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...on Policy Issues

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Winter 2009

Claims of amnesia for criminal offenses: Psychopathology, substance abuse, and malingering.

Stout RG; Farooque RS. Journal of Forensic Sciences 53(5): 1218-1222, 2008. (47 refs.)
The forensic psychiatric examiner often encounters defendants who deny memory for their offense. Past research proposes a variety of factors to account for offense amnesia. To date there have been few systematic studies of offense amnesia in relation to psychiatric diagnosis, either alone or in combination with other known factors such as substance use and malingering. We studied 53 pretrial felony defendants who had been referred for psychiatric examination: 40% claimed amnesia for their offense. Examinees with psychotic disorders in general, and schizophrenia in particular, were relatively less likely to claim amnesia than were examinees with other diagnoses. Substance use at the time of the offense and associated substance use disorder diagnoses were positively associated with offense amnesia. Malingering diagnosed by general clinical criteria was a poor predictor of amnesia claims. These data suggests that two prominent reasons for referral for forensic psychiatric evaluation include the presence of psychotic symptoms and claims of amnesia for the offense.

An evidence-based alcohol policy.

Sheron N; Olsen N; Gilmore I. Gut 57(10): 1341-1344, 2008. (30 refs.)
In the last 30 years of the 20th century deaths from liver cirrhosis steadily increased, in people aged 35 to 44 years the death rate went up 8-fold in men and almost 7-fold in women, in 25Đ34 year-olds a 4-fold increase was seen over the 30 year period. The UK situation is in stark contrast to the decrease in liver mortality in Mediterranean countries over the same period of time. So why is the UK facing this increase in liver deaths when mortality elsewhere is falling? According to death certification data more than 80% of UK liver deaths are due to alcohol-related cirrhosis. Other causes of liver disease are also increasing; for example, steatosis and viral hepatitis, but only 205 out of 6889 reported liver deaths in 2005 were due to viral hepatitis.2 While viruses and, more importantly, steatosis secondary to obesity may be co-factors in some cases, the evidence suggests that it is our drinking habits that are the problem. Alcoholic drinks have also increased in strength, 5% alcohol by volume (bv) lager has largely replaced 3.5% bv beer, a 40% increase. Similarly, most wine sold at supermarkets is no longer 10Đ12% but 14Đ15% bv, the point at which duty increases to the next threshold. Promotion includes Ł250 million spent on direct alcohol advertising and a greater sum spent on other forms of marketing, much of it directed towards young people. These marketing techniques include the sale of alcohol in larger measures, a large pub measure of wine contains around 3.5 units, an increase of 350%. Similarly, spirits measures in many pubs have gone up from 25 to 35 cl, a 40% increase. Finally, the retail outlets have changed markedly. Pubs, particularly in city centres, have become standing-only (vertical drinking) establishments with extended hours, and off-sales outlets have become dominated by supermarkets, whose purchasing power encourages heavy discounting and loss-leaders. Traditional pubs and independent wine and spirit merchants have struggled against this competition.

Alcohol industry sponsorship and hazardous drinking among sportspeople.

O'Brien KS; Kypri K. Addiction 103(12): 1961-1966, 2008. (20 refs.)
To examine the nature and extent of alcohol industry sponsorship of sportspeople, and its association with drinking. A purposive sample of participants (n = 1279) from various sporting codes were asked whether they personally, their team, or club received free and/or discounted alcohol or funding from an alcohol industry body (e.g. pub, brewery, wholesaler); how much they received; and whether they felt they should drink their sponsor's product and/or at the sponsor's premises. Drinking behaviour was assessed with the Alcohol Use Disorders Identification Test (AUDIT) questionnaire. Alcohol industry sponsorship was reported by 47.8% of the sample. Of those sponsored, 47% reported receiving free and/or discounted alcohol products. In multivariate models, those receiving sponsorship at the individual, team and club level had AUDIT scores that were, on average, 2.4 points higher [95% confidence interval (CI): 0.70-4.09] than those who received no sponsorship. Receiving free and/or discounted alcohol (beta(adj) = 0.95, 95% CI: 0.01-1.88) and feeling that they should go to the sponsor's pub/club to drink (beta(adj) = 1.91, 95% CI: 0.85-2.98) were also associated with higher AUDIT scores. Provision of free or discounted alcoholic beverages was associated more strongly with AUDIT scores (beta(adj) = 1.56; 95% CI: 0.62-2.51) than other forms of sponsorship from the alcohol industry (e.g. provision of uniforms). Alcohol industry sponsorship of sportspeople, and in particular the provision of free or discounted alcoholic beverages, is associated with hazardous drinking after adjustment for a range of potential confounders. Sports administration bodies should consider the health and ethical risks of accepting alcohol industry sponsorship.

