Library Watch - On Policy Issues

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...on Policy Issues

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Summer 2010

Evaluation of the economic impact of California's Tobacco Control Program: A dynamic model approach.

Miller LS; Max W; Sung HY; Rice D; Zaretsky M. Tobacco Control 19(Supplement 1): I68-I76, 2010. (60 refs.)
Objective To evaluate the long-term net economic impact of the California Tobacco Control Program. Methods: This study developed a series of dynamic models of smoking-caused mortality, morbidity, health status and healthcare expenditures. The models were used to evaluate the impact of the tobacco control programme. Outcomes of interest in the evaluation include net healthcare expenditures saved, years of life saved, years of treating smoking-related diseases averted and the total economic value of net healthcare savings and life saved by the programme. These outcomes are evaluated to 2079. Due to data limitations, the evaluations are conducted only for men. Results: The California Tobacco Control Program resulted in over 700 000 person-years of life saved and over 150 000 person-years of treatment averted for the 14.7 million male California residents alive in 1990. The value of net healthcare savings and years of life saved resulting from the programme was $22 billion or $107 billion in 1990 dollars, depending on how a year of life is discounted. If women were included, the impact would likely be much greater. Conclusions: The benefits of California's Tobacco Control Program are substantial and will continue to accrue for many years. Although the programme has resulted in increased longevity and additional healthcare resources for some, this impact is more than outweighed by the value of the additional years of life. Modelling the programme's impact in a dynamic framework makes it possible to evaluate the multiple impacts that the programme has on life, health and medical expenditures.

Reaching Healthy People 2010 by 2013: A SimSmoke simulation.

Levy DT; Mabry PL; Graham AL; Orleans CT; Abrams DB. American Journal of Preventive Medicine 38(3, Supplement 3): S373-S381, 2010. (62 refs.)
Background: Healthy People (HP2010) set as a goal to reduce adult smoking prevalence to 12% by 2010. Purpose: This paper uses simulation modeling to examine the effects of three tobacco control policies and cessation treatment policies-alone and in conjunction-on population smoking prevalence. Methods: Building on previous versions of the SimSmoke model, the effects of a defined set of policies on quit attempts, treatment use, and treatment effectiveness are estimated as potential levers to reduce smoking prevalence. The analysis considers the effects of (1) price increases through cigarette tax increases, (2) smokefree indoor air laws, (3) mass media/educational policies, and (4) evidence-based and promising cessation treatment policies. Results: Evidence-based cessation treatment policies have the strongest effect, boosting the population quit rate by 78.8% in relative terms. Treatment policies are followed by cigarette tax increases (65.9%); smokefree air laws (31.8%); and mass media/educational policies (18.2%). Relative to the status quo in 2020, the model projects that smoking prevalence is reduced by 14.3% through a nationwide tax increase of $2.00, by 7.2% through smokefree laws, by 4.7% through mass media/educational policies, and by 16.5% through cessation treatment policies alone. Implementing all of the above policies at the same time would increase the quit rate by 296%, such that the HP2010 smoking prevalence goal of 12% is reached by 2013. Conclusions: The impact of a combination of policies led to some surprisingly positive possible futures in lowering smoking prevalence to 12% within just several years. Simulation models can be a useful tool for evaluating complex scenarios in which policies are implemented simultaneously, and for which there are limited data.

Alcohol consumption before and after a significant reduction of alcohol prices in 2004 in Finland: were the effects different across population subgroups?

