"Addiction Policy Research Update" Newsletter - Spring 2009

Community-based substance abuse treatment for criminal offenders has been shown to reduce both substance use and recidivism. The availability of treatment for substance abuse in general is ensured through funding by the state’s Department of Corrections (DOC), all of which offer in-prison treatment, and some also pay for community-based treatment. But until now, DOC as both a purchaser and regulator of community-based services has been under-examined.  The majority of research on substance abuse treatment has focused on the difference between public and private treatment, rather than the impact of multiple publicly-funded systems.

A new study published in the November 2008 online edition of the Journal of Substance Abuse, and led by Sheryl Pimlott Kubiak, PhD, with the Michigan State University’s School of Social Work, looks at how many states have DOCs that are purchasing community-based substance abuse treatment. This is an important distinction, Kubiak says, because DOCs have different performance expectations for substance abuse treatment.

The study was funded by the Substance Abuse Research Policy Program (SAPRP) of the Robert Wood Johnson Foundation.

“For instance in one state,” notes Kubiak, “the DOC didn’t support any individual sessions or pharmacotherapy. So they’d pay for group therapy only.”

The Single State Authority (SSA) administers what is known as a publicly funded substance abuse system in which each state gets federal block grant money for substance abuse treatment for ‘funds of last resort,’ or to cover those people who otherwise couldn’t pay for treatment. Kubiak’s national survey of administrators from the Single State Authority (SSA) and DOC in each state found that, while all state DOCs offer in-prison substance abuse treatment, 35 state DOCs are also operating parallel publicly-funded substance abuse systems within a community.

Although both DOCs and SSAs had workforce and program requirements, there were differences within and between states. This report represents the first step in describing the availability, mechanisms and regulations of these two publicly-funded community-based treatment systems.

These findings are very important for the substance abuse treatment community, which is working to move to standards of best practice, and to incorporate a medical model for improving treatment.  However, if one mode of treatment is more public health-focused than public safety-focused, the philosophical differences may result in variations in practice.  The DOC’s emphasis on preventing recidivism, rather than on the recovery of the individual (which SSAs accentuate) can result in a different standard of care.

“In other words, if I know that the best intervention is methadone and psychosocial treatment, but a DOC regulation prohibits methadone, I might not be able to give a ‘best practice’ treatment,” says Kubiak. “Additionally, in the interest of public safety, a DOC may want someone to be in residential treatment because of their risk to the community, but that individual may not meet the criteria for that level of severity.”

The problem, Kubiak notes, is that there are two state level bureaucracies that have differing expectations – often resulting in different standards of care and levels of treatment - but that are relying on the same providers. There are numerous situations in which providers are trying to fulfill the dictates of two different institutions—illustrated by the difference in licensing and accreditation requirements that are mandated by the Single State Authority, but often not by the DOCs. 

 “Providers dance to whatever tune is paying the bills and they’re doing the best they can,” says Kubiak. “Our national goal is to enhance treatment efficacy, but from a policy standpoint, the funding source affects the standards of care. State and federal dollars support both public systems, but we have different sets of requirements for treatment in each.. Should the standards be uniform across the board? Do we know how the different standards effect outcomes?”

The authors also noted that DOC funding for substance abuse treatment is generally hidden money—that is, these monies aren’t factored in analyses of national substance abuse spending, and are typically unaccounted for in human service delivery data.
“Historically, the DOC has not really been part of this more human service delivery system so people aren’t thinking of them as contractors for services,” says Kubiak.

If you would like to speak with the researchers or obtain a copy of the article, please contact Carol Vieira at cvieira@burnesscommunications.com.

Methadone or Buprenorphine

What are the Costs?

There are now multiple options for treating heroin or other opioid dependence. Until recently, it hasn’t been clear which option costs less for treatment providers and patients.

A team of researchers led by David Fiellin with the Yale University School of Medicine analyzed treatment and patient costs (including cost of childcare and time spent getting back and forth from visits) over six months of maintenance in patients who had previously been stabilized with treatment for at least one year.

They studied the following options:  treatment with methadone in a addiction specialty clinic setting and in a physician office setting and treatment with buprenorphine, which can only be given in a physician office setting. 

They found that the cost of clinic-based methadone was the least expensive option for providers, while office treatment with either methadone or buprenorphine was less expensive for the patient.

Since buprenorphine and methadone maintenance have similar efficacy – and some studies show greater retention and less illicit drug use with methadone – it appears as though methadone maintenance is the most cost-effective way to treat opioid dependence, the authors say.