Alcohol disorders among Asian Americans: Associations with unfair treatment, racial/ethnic discrimination, and ethnic identification (the National Latino and Asian Americans Study, 2002-2003).

Chae DH; Takeuchi DT; Barbeau EM; Bennett GG; Lindsey JC; Stoddard AM et al. Journal of Epidemiology and Community Health 62(11): 973-979, 2008. (50 refs.)
Study objective: To examine history of alcohol abuse/dependence disorder in relation to unfair treatment, racial/ethnic discrimination, and ethnic identification among Asian Americans. Design: Weighted multivariate analyses of cross-sectional national survey data predicting lifetime history of alcohol abuse/dependence disorders. Setting: USA, Asian Americans. Participants: 2007 Asian American adults recruited to the National Latino and Asian American Study (NLAAS; 2002-2003). Results: Controlling for sociodemographic characteristics, Asian Americans who reported experiencing unfair treatment had higher odds of history of alcohol abuse/dependence disorder (OR 5.26, 95% CI 1.90 to 14.56). Participants who reported high levels of ethnic identification had lower odds of history of alcohol abuse/dependence disorders (OR 0.46, 95% CI 0.23 to 0.90). Ethnic identification moderated the influence of racial/ethnic discrimination (p = 0.097). Among participants with low levels of ethnic identification, racial/ethnic discrimination was associated with greater odds of having a history of alcohol disorder compared with those with high levels of ethnic identification. Conclusions: Social hazards such as unfair treatment and racial/ethnic discrimination should be considered in the development of programmes addressing alcohol disorders among Asian Americans. Interventions that promote ethnic identification in this population may be particularly relevant in mitigating the negative influence of racial/ethnic discrimination on alcohol disorders.

Assessing health care organizations' ability to implement screening, brief intervention, and referral to treatment.

Bohman TM; Kulkarni S; Waters V; Spence RT; Murphy-Smith M; McQueen K. Journal of Addiction Medicine 2(3): 151-157, 2008. (18 refs.)
Objectives: To determine if a new measure of organizational readiness for change reflects site and staff role differences when implementing a screening, brief intervention, and referral to treatment (SBIRT) program) for alcohol and drug misuse in a healthcare organization. Sample: One hundred forty-one Community Health Program (CHP) and 45 Emergency Center (FC) respondents completed the survey. Methods: Medical and ancillary staff from a Level 1 trauma hospital EEC and 3 CHP clinics within a large, urban, publicly funded health-care system were asked to complete the 45-item Medical Organizational Readiness for Change (MORC) survey 5 to 7 months after the start of implementation planning. One-way ANOVAs compared the 4 sites' responses and independent t tests compared the clinical versus administrative staff responses on MORC scales. Results: There were statistically significant differences between the EC and CHP sites on Need for External Guidance, Pressure to Change, Organizational Readiness to Change, Workgroup Functioning, Work Environment, and Autonomy Support. Clinical and administrative staff differed significantly on Need for External Guidance, Pressure to Change, and Organizational Readiness to Change. When change agents used the MORC data to inform their implementation process, the results were positive. Conclusions: Among CHP sites, there were differences in organizational functioning, which were consistent with CHP implementation Outcomes. The MORC scales can help planners and change agents understand their organization's current readiness to integrate screening, brief intervention, and referral to treatment services into their medical setting.