Helakorpi S; Makela P; Uutela A. Alcohol and Alcoholism 45(3): 286-292, 2010. (17 refs.) Aims: To examine trends in adult alcohol consumption by age, gender and education from 1982 to 2008 and evaluate the effects that a significant reduction in alcohol prices in 2004 had on alcohol consumption in different population subgroups. Methods: The study population comprised respondents aged 25-64 (n = 79,100) replying to nationally representative annual postal surveys from 1982 to 2008 (average response rate 72%). The main measurements were the prevalence of respondents who had drunk at least eight (men) or five (women) drinks in the previous week ('moderate to heavy drinkers') and prevalence of those who weekly (men) or monthly (women) drank six or more drinks on a single occasion ('heavy episodic drinkers') (one 'drink' containing 11-13 g ethanol). Logistic models were used to test differences across population subgroups in the changes in drinking. Results: Following the reduction of alcohol prices in 2004, drinking increased among men and women aged 45-64. Among men, both moderate to heavy drinking and heavy episodic drinking increased in the lowest educational group. Among women, moderate to heavy drinking increased mostly in the lowest and intermediate educational groups, while the highest increases for heavy episodic drinking were in the intermediate and highest female educational groups. Conclusion: Alcohol consumption increased especially among those aged 45-64 and among lower educated people following the reduction in alcohol prices in 2004 in Finland.

Alcohol: No Ordinary Commodity: A summary of the second edition.

Babor TF; Caetano R; Casswell S; Edwards G; Giesbrecht N; Graham K et al. Addiction 105(5): 769-779, 2010. (64 refs.) This article summarizes the contents of "Alcohol: No Ordinary Commodity" (2nd edn). The first part of the book describes why alcohol is not an ordinary commodity, and reviews epidemiological data that establish alcohol as a major contributor to the global burden of disease, disability and death in high-, middle- and low-income countries. This section also documents how international beer and spirits production has been consolidated recently by a small number of global corporations that are expanding their operations in Eastern Europe, Asia, Africa and Latin America. In the second part of the book, the scientific evidence for strategies and interventions that can prevent or minimize alcohol-related harm is reviewed critically in seven key areas: pricing and taxation, regulating the physical availability of alcohol, modifying the drinking context, drink-driving countermeasures, restrictions on marketing, education and persuasion strategies, and treatment and early intervention services. Finally, the book addresses the policy-making process at the local, national and international levels and provides ratings of the effectiveness of strategies and interventions from a public health perspective. Overall, the strongest, most cost-effective strategies include taxation that increases prices, restrictions on the physical availability of alcohol, drink-driving countermeasures, brief interventions with at risk drinkers and treatment of drinkers with alcohol dependence.

Contemplaing cognitive enhancement in medical students and residents.

Webb JR; Thomas JW; Valasek MA. Perspectives in Biology and Medicine 2(200-214), 2010. (76 refs.) Medical school and residency can be stressful times, involving years of intensive academic study and pressure to earn high grades. Students and residents must learn to care for the sick, a task requiring long work hours and sleep deprivation. In such an environment, it is important to monitor the mental health of trainees and the factors that influence it. This essay examines a relatively unexplored facet of physician mental health: the use of pharmacological stimulants by students and residents to study better, earn higher grades, stay awake longer, and take better care of patients. Practical and ethical considerations of stimulant use in the medical profession, along with future directions for medical student mental health, are discussed.

Disparities in access to substance abuse treatment among people with intellectual disabilities and serious mental illness.

layter EM. Health & Social Work 35(1): 49-59, 2010. (60 refs.) People with intellectual disabilities (ID) have experienced increasing levels of community participation since deinstitutionalization. This freedom has facilitated community inclusion, access to alcohol and drugs, and the potential for developing substance abuse (SA) disorders. People with ID, who are known to have high rates of co-occurring serious mental illness (SMI), may be especially vulnerable to the consequences of this disease and less likely to use SA treatment. Using standardized performance measures for SA treatment access (initiation, engagement), rates were examined retrospectively for Medicaid beneficiaries with ID/SA/SMI ages 12 to 99 (N = 5,099) and their counterparts with no ID/SA/SMI (N = 221,875). Guided by the sociobehavioral model of health care utilization, age-adjusted odds ratios and logistic regression models were conducted. People with ID/SA/SMI were less likely than their counterparts to access treatment. Factors associated with initiation included being nonwhite, living in a rural area, and not being dually eligible for Medicare; factors associated with engagement included all of the same and having a fee-for-service plan, a chronic SA-related disorder, or both. Social work policy and practice implications for improving the health of people with ID/SA/SMI through policy change, cross-system collaboration, and the use of integrated treatment approaches are discussed.

