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...on Policy Issues
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www.ProjectCork.org
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Summer 2012
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What public health strategies are needed to reduce smoking initiation?
Pierce JP; White VM; Emery SL. Tobacco Control 21(2): 258-264, 2012. (80 refs.)
Smoking initiation is a key behaviour that determines the future health consequences of smoking in a society. There is a marked difference in smoking patterns around the world, driven by initiation rates. While a number of high-income countries have seen smoking prevalence decline markedly from peak, many low-income and middle-income countries appear to still be on an upward trend. Unlike cessation where changes are limited by nicotine dependence, rates of smoking initiation can change rapidly over a short time span. Interventions that can be effective in achieving this include increases in the price of tobacco products, mass media anti-smoking advertising, smoke-free policies, smoking curricula in schools, restrictions on marketing opportunities for the tobacco industry as well as social norms that lead to restrictions on adolescents' ability to purchase cigarettes. Comprehensive tobacco control programmes that aim to denormalise smoking behaviour in the community contain all of these interventions. Rapid reductions in smoking initiation in adolescents have been documented in two case studies of comprehensive tobacco control programmes in California and Australia. Consistent and inescapable messages from multiple sources appear to be key to success. However, the California experience indicates that the rapid decline in adolescent smoking will not continue if tobacco control expenditures and the relative price of cigarettes are reduced. These case studies provide strong additional evidence of the importance of countries implementing the provisions of the Framework Treaty on Tobacco Control. Copyright 2012, BMJ Publishing.
Do medical marijuana laws increase marijuana use? Replication study and extension.
Harper S; Strumpf EC; Kaufman JS. Annals of Epidemiology 22(3): 207-212, 2012. (17 refs.)
PURPOSE: To replicate a prior study that found greater adolescent marijuana use in states that have passed medical marijuana laws (MMLs), and extend this analysis by accounting for confounding by unmeasured state characteristics and measurement error. METHODS: We obtained state-level estimates of marijuana use from the 2002 through 2009 National Survey on Drug Use and Health. We used 2-sample t-tests and random-effects regression to replicate previous results. We used difference-in-differences regression models to estimate the causal effect of MMLs on marijuana use, and simulations to account for measurement error. RESULTS: We replicated previously published results showing higher marijuana use in states with MMLs. Difference-in-differences estimates suggested that passing MMLs decreased past-month use among adolescents by 0.53 percentage points (95% confidence interval [CI], 0.03-1.02) and had no discernible effect on the perceived riskiness of monthly use. Models incorporating measurement error in the state estimates of marijuana use yielded little evidence that passing MMLs affects marijuana use. CONCLUSIONS: Accounting for confounding by unmeasured state characteristics and measurement error had an important effect on estimates of the impact of MMLs on marijuana use. We find limited evidence of causal effects of MMLs on measures of reported marijuana use. Copyright 2012, Elsevier Science.
Acute care hospital utilization among medical inpatients discharged with a substance use disorder diagnosis.
Walley AY; Paasche-Orlow M; Lee EC; Forsythe S; Chetty VK; Mitchell S et al. Journal of Addiction Medicine 6(1): 50-56, 2012. (65 refs.)
Objective: Hospital discharge may be an opportunity to intervene among patients with substance use disorders to reduce subsequent hospital utilization. This study determined whether having a substance use disorder diagnosis was associated with subsequent acute care hospital utilization. Methods: We conducted an observational cohort study among 738 patients on a general medical service at an urban, academic, safety-net hospital. The main outcomes were rate and risk of acute care hospital utilization (emergency department visit or hospitalization) within 30 days of discharge. The main independent variable was presence of a substance use disorder primary or secondary discharge diagnosis code at the index hospitalization. Results: At discharge, 17% of subjects had a substance use disorder diagnosis. These patients had higher rates of recurrent acute care hospital utilization than patients without substance use disorder diagnoses (0.63 vs 0.32 events per subject at 30 days, P < 0.01) and increased risk of any recurrent acute care hospital utilization (33% vs 22% at 30 days, P < 0.05). In adjusted Poisson regression models, the incident rate ratio at 30 days was 1.49 (95% confidence interval, 1.12-1.98) for patients with substance use disorder diagnoses compared with those without. In subgroup analyses, higher utilization was attributable to those with drug diagnoses or a combination of drug and alcohol diagnoses, but not to those with exclusively alcohol diagnoses. Conclusions: Medical patients with substance use disorder diagnoses, specifically those with drug use-related diagnoses, have higher rates of recurrent acute care hospital utilization than those without substance use disorder diagnoses. Copyright 2012, Lippinocott, Williams & Wilkins.