Changes in alcohol-related mortality and its socioeconomic differences after a large reduction in alcohol prices: A natural experiment based on register data.

Herttua K; Makela P; Martikainen P. American Journal of Epidemiology 168(10): 1110-1118, 2008. (32 refs.)
The authors examined the effect of a large reduction in the price of alcohol in Finland in 2004 on alcohol-related mortality by age and socioeconomic group. For this register-based study of Finns aged >= 15 years, data on independent variables were extracted from the employment statistics of Statistics Finland. Mortality follow-up was carried out for 2001-2003 (before the price reduction) and 2004-2005 (after). Alcohol-related causes were defined using both underlying and contributory causes of death. Alcohol-related mortality increased by 16% among men and by 31% among women; 82% of the increase was due to chronic causes, particularly liver diseases. The increase in absolute terms was largest among men aged 55-59 years and women aged 50-54 years. Among persons aged 30-59 years, it was biggest among the unemployed or early-age pensioners and those with low education, social class, or income. The relative differences in change between the education and social class subgroups were small. The employed and persons aged < 35 years did not suffer from increased alcohol-related mortality during the 2 years after the change. These results imply that a large reduction in the price of alcohol led to substantial increases in alcohol-related mortality, particularly among the less privileged, and in chronic diseases associated with heavy drinking.

Clinical supervision, emotional exhaustion, and turnover intention: A study of substance abuse treatment counselors in the Clinical Trials Network of the National Institute on Drug Abuse.

Knudsen HK; Ducharme LJ; Roman PM. Journal of Substance Abuse Treatment 35(4): 387-395, 2008. (59 refs.)
An intriguing hypothesis is that clinical supervision may protect against counselor turnover. This idea has been mentioned in recent discussions of the substance abuse treatment workforce. To test this hypothesis, we extend our previous research on emotional exhaustion and turnover intention among counselors by estimating the associations between clinical supervision and these variables in a large sample (N = 823). An exploratory analysis reveals that clinical supervision was negatively associated with emotional exhaustion and turnover intention. Given our previous findings that emotional exhaustion and turnover intention were associated with job autonomy, procedural justice, and distributive justice, we estimate a structural equation model to examine whether these variables mediated clinical supervision's associations with emotional exhaustion and turnover intention. These data support the fully mediated model. We found that the perceived quality of clinical supervision is strongly associated with counselors' perceptions of job autonomy, procedural justice, and distributive justice, which are, in turn, associated with emotional exhaustion and turnover intention. These data offer support for the protective role of clinical supervision in substance abuse treatment counselors' turnover and occupational well-being.

Density of alcohol outlets and teenage drinking: Living in an alcogenic environment is associated with higher consumption in a metropolitan setting.

Huckle T; Huakau J; Sweetsur P; Huisman O; Casswell S. Addiction 103(10): 1614-1621, 2008. (38 refs.)
Aim: This study examines the relationship between physical, socio-economic and social environments and alcohol consumption and drunkenness among a general population sample of drinkers aged 12-17 years. Design, setting, participants and measures: The study was conducted in Auckland, New Zealand. The design comprised two components: (i) environmental measures including alcohol outlet density, locality-based measure of willingness to sell alcohol (derived from purchase surveys of outlets) and a locality-based neighbourhood deprivation measure calculated routinely in New Zealand (known as NZDEP); and (ii) the second component was a random telephone survey to collect individual-level information from respondents aged 12-17 years including ethnicity, frequency of alcohol supplied socially (by parents, friends and others), young person's income; frequency of exposure to alcohol advertising; recall of brands of alcohol and self-reported purchase from alcohol outlets. A multi-level model was fitted to predict typical-occasion quantity, frequency of drinking and drunkenness in drinkers aged 12-17 years. Findings Typical-occasion quantity was predicted by: frequency of social supply (by parents, friends and others); ethnicity and outlet density; and self-reported purchasing approached significance. NZDEP was correlated highly with outlet density so could not be analysed in the same model. In a separate model, NZDEP was associated with quantity consumed on a typical drinking occasion. Annual frequency was predicted by: frequency of social supply of alcohol, self-reported purchasing from alcohol outlets and ethnicity. Feeling drunk was predicted by frequency of social supply of alcohol, self-reported purchasing from alcohol outlets and ethnicity; outlet density approached significance. Age and gender also had effects in the models, but retailers' willingness to sell to underage patrons had no effects on consumption, nor did the advertising measures. The young person's income was influential on typical-occasion quantity once deprivation was taken into account. Conclusion: Alcohol outlet density was associated with quantities consumed among teenage drinkers in this study, as was neighbourhood deprivation. Supply by family, friends and others also predicted quantities consumed among underage drinkers and both social supply and self-reported purchase were associated with frequency of drinking and drunkenness. The ethnic status of young people also had an effect on consumption.

