation cases and state and federal laws and regulations provides the foundation for the alcopops case study. The tobacco litigation experience demonstrates that litigation is a powerful tool in addressing aggressive marketing by purveyors of addictive products such as alcohol. To be effective at both national and international levels, litigation should encompass a broad array of legal tactics designed to identify and restrict unfair, deceptive and misleading alcohol marketing tactics and should be utilized in conjunction with complementary prevention strategies. Research conducted on the impact of alcohol marketing on youth alcohol consumption and problems is needed to support potential litigation claims. Developing litigation expertise within the alcohol policy field and building collaboration with litigation specialists in tobacco control should also be considered a high priority.

Selected community characteristics and underage drinking.

Song EY; Reboussin BA; Foley KL; Kaltenbach LA; Wagoner KG; Wolfson M. Substance Use & Misuse 44(2): 179-194, 2009. (48 refs.)
This study assessed the relationship between community characteristics and alcohol use among 6,636 youth, aged from 14 to 20, in 2004. After adjusting for individual-level characteristics, youth from communities with a greater proportion of grandparents as caregivers, larger numbers of married couple families, and higher employment rates were significantly less likely to report past 30-day alcohol use. Youth from communities with higher median household income were significantly more likely to report past 30-day alcohol use. Adolescents in communities with a greater percentage of whites were significantly more likely to report binge drinking. The results indicate that the community context is an important predictor of alcohol use.

The promotion and marketing of OxyContin: Commercial triumph, public health tragedy. (editorial).

Zee AV. American Journal of Public Health 99(2): 221-227, 2009. (70 refs.)
I focus on issues surrounding the promotion and marketing of controlled drugs and their regulatory oversight. Compared with noncontrolled drugs, controlled drugs, with their potential for abuse and diversion, pose different public health risks when they are overpromoted and highly prescribed. An in-depth analysis of the promotion and marketing of OxyContin illustrates some of the associated issues. Modifications of the promotion and marketing of controlled drugs by the pharmaceutical industry and an enhanced capacity of the Food and Drug Administration to regulate and monitor such promotion can have a positive impact on the public health.

The alcohol industry and trade agreements: A preliminary assessment. (review).

Zeigler DW. Addiction 104(Supplement 1): 13-26, 2009. (102 refs.)
To review trade agreements, their relation to alcohol control policy and examine the role of the alcohol industry in supporting and attempting to influence trade policy. Review of peer review, public health advocacy literature (both pro and con on free trade), business, press and government documents on trade agreements, assess current and potential challenges by trade agreements to alcohol control policy and investigate the means and extent of industry influence in trade agreements. 'Free' trade agreements reduce trade barriers, increase competition, lower prices and promote alcohol consumption. However, international treaties, negotiated by free trade experts in close consultation with corporate lobbyists and without significant, if any, public health input, governments and corporations contain significant provisions that will result in increased alcohol consumption and may challenge public health measures of other nations as constraints on trade. Conversely, alcohol control measures seek to reduce access and consumption, raise prices and restrict advertising and product promotion. The prospect is for increased alcohol consumption and concomitant problems throughout the world. Trade agreements challenge effective alcohol control policies. The alcohol industry seeks to influence agreements and can be expected to work through trade agreements to reduce tariffs, increase market access and seek to restrict effective domestic regulations. Further research is needed on the impact of trade agreements and the ongoing role of the industry. Advocates must recognize the inherent conflicts between unbridled free trade and public health, work to exclude alcohol from trade agreements, counter industry influence and protect alcohol control policies.

The global diversion of pharmaceutical drugs.

Paoli L; Greenfield VA; Charles M; Reuter P. Addiction 104(3): 347-354, 2009. (29 refs.)
This paper explores India's role in the world illicit opiate market, particularly its role as a producer. India, a major illicit opiate consumer, is also the sole licensed exporter of raw opium: this unique status may be enabling substantial diversion to the illicit market. Participant observation and interviews were carried out at eight different sites. Information was also drawn from all standard secondary sources and the analysis of about 180 drug-related criminal proceedings reviewed by Indian High Courts and the Supreme Court from 1985 to 2001. Diversion from licit opium production takes place on such a large scale that India may be the third largest illicit opium producer after Afghanistan and Burma. With the possible exceptions of 2005 and 2006, 200-300 tons of India's opium may be diverted yearly. After estimating India's opiate consumption on the basis of UN-reported prevalence estimates, we find that diversion from licit production might have satisfied a quarter to more than a third of India's illicit opiate demand to 2004. India is not only among the world's largest consumer of illicit opiates but also one of the largest illicit opium producers. In contrast to all other illicit producers, India owes the latter distinction not to blatantly illicit cultivation but to diversion from licit cultivation. India's experience suggests the difficulty of preventing substantial leakage, even in a relatively well-governed nation.