'Does anyone know where to get fits from around here?' Policy implications for the provision of sterile injecting equipment through pharmacies in Sydney, Australia.

Treloar C; Hopwood M; Bryant J. Drugs: Education, Prevention, and Policy 17(1): 72-83, 2010. (28 refs.) Method: In-depth interviews were conducted with 15 IDUs about their experiences of accessing injecting equipment from pharmacies that participated in the government-sponsored pharmacy needle and syringe scheme. Results: A range of factors influenced participants' decisions about equipment access. The advantages of the pharmacy scheme access included convenience, relative anonymity, increased positive feelings of self-worth when accessing equipment from pharmacies where they had a good relationship with staff, less police surveillance and access to a greater range of equipment than available in publicly funded Needle and Syringe Programmes. The disadvantages of pharmacy access included the cost of equipment and complications related to methadone dosing and equipment access. Conclusion: Pharmacy access to injecting equipment is highly valued by IDUs. The results of this study direct attention to several elements of programme and policy in the area that would increase access to equipment from pharmacies relating to cost, need for exchange, police surveillance practices, out-of-hours access and anonymity.

Empirical view of opioid dependence.

Ruetsch C. Journal of Managed Care Pharmacy 16(1, Supplement B): s9-s13, 2010. (28 refs.) BACKGROUND: The impact of opioid dependence on employers, managed care, and society is significant. Inappropriate use of narcotic analgesics leads to uncontrolled pain management, dependence, and may lead to patient deaths, creating a tremendous cost burden to the health care system. OBJECTIVE: To provide an overview of the clinical and economic impact of treating opioid dependence on managed care, employers, and society. SUMMARY: An estimated 6% to 15% of people in the United States abuse drugs, and approximately 20% of Americans report using prescription opioids for nonmedical use. This is associated with an annual cost of nearly half a trillion dollars, taking into account the medical, economic, social, and criminal impact of this abuse. A recent study showed that patients who abuse opioids generate mean annual direct health care costs 8.7 times higher than nonabusers. The National Survey on Drug Use and Health (NSDUH), conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), found that patients who report opioid abuse miss more than 2.2 days of work monthly, compared with the 0.83 days per month reported for the average person. Presenteeism and productivity are also affected by misuse and dependence on opioids. CONCLUSION: The costs associated with opioid dependence are significant. Physicians, employers, and managed care organizations must be proactive in appropriately diagnosing and treating patients who suffer from substance abuse disorders in order to lessen this economic burden.

Hair analysis for drugs in driver's license regranting. A Swedish pilot study.

Kronstrand R; Nystrom I; Forsman M; Kall K. Forensic Science International 196(1-3): 55-58, 2010. (21 refs.) When being convicted for petty drug offence or driving under the influence of drugs in Sweden, the driving license may be suspended. To regain the license, the person has to prove that he or she has been drug free during an observation period. This is controlled by urine samples taken at several occasions. However, the risk of manipulation and the risk of false negative urine samples are high. In addition, many people find it difficult or embarrassing to urinate when observed. Hair sampling might therefore be a welcome option to this procedure, with its easy sampling and minimal risk of manipulation. The longer detection window may also provide better information to the physician. The aim of this work was to evaluate if clients preferred hair samples to urine and to investigate practical and interpretive problems or advantages with hair samples. Ninety-nine hair samples and 198 urine samples were collected from 84 clients during the 12 month study period. Hair samples were divided into either one segment (0-3 cm) or two segments (0-3 and 3-6 cm) depending on the length. The hair samples were screened with LC-MS-MS for 20 drugs and confirmation of positive results were performed with GC-MS or LC-MS-MS. The results were compared to urine samples taken at two occasions during the observation period. To cover the timeframe of the urine samples hair was collected 2 weeks after the second sample. The urine samples were analysed with immunochemical screening and positive results confirmed with GC-MS or LC-MS-MS. Seventy-four clients presented with negative results in both urine and hair. Hair analysis identified illegal drugs at seven different occasions whereas urine failed to identify any illegal drugs. However the thresholds used may still be too high to find sporadic use as clients that admitted to use drugs sporadically presented with drug concentrations lower than the agreed thresholds but above the limit of detection. This implicates that the physician must have an understanding and knowledge of the limitations of the screening methods used. Another important outcome was that the clients approved of hair sampling considering it a better means to prove their drug abstinence. In addition, both the clients and the clinicians thought hair sampling easier than urine sampling. We believe that hair analysis can offer several advantages compared to urine analysis for clinicians working with driving license regranting.