Drugs, money, and graphic ads: A critical review of the Montana Meth Project. (review).

Erceg-Hurn D. Prevention Science 9(4): 256-263, 2008. (35 refs.)
The Montana Meth Project (MMP) is an organization that launched a large-scale methamphetamine prevention program in Montana in 2005. The central component of the program is a graphic advertising campaign that portrays methamphetamine users as unhygienic, dangerous, untrustworthy, and exploitive. Montana teenagers are exposed to the advertisements three to five times a week. The MMP, media and politicians have portrayed the advertising campaign as a resounding success that has dramatically increased anti-methamphetamine attitudes and reduced drug use in Montana. The program is currently being rolled out across the nation, and is receiving considerable public funding. This article critically reviews the evidence used by the MMP to claim that its advertising campaign is effective. The main finding is that empirical support for the campaign is weak. Claims that the campaign is effective are not supported by data. The campaign has been associated with increases in the acceptability of using methamphetamine and decreases in the perceived danger of using drugs. These and other negative findings have been ignored and misrepresented by the MMP. There is no evidence that reductions in methamphetamine use in Montana are caused by the advertising campaign. On the basis of current evidence, continued public funding and rollout of Montana-style methamphetamine programs is inadvisable.

Impact of Internet pharmacy regulation on opioid analgesic availability.

Boyer EW; Wines JD. Journal of Studies on Alcohol and Drugs 69(5): 703-708, 2008. (19 refs.)
Objective: Access to prescription opioid analgesics has made Internet pharmacies the object of increased regulatory scrutiny, but the effectiveness of regulatory changes in curtailing availability of opioid analgesics from online sources has been not assessed. As part of an ongoing investigation into the relationship between the Internet and substance abuse, we examined the availability of prescription opioid analgesics from online pharmacies. Method: From a pharmacy watch Web site, we constructed a data set of postings entered every 3 months beginning November 1, 2005, that were related to the purchase of prescription opioid analgesics. Trained examiners assessed whether the final post described accessibility of pain medications that was increasing or decreasing. Results: We identified 45 threads related to the availability of opioid analgesics from Internet pharmacies. Of the 41 (91%) threads describing the declining availability of opioid analgesic agents from Internet pharmacies, 34 (82%) received posts on November 1, 2007. Despite the subjective nature of the research question, there was high interobserver agreement between coders (K = .845) that availability of opioid analgesics from online pharmacies had decreased. This finding was supported by a dramatic rise in the number of pageviews (an accepted measure of Web site visitor interest in a page's content) of Web pages describing decreased availability of opioid analgesics. Conclusions: These data suggest striking decreases in the availability of prescription opioid analgesic pharmaceuticals. This self-reported change in drug availability may be related to increased regulation of and law enforcement operations directed against Internet pharmacies.

Opium in Afghanistan: Prospects for the success of source country drug control policies.