Type of health insurance and the substance abuse treatment gap.
Bouchery EE; Harwood HJ; Dilonardo J; Vandivort-Warren R. Journal of Substance Abuse Treatment 42(3): 289-300, 2012. (53 refs.)
Objective: Most individuals reporting symptoms consistent with substance use disorders do not receive care. This study examines the correlation between type of insurance coverage and receipt of substance abuse treatment, controlling for other observable factors that may influence treatment receipt. Method: Descriptive and multivariate analyses are conducted using pooled observations from the 2002-2007 editions of the National Survey on Drug Use and Health. The likelihood of treatment entry is estimated by type of insurance coverage controlling for personal characteristics and characteristics of the individual's substance use disorder. Results: Multivariate analyses that control for type of substance and severity of disorder (dependence vs. abuse) find that those with Civilian Health and Medical Program of the Uniformed Services/Veterans Affairs, Medicaid only, Medicare only, and Medicare and Medicaid (dual eligibles) have 50% to almost 90% greater odds of receiving treatment relative to those with private insurance. Conclusions: The privately insured population has substantially lower treatment entry rates than those with publicly provided insurance. Additional research is warranted to understand the source of the differences across insurance types so that improvements can be achieved. Copyright 2012, Elsevier Science.
Adding positive reinforcement in justice settings: Acceptability and feasibility.
Rudes DS; Taxman FS; Portillo S; Murphy A; Rhodes A; Stitzer M et al. Journal of Substance Abuse Treatment 42(3): 260-270, 2012. (44 refs.)
Although contingency management (CM) approaches are among the most promising methods for initiating drug abstinence, adoption and implementation of CM protocols into treatment programs are both challenging and infrequent. In criminal justice agencies, where roughly 70% of clients report substance abuse issues, CM interventions are virtually nonexistent. The Justice Steps (JSTEPS) study uses a longitudinal, mixed-method design to examine the implementation of a CM-based protocol in five justice settings. This article presents qualitative data collected during Phase I of the JSTEPS project regarding the acceptability and feasibility of CM in these justice settings. The study finds a level of acceptability (find CM tolerable) and feasibility (find CM suitable) within justice agencies, but with some challenges. These challenges are reflected in the following: (a) incorporating too many desired target behaviors into CM models; (b) facing intraorganizational challenges when designing CM systems; and (c) emphasizing sanctions over rewards despite the evidence-base for positive reinforcers. These findings have implications for advancing the dissemination, adoption, and implementation of evidence-based treatments (and CM in particular) in criminal justice settings. Copyright 2012, Elsevier Science.
Bending the prescription opioid dosing and mortality curves: Impact of the Washington State opioid dosing guideline.
Franklin GM; Mai J; Turner J; Sullivan M; Wickizer T; Fulton-Kehoe D. American Journal of Industrial Medicine 55(4): 325-331, 2012. (29 refs.)
Background Opioid use and dosing for patients with chronic non-cancer pain have dramatically increased over the past decade, resulting in a national epidemic of mortality associated with unintentional overdose, and increased risk of disability among injured workers. We assessed changes in opioid dosing patterns and opioid-related mortality in the Washington State (WA) workers' compensation system following implementation of a specific WA opioid dosing guideline in April, 2007. Methods Using detailed computerized billing data from WA workers' compensation, we report overall prevalence of opioid prescriptions, average morphine-equivalent dose (MED)/day, and proportion of workers on disability compensation receiving opioids and high-dose (>= 120 mg/day MED) opioids over the past decade. We also report the trend of unintentional opioid deaths during the same time period. Results Compared to before 2007, there has been a substantial decline in both the MED/day of long-acting DEA Schedule II opioids (by 27%) and the proportion of workers on doses >= 120 md/day MED (by 35%). There was a 50% decrease from 2009 to 2010 in the number of deaths. Conclusions The introduction in WA of an opioid dosing guideline appears to be associated temporally with a decline in the mean dose for long-acting opioids, percent of claimants receiving opioid doses >= 120 mg MED per day, and number of opioidrelated deaths among injured workers. Copyright 2012, Wiley-Blackwell.