Increased cannabinoids concentrations found in specimens from fatal aviation accidents between 1997 and 2006.

Canfield DV; Dubowski KM; Whinnery JE; Lewis RJ; Ritter RM; Rogers PB. Forensic Science International 197(1-3): 85-88, 2010. (24 refs.) The National Institute on Drug Abuse (NIDA) and the Office of National Drug Control Policy (ONDCP) reported a 1.5-fold increase in the delta-9-tetrahydrocannabinol (THC) content of street cannabis seizures from 1997 to 2001 versus 2002 to 2006. This study was conducted to compare the changes, over those years, in blood and urine cannabinoid concentrations with the potency of THC reported in the cannabis plant. Cannabinoids were screened using radioimmunoassay (RIA) for blood and fluorescence polarization immunoassay (FPIA) for urine and confirmed using GC/MS. A total of 95 individuals were found to be using cannabis from a total number of 2769 (3.4%) individuals tested over the period 1997 through 2006. Other impairing drugs were found in 38% of the cannabinoids-positive individuals. The mean concentration of THC in blood for 1997-2001 was 2.7 ng/mL; for 2002-2006, it was 7.2 ng/mL, a 2.7-fold increase in the mean THC concentration of specimens from aviation fatalities, compared to a 1.5-fold increase in cannabis potency reported by the NIDA and ONDCP. The mean age for cannabis users was 40 years (range 18-72) for aviation fatalities. For all blood and urine specimens testing negative for cannabinoids from aviation fatalities, the mean age of the individuals was 50 years (range 14-92). More than half of the fatalities tested were 50 years or older, whereas, 80% of the positive cannabis users were under 50. As indicated by these findings, members of the transportation industry, government regulators, and the general public should be made aware of the increased potential for impairment from the use of high-potency cannabis currently available and being used.

Khat in Colonial Kenya: A history of prohibition and control.

Anderson D; Carrier N. Journal of African History 50(3): 377-397, 2009. (50 refs.) Efforts to institute a system for the control and prohibition of khat in Kenya are examined in this article. Prohibition was introduced in the 1940s after an advocacy campaign led by prominent colonial officials. The legs legislation imposed a racialized view of the effect of khat, seeking to protect an allegedly 'vulnerable' community in the north of the country while allowing khat to be consumed and traded in other areas, Including Meru where 'traditional' production and consumption was permitted. Colonial policy took little account of African opinion, although African agency was evident in the failure and ultimate collapse of the prohibition in the face of Wwdespread smuggling and general infringement. Trade in khat became ever more lucrative, and in the final years of colonial rule economic arguments overcame the prohibition lobby. The imposition of prohibition and control indicates the extent to which colonial attitudes towards and beliefs about cultural behaviour among Africans shaped policies, but the story also illustrates the fundamental weakness of the colonial state in its failure to uphold the legislation.

Liberty lost: The moral case for marijuana law reform.

Blumenson E; Nilsen E. Indiana Law Journal 85(1): 279-299, 2010. (115 refs.) Marijuana policy analyses typically focus on the relative costs and benefits of present policy and its feasible alternatives. This Essay addresses a prior, threshold issue: whether marijuana criminal laws abridge fundamental individual rights, and if so, whether there are grounds that justify doing so. Over 700, 000 people are arrested annually for simple marijuana possession, a small but significant proportion of the 100 million Americans who have committed the same crime. In this Essay, we present a civil libertarian case for repealing marijuana possession laws. We put forward two arguments corresponding to the two distinct liberty concerns implicated by laws that both ban marijuana use and punish its users. The first argument opposes criminalization and demonstrates that marijuana use does not constitute the kind of wrongful conduct that is a prerequisite for just punishment. The second argument demonstrates that even in the absence of criminal penalties, prohibition of marijuana use violates a moral right to exercise autonomy in personal matters-a corollary to John Stuart Mill's harm principle in the utilitarian tradition, or, in the nonconsequentialist tradition, to the respect for personhood that was well described by the Supreme Court in its Lawrence v. Texas opinion. Both arguments are based on principles of justice that are uncontroversial in other contexts.