Clemens J. Journal of Law & Economics 51(3): 407-432, 2008. (41 refs.)
Recent estimates suggest that in 2007, Afghan opiate production accounted for about 93 percent of the world's total. This article presents a framework for estimating the potential for source country drug control policies to reduce this production. It contains a first pass at estimating the potential for policy to shift the supply of opium upward, as well as a range of supply and demand elasticities. The estimates suggest that meager reductions in production can be expected through alternative development programs alone (reductions are less than 6.5 percent in all but one of the specifications presented). They also suggest that substantial increases in crop eradication would be needed to achieve even moderate reductions in production (reductions range from 3.0 percent to 19.4 percent for various specifications). The results also imply that, all else being equal, the cessation of crop eradication would result in only modest increases in opiate production (with estimates ranging from 1.6 percent to 9.6 percent).

Social costs of robbery and the cost-effectiveness of substance abuse treatment.

Basu A; Paltiel AD; Pollack HA. Health Economics 17(8): 927-946, 2008. (49 refs.)
Reduced crime provides a key benefit associated with substance abuse treatment (SAT). Armed robbery is an especially costly and frequent crime committed by some drug-involved offenders. Many studies employ valuation methods that understate the true costs of robbery, and thus the true social benefits of SAT-related robbery reduction. At the same time, regression to the mean and self-report bias may lead pre-post comparisons to overstate crime reductions associated with SAT. Using 1992-1997 data from the National Treatment Improvement Evaluation Study (NTIES), we examined pre-post differences in self-reported robbery among clients in five residential and outpatient SAT modalities. Fixed-effect negative binomial regression was used to examine incidence rate reductions (IRR) in armed robbery. Published data on willingness to pay to avoid robbery were used to determine the social valuation of these effects. Differences in IRR across SAT modalities were explored to bound potential biases. All SAT modalities were associated with large and statistically significant reductions in robbery. The average number of self-reported robberies declined from 0.83/client/year pre-entry to 0.12/client/year following SAT (p < 0.001). Under worst-case assumptions, monetized valuations of reductions in armed robbery associated with outpatient methadone and residential SAT exceeded economic costs of these interventions. Conventional wisdom posits the economic benefits of SAT. We find that SAT is even more beneficial than is commonly assumed.

The cost of alcohol in California.

Rosen SM; Miller TR; Simon M. Alcoholism: Clinical and Experimental Research 32(11): 1925-1936, 2008. (68 refs.)
Background: California is the largest alcohol market in the United States. In 2005 alone, Californians consumed almost 14 billion alcoholic drinks, which contributed to many severe and potentially fatal alcohol-related illnesses and conditions. Alcohol use also causes violent and nonviolent crimes, as well as injuries and traffic collisions. While several studies have estimated the magnitude and cost of these problems nationally and others have analyzed underage drinking costs, no overall cost estimate at the state level currently exists for California. We present the first comprehensive estimate of the cost of alcohol consumption in California. Methods: For each category of alcohol-related problems, we estimated fatal and nonfatal cases attributable to alcohol use. We multiplied alcohol-attributable cases by estimated costs per case to obtain total costs for each problem. Our estimates are presented in 2 sections, the economic costs, estimated using a human capital approach, and quality-of-life costs estimated using a quality adjusted life year framework. Results: Alcohol consumption in California led to an estimated 9,439 deaths and 921,929 alcohol-related problems, such as crime and injury in 2005. The economic cost of these problems is estimated at between $35.4 billion and $42.2 billion. Our main estimate is $38.5 billion, of which $5.4 billion was for medical and mental health spending, $25.3 billion in work losses, and $7.8 billion in criminal justice spending, property damage and public program costs. In addition, alcohol is responsible for severe reductions in individuals' quality of life in California. We estimate that the disability caused by injury, the personal anguish of violent crime victims, and the life years lost to fatality are the largest costs imposed by alcohol. The total value for this reduced quality of life in California is between $30.3 billion and $60.0 billion. Our main estimate for quality-of-life costs is $48.8 billion. Conclusions: In light of the associated substantial illness, injuries, death, and high cost to society, alcohol consumption in California needs serious attention. In addition, the methods developed in this paper can be expanded to estimate the cost of alcohol in other states.