Cocaine's long march north, 1900-2010.
Gootenberg P. Latin American Politics and Society 54(1): 159-180, 2012. (34 refs.)
This essay charts the entanglements and blowback effects of U.S. policy toward Latin American drug exports over the last century as the backdrop to today's cascading drug violence in northern Mexico. The history of cocaine reveals a series of major geopolitical shifts (closely related to U.S. interdictionist drug war policies) that bring drug commodity chains, illicit trafficking centers, and conflicts, over the long run, closer to the United States. It analyzes shifts from initial legal cocaine and small-time postwar smuggling of the central Andes to the concentrating 1970s - 1990s cartel epicenter in northern Andean Colombia, to the 1990s political shift north to Mexican transhipment and organizational leadership. Violence around cocaine has intensified at every step, and the present conflict portends another shift in the chain. Copyright 2012, Wiley-Blackwell.
Dangerous drugs online.
Davies B. Australian Prescriber 35(1): 32-33, 2012. (5 refs.)
The risks associated with self-medication have been amplified by the ability to order prescription, non-prescription and complementary medicines online. Products bought over the internet may be counterfeits or contain undeclared ingredients. Undeclared pharmaceuticals are increasingly being found in complementary medicines. Marketing of medicines on the internet has not been limited to therapeutic drugs. There is a growing variety of new recreational or 'designer' drugs. Without effective methods for detecting emerging drugs and with limited knowledge of their effects on users, online ordering presents a new challenge to public health. Copyright 2012, National Prescribing Service.
Does minimum pricing reduce alcohol consumption? The experience of a Canadian province.
Stockwell T; Auld MC; Zhao JH; Martin G. Addiction 107(5): 912-920, 2012. (28 refs.)
Aims: Minimum alcohol prices in British Columbia have been adjusted intermittently over the past 20 years. The present study estimates impacts of these adjustments on alcohol consumption. Design: Time-series and longitudinal models of aggregate alcohol consumption with price and other economic data as independent variables. Setting British Columbia (BC), Canada. Participants: The population of British Columbia, Canada, aged 15 years and over. Measurements Data on alcohol prices and sales for different beverages were provided by the BC Liquor Distribution Branch for 1989-2010. Data on household income were sourced from Statistics Canada. Findings: Longitudinal estimates suggest that a 10% increase in the minimum price of an alcoholic beverage reduced its consumption relative to other beverages by 16.1% (P < 0.001). Time-series estimates indicate that a 10% increase in minimum prices reduced consumption of spirits and liqueurs by 6.8% (P = 0.004), wine by 8.9% (P = 0.033), alcoholic sodas and ciders by 13.9% (P = 0.067), beer by 1.5% (P = 0.043) and all alcoholic drinks by 3.4% (P = 0.007). Conclusions: Increases in minimum prices of alcoholic beverages can substantially reduce alcohol consumption. Copyright 2012, Wiley-Blackwell.
Effects of alcohol retail privatization on excessive alcohol consumption and related harms: A community guide systematic review.
Hahn RA; Middleton JC; Elder R; Brewer R; Fielding J; Naimi TS et al. American Journal of Preventive Medicine 42(4): 418-427, 2012. (55 refs.)