Mock jurors' perceptions of identifications made by intoxicated eyewitnesses.

Evans JR; Compo NS. Psychology, Crime & Law 16(3): 191-210, 2010. (83 refs.) Psychology research has generally neglected intoxicated eyewitnesses. The current study addressed this need by exploring mock jurors' perceptions of intoxicated witnesses. Undergraduate participants read summarized sexual or aggravated battery cases in which either the victim or a bystander identified the defendant under varying intoxication levels. They answered questions about the case and provided verdicts. Participants were sensitive to the effect that intoxication may have on witnesses' cognitive ability, but not to varying degrees of intoxication. Neither the role of the eyewitness nor the type of crime committed had an effect on perceptions of witness impairment. Participants' perceptions of witness impairment informed identification credibility ratings, and credibility assessments affected verdicts. Impairment and credibility ratings fully mediated intoxication's effect on verdicts. Unlike much prior research, our results suggest that mock jurors can consider potentially important witness information when rendering verdicts.

Moving empirically supported practices to addiction treatment programs: Recruiting supervisors to help in technology transfer.

Amodeo M; Storti SA; Larson MJ. Substance Use & Misuse 45(6): 968-982, 2009. (33 refs.) Federal and state funding agencies are encouraging or mandating the use of empirically supported treatments in addiction programs, yet many programs have not moved in this direction (Forman, Bovasso, and Woody, 2001; Roman and Johnson, 2002; Willenbring et al., 2004). To improve the skills of counselors in community addiction programs, the authors developed an innovative Web-based course on Cognitive Behavioral Therapy (CBT), a widely accepted empirically-supported practice (ESP) for addiction. Federal funding supports this Web course and a randomized controlled trial to evaluate its effectiveness. Since supervisors often play a pivotal role in helping clinicians transfer learned skills from training courses to the workplace, the authors recruited supervisor-counselor teams, engaging 54 supervisors and 120 counselors. Lessons learned focus on supervisor recruitment and involvement, supervisors' perceptions of CBT, their own CBT skills and their roles in the study, and implications for technology transfer for the addiction field as a whole. Recruiting supervisors proved difficult because programs lacked clinical supervisors. Recruiting counselors was also difficult because programs were concerned about loss of third-party reimbursement. Across the addiction field, technology transfer will be severely hampered unless such infrastructure problems can be solved. Areas for further investigation are identified.

No Train, No Gain? (editorial).

Carroll KM; Martino S; Rounsaville BJ. Clinical Psychology: Science and Practice 17(1): 36-40, 2010. (20 refs.) What kind of training is needed for what type of clinician to deliver what type of therapy? Beidas and Kendall's (2010) well-considered recommendations for further research into systematic strategies for training clinicians to utilize evidence-based treatments highlight the limitations of didactic training alone (without supervision, fidelity monitoring, and feedback) in conferring specific skills to clinicians. To further amplify some of the points made, we summarize findings from our recent series of trials, which involved training community-based addiction clinicians to perform evidence-based therapies in a multisite randomized clinical trial. In particular, review of tapes from the "treatment as usual" condition in that study suggests that (a) delivery of interventions associated with evidence-based treatment was infrequent, (b) clinicians overestimated the time spent on evidence-based interventions, and (c) ongoing supervision and performance-based feedback appear to suppress time spent in session on discourse unrelated to the patient's problems and concerns. We also discuss computer-assisted treatment and computer-assisted clinician training as important new tools for disseminating evidence-based therapies.