The effect of a jail methadone maintenance therapy (MMT) program on inmate recidivism.

McMillan GP; Lapham S; Lackey M. Addiction 103(12): 2017-2023, 2008. (21 refs.)
To evaluate the effects of a jail-based continuation of methadone maintenance therapy (MMT) on subsequent inmate recidivism risks. Prospective, longitudinal, observational study. A large, Southwestern United States jail that continues MMT for heroin-addicted inmates on MMT at the time of booking. A total of 589 inmates booked between 22 November 2005 (the start date for the MMT program) and 31 October 2006. The outcome measure was time from release to subsequent re-booking in the jail. Predictors included binary dosing with methadone in the jail, final dose received (mg), age, gender, race/ethnicity, previous bookings and days in jail. Random effects Weibull proportional hazards models were fit to the recidivism times to estimate the impact of treatment with MMT in the jail on re-booking risks. There was no statistically significant effect of receiving methadone in the jail or dosage on subsequent recidivism risks (hazard ratio = 1.16; 95% confidence interval = 0.8-1.68). Offering jail-based MMT does not increase recidivism risks by eliminating the deterrent effect of imposed withdrawal, nor does it reduce recidivism in this high-risk population.

Trade and health: How World Trade Organization (WTO) law affects alcohol and public health.

Baumberg B; Anderson P. Addiction 103(12): 1952-1958, 2008. (55 refs.)
The alcohol field is becoming more aware of the consequences of world trade law for alcohol policies. However, there is a need for greater clarity about the different effects of trade on alcohol-related harm. A comprehensive review of all literature on alcohol and world trade [including World Trade Organization (WTO) disputes on alcohol], supported by a more selective review of other relevant cases, academic reports and the grey literature on trade and health. The burden of WTO law on alcohol policies depends upon the type of policy in question. Purely protectionist policies are likely to be struck down, which may lead to increases in alcohol-related harm. Partly protectionist and partly health-motivated policies are also at risk of being struck down. However, purely health-motivated policies are likely to be defended by the WTO-and to the extent that policy makers misunderstand this, they are needlessly avoiding effective ways of reducing alcohol-related harm. WTO agreements contain genuine and substantial risks to alcohol policies, and various ways of minimizing future risks are suggested. However, the 'chilling effect' of mistakenly overestimating these constraints should be avoided. Health policy makers should decide on which policies to pursue based primarily on considerations of effectiveness, ethics and politics rather than legality. As long as any effect of these policies on trade is minimized, they are overwhelmingly likely to win any challenges at the WTO.

Alcohol outlet density and alcohol consumption in Los Angeles county and southern Louisiana.

Schonlau M; Scribner R; Farley TA; Theall KP; Bluthenthal RN; Scott M et al. Geospatial Health 3(1): 91-101, 2008. (26 refs.)
The objective of this study was to assess the relationship between alcohol availability, as measure by the density of off-premise alcohol outlets, and alcohol consumption in Los Angeles county and southern Louisiana, USA. Consumption information was collected through a telephone survey of 2,881 households in Los Angeles county and pre-Katrina southern Louisiana, nested within 220 census tracts. Respondents' addresses were geo-coded and both neighbourhood (census tracts and buffers of varying sizes) and individual (network distance to the closest alcohol outlet) estimates of off-sale alcohol outlet density were computed. Alcohol outlet density was not associated with the percentage of people who were drinkers in either site. Alcohol outlet density was associated with the quantity of consumption among drinkers In Louisiana but not in Los Angeles. Outlet density within a one-mile buffer of the respondent's home was more strongly associated with alcohol consumption than outlet density in the respondent's census tract. The conclusion is that the relationship between neighbourhood alcohol outlet density and alcohol consumption is complex and may vary due to differences in neighbourhood design and travel patterns.