Context: Excessive alcohol consumption is the third-leading cause of preventable death in the U.S. This systematic review is one in a series exploring effectiveness of interventions to reduce alcohol-related harms. Evidence acquisition: The focus of this review was on studies evaluating the effects of the privatization of alcohol retail sales on excessive alcohol consumption and related harms. Using Community Guide methods for conducting systematic reviews, a systematic search was conducted in multiple databases up to December 2010. Reference lists of acquired articles and review papers were also scanned for additional studies. Evidence synthesis: A total of 17 studies assessed the impact of privatizing retail alcohol sales on the per capita alcohol consumption, a well-established proxy for excessive alcohol consumption; 9 of these studies also examined the effects of privatization on the per capita consumption of alcoholic beverages that were not privatized. One cohort study in Finland assessed the impact of privatizing the sales of medium-strength beer (MSB) on self-reported alcohol consumption. One study in Sweden assessed the impact of re-monopolizing the sale of MSB on alcohol-related harms. Across the 17 studies, there was a 44.4% median increase in the per capita sales of privatized beverages in locations that privatized retail alcohol sales (interquartile interval: 4.5% to 122.5%). During the same time period, sales of nonprivatized alcoholic beverages decreased by a median of 2.2% (interquartile interval: -6.6% to -0.1%). Privatizing the sale of MSB in Finland was associated with a mean increase in alcohol consumption of 1.7 liters of pure alcohol per person per year. Re-monopolization of the sale of MSB in Sweden was associated with a general reduction in alcohol-related harms. Conclusions: According to Community Guide rules of evidence, there is strong evidence that privatization of retail alcohol sales leads to increases in excessive alcohol consumption. Copyright 2012, Elsevier Science.
Mental health spending by private insurance: Implications for the Mental Health Parity and Addiction Equity Act.
Mark TL; Vandivort-Warren R; Miller K. Psychiatric Services 63(4): 313-318, 2012. (12 refs.)
Objective: The study developed information on behavioral health spending and utilization that can be used to anticipate, evaluate, and interpret changes in health care spending following implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA). Methods: Data were from the Thomson Reuters' Market Scan database of insurance claims between 2001 and 2009 from large group health plans sponsored by self-insured employers. Annual rates in growth of total health spending and behavioral health spending and the contribution of behavioral health spending; to growth in spending for all diseases were determined. Separate analyses examined behavioral health and total health spending by 135 employers in 2008 and 2009, and simulations were conducted to determine how increases in use of mental health services after implementation of parity would affect overall health care expenditures. Results: Across the nine years examined, behavioral health expenditures contributed .3%, on average, to the total rate of growth in all health expenditures, a contribution that fell to .1%, on average, when prescription drugs were excluded. About 2% of employers experienced an increased contribution by behavioral health spending of more than 1%. More than 90% of enrollees used well below the maximum 30 inpatient days or outpatient visits typical of health insurance plans before parity. Simulations indicated that even large increases in utilization would increase total health care expenditures by less than 1%. Conclusions: The MHPAEA is unlikely to have a large effect on the growth rate of employers' health care expenditures. The data provide baseline information to further evaluate the implementation effect of the MHPAEA. Copyright 2012, American Psychiatric Association.
Paying substance abusers in research studies: Where does the money go?
Festinger DS; Dugosh KL. American Journal of Drug and Alcohol Abuse 38(1): 43-48, 2012. (37 refs.)
Background: Research involving substance-abusing participants is often hindered by low rates of recruitment and retention. Research suggests that monetary payment or remuneration can be an effective strategy to overcome these obstacles. Objectives: This article provides a brief overview of these issues and provides data reflecting how substance-abusing participants in several of our studies used their baseline and follow-up payments. We also present research findings related to how the mode of payment (i.e., cash, check, gift card) may affect how payments are used. Conclusions and Significance: Overall, our findings suggest that participants use their research payments in a responsible and safe manner. Limitations and recommendations for future research are discussed. Copyright 2012, Informa HealthCare.
Reconciling the multiple objectives of prison diversion programs for drug offenders: Evidence from Kansas' Senate Bill 123.
Stemen D; Rengifo AF. Evaluation Review 35(6): 642-672, 2011. (40 refs.)