Opioid prescription underfilling among retail pharmacies.

Reisfield G; Paulian G; Merlo L; Bertholf R; Wilson G. Pain Medicine 11(4): 586-590, 2010. (12 refs.) Introduction. Prescription opioid abuse is a major public health problem in the United States. Physicians who prescribe opioid analgesics are sometimes confronted with patients who request early refills, claiming that they have been "shorted" by their pharmacy. While a substantial differential diagnosis exists for apparent opioid overuse, the underfilling of opioid prescriptions at the level of retail pharmacies has not yet been systematically investigated. Objective. The goals of the present study were to: 1) determine the incidence and magnitude of opioid prescription underfilling among retail pharmacies in Northeast Florida and 2) to compare the rates of under- and overfilling with noncontrolled substance prescription controls. Design. Patients receiving opioid prescriptions were recruited for this study during routine primary care office visits. These patients, blinded to the study goals, filled their prescriptions, and returned to the clinic with unopened medication bag(s) for dosage unit counts. Results. One hundred and twenty-one patients filled 134 opioid prescriptions from 103 unique pharmacies. Dosage unit counts revealed three slight opioid prescription underfills (1-3 dosage units) and three slight opioid prescription overfills (1-3 dosage units). We found no statistically significant differences between opioids and noncontrolled substance controls with regard to prescription underfills. Conclusions. There was no evidence supporting patients' claims of significant opioid analgesic underfilling by retail pharmacies. Patients who repeatedly report medication shortages should be evaluated for opioid use disorders.

Should anesthesia residents with a history of substance abuse be allowed to continue training in clinical anesthesia? The results of a survey of anesthesia residency program directors.

Bryson EO. Journal of Clinical Anesthesia 21(7): 508-513, 2009. (11 refs.) Study Objective: To determine the experience, attitudes, and opinions of program directors regarding the reintroduction of residents in recovery from substance abuse into the clinical practice of anesthesiology. Design: Survey instrument. Setting: Anesthesia residency training programs in the United States. Measurements: After obtaining institutional review board approval, a list of current academic anesthesia residency programs in the United States was compiled. A survey was mailed to 131 program directors along with a self-addressed stamped return envelope to ensure anonymity. Returned surveys were reviewed and data compiled by hand, with categorical variables described as frequency and percentages. Main Results: A total of 91 (69%) surveys were returned, representing experience with 11,293 residents over the ten-year period from July of 1997 through June of 2007. Fifty-six (62%) program directors reported experience with at least one resident requiring treatment for substance abuse. For residents allowed to continue with anesthesia residency training after treatment, the relapse rate was 29%. For those residents, death was the initial presentation of relapse in 10% of the reported cases. 43% of the program directors surveyed believe residents in recovery from addiction should be allowed to attempt re-entry while 30% believe that residents in recovery from addiction should not. Conclusions: The practice of allowing residents who have undergone treatment for substance abuse to return to their training program in clinical anesthesia remains highly controversial. They are often lost to follow-up, making it difficult, if not impossible to determine if re-training in a different medical specialty decreases their risk for relapse. A comprehensive assessment of the outcomes associated with alternatives to re-entry into clinical anesthesia training programs is needed.

The Hippocratic Bargain and Health Information Technology.

Rothstein MA. Journal of Law, Medicine & Ethics 38(1): 7-13, 2010. (21 refs.) The shift to longitudinal, comprehensive electronic health records (EHRs) means that any health care provider (e.g., dentist, pharmacist, physical therapist) or third-party user of the EHR (e.g., employer, life insurer) will be able to access much health information of questionable clinical utility and possibly of great sensitivity. Genetic test results, reproductive health, mental health, substance abuse, and domestic violence are examples of sensitive information that many patients would not want routinely available. The likely policy response is to give patients the ability to segment information in their EHRs and to sequester certain types of sensitive information, thereby limiting routine access to the totality of a patient's health record. This article explores the likely effect on the physician-patient relationship of patient-directed sequestration of sensitive health information, including the ethical and legal consequences.