Background: In recent years, several states have created mandatory prison-diversion programs for felony drug possessors. These programs have both individual-level goals of reducing recidivism rates and system-level goals of reducing prison populations. Objective: This study examines the individual level and system level impact of Kansas' Senate Bill 123 (SB 123), which created mandatory probation/ treatment sentences for felony drug possessors. Reseaarch Design: A nonrandomized quasi-experimental design was used to evaluate the recidivism rates of drug possessors sentenced to SB 123 relative to drug possessors sentenced to standard probation, intensive probation, or prison. Propensity score matching techniques were used to identify comparison groups. Changes in probabilities of prison sentences preimplementation and postimplementation were used to assess changes in prison admissions and prison populations. Subjects: The treatment group included all eligible drug possessors sentenced to SB 123 between November 1, 2003, and October 31, 2006. The comparison groups included all eligible drug possessors sentenced to standard probation, intensive probation, or prison during the same time period. Measures: Arrests, violations, revocation resulting in a prison sentence, and reconviction resulting in a prison sentence within 24 months of risk in the community served as the key individual-level outcome measures. Prison admissions and bed days served as the key system-level outcome measures. Results: At the individual level, SB 123 increased likelihood of recidivism compared to standard probation and had no significant effect compared to intensive probation or prison. At the system level, SB 123 diverted offenders from prison at sentencing but only marginally reduced prison admissions or saved bed days. Conclusions: Conflicting impacts are a consequence of program design-eligibility requirements diverting probation-bound offenders, mandatory sentencing requiring the same diversion sentence for all offenders, and diversion sentences longer than those imposed preimplementation. Results cast doubt on the effectiveness of mandatory diversion programs to achieve both individual-level and system-level impacts. Copyright 2011, Sage Publications.
Requiring stabilized heroin addicts to stop successful agonist opioid treatment before liver transplantation can shift patients over a cross-acting (alcohol) substance abuse.
Piz L; Maremmani AGI; Rugani F; Pacini M; Rovai L; Dell'Osso L et al. Heroin Addiction and Related Clinical Problems 13(4): 35-38, 2011. (16 refs.)
Methadone Maintenance Treatment patients are significantly under-represented in most liver transplant programmes, but the number of patients receiving agonist opioid treatment (AOT) is increasing, and few data are available at the moment when patients are selected for surgery. We present a case in which an Italian patient affected by heroin dependence and successfully treated with AOT had to stop opioid medical treatment to be able to enter a liver transplantation programme. He successfully discontinued AOT, received a liver transplant and continued not to abstain from heroin in the post-transplant period. Unfortunately, he engaged in alcohol use, so shifting over into another cross-acting substance abuse disorder, and endangering his newly restored liver functions. He was a non-responder to alcohol abuse treatment and, while he was abstaining from alcohol, he reported a craving for heroin. We reintroduced opioid agonist treatment, so obtaining a non-relapsing condition regarding heroin and a significant patient recovery on alcohol abuse, with a complete liver function normalization. We suggest that successful agonist opioid treatment should be continued even when transplantation is needed, not only to avoid the risk of relapse into heroin use, but also to avoid the risk that the patient may shift over into another substance abuse disorder (in this case, alcoholism). The shift from heroin to alcohol also means the transition from a highly curable disease, as heroin addiction is, to one that is hard to cure, as alcoholism is, which implies a greater risk to endangering the new liver function with respect to the continuation of AOT. Copyright 2011, Pacini Editore.
The Alcohol Policy Information System (APIS) and policy research at NIAAA. (editorial).
Bloss G. Alcohol Research & Health 34(2): 246-247, 2011. (14 refs.)
The Alcohol Policy Information System (APIS) (http://alcoholpolicy.niaaa.nih.gov) was created by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) as a tool to facilitate research on the effects and effectiveness of alcohol-related public policies by providing authoritative, detailed, and comparable information on alcohol-related policies at the State and Federal levels in the United States. APIS data is based on primary legal research on the statutes and regulations through which policies are established. APIS provides detailed coverage for 35 specific policy topics organized in eight categories: 1) Underage Drinking (possession, consumption, purchase, sales, driving, false IDs); 2.) BAC (drivers, underage drivers, boaters); 3.) Transportation; 4.) Beverage Taxes; 5.) Retail Sales; 6.) Alcohol Control Systems; 7.) Pregnancy and Alcohol (warning signs during pregancy, criminal prosecution, treatment, child abuse and neglect; 8.) Health Care Services and Financing (insurance, losses attributed to intoxication, health insurance parity.) The coverage period for most topics begins January 1, 1998, and extends through January 1, 2010. Material is added quarterly. Public Domain.
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