For patients, physician office-based treatment has certain advantages over clinic treatment. The same physicians who provide a patient’s substance abuse treatment can also treat a co-morbid condition like hepatitis or depression. And the relative privacy of an office-visit over a clinic visit is more likely to appeal to patients who are more socially stable (i.e. those who have jobs, a family, etc.)

“The good news for socially stable patients is that that office-based treatment for opioid addiction, including office-based methadone treatment, actually may be less expensive than methadone clinics,” notes Fiellin.

Fiellin points out that if only clinic-based treatment is available, many patients, will forgo treatment altogether if they don’t find it desirable.

“Because of potential stigma associated with methadone clinics, the best treatment system is one that allows both clinic-based and office-based treatments to be widely available and allows patients to make decisions based on their ability to pay. You end up saving money and treating more people by attracting patients to other options,” he says.

The cost to providers for one month of treatment per patient was:

$147 (Methadone Clinic)
$220 (Methadone Office)
$336 (Buprenorphine Office).

The mean monthly medication cost was:

$93 (Methadone Clinic),
$86 (Methadone Office)
$257 (Buprenorphine Office).

Meanwhile, the monthly costs to patients for these treatments were:

$92 (Methadone Clinic)
$63 (Methadone Office)
$38 (Buprenorphine Office).

The price of buprenorphine accounts for a major portion of the difference in costs.  The monthly cost for buprenorphine can be at least 10 times that for methadone. In fact, physicians who prescribe buprenorphine reported cost as a challenge, most frequently, when asked about challenges to treatment.

“The public should know that there is more than one effective treatment for opioid dependence and the new mechanisms for delivering these medications are using physicians’ offices. If they or someone they know is affected by this disorder there are now a greater variety of treatment options, and they may need to advocate for these treatment options,” says Fiellin.

If you would like to speak with the researchers or obtain a copy of the article, please contact Carol Vieira at cvieira@burnesscommunications.com.

New research examining drug prevention in U.S. schools since the federal No Child Left Behind (NCLB) legislation passed in 2001 shows that there is a disconnect between what NCLB requires and what is happening in schools.  The authors found that although NCLB explicitly mandates the use of evidence-based prevention programs, only a minority of school districts are complying.  Moreover, the majority of states and local districts give low priority to many of the federally authorized activities such as drug testing.

This is the first study to examine how schools have responded to federal Safe and Drug-Free Schools (SDFS) policy changes made under NCLB. These changes included authorizing new drug prevention activities like drug testing and locker searchers, but deleted DARE and before- and after-school programs from the list of authorized prevention activities. 

Using  2005 survey data from state education agencies (SEA) and a population-based sample of school districts, researchers found that only one third of U.S. public school districts rely on evidence-based prevention curriculum in middle schools even though 88% of US public school districts receive SDFS prevention funding. 

According to author Denise Hallfors, PhD, with the Pacific Institute for Research and Evaluation (PIRE), “funding appears to be the critical barrier to incorporating evidence-based drug prevention programs.”

Researchers found that districts with more than 20% of their prevention funding
from non- federal Safe and Drug-Free Schools sources were more likely to use an evidence-based curriculum than those without this supplemental funding.  Large school districts (those with more than 10,000 students) were more likely to use an evidence-based curriculum than smaller districts.

The study, “The influence of “No Child Left Behind” Legislation on Drug Prevention in U.S. Schools,” appears on May 8, 2009 in the online version of the journal Evaluation Review and was funded by the Substance Abuse Research Policy Program (SAPRP) of the Robert Wood Johnson Foundation.

The authors note that federal funding has steadily eroded since 2000, the year prior to the implementation of NCLB.  Thus, federal policy presents a contradictory message to states and districts by reducing SDFS funding while raising the bar for the quality of prevention programming.  Moreover, researchers found a lack of connection between high priority federal initiatives and the priority perceptions of policy targets (i.e., local school districts).  Policy evaluation is an essential tool in sorting out such conflicting goals and perceptions, and in finding a way forward in the political, as well as the policy making process.   

States and districts differed on the priority ranking of many of the SDFS prevention activities that the legislation authorizes for funding.  For example, states were much more likely to give high priority to professional development and training in violence and substance use prevention than local school districts (67% versus 22%, respectively).  On the other hand, more than 80% of both state and local SDFS respondents agreed that student drug testing was low or no priority as a drug prevention strategy.

The study also reports that about 70% of districts received SDFS funds but did not take advantage of NCLB’s flexibility provisions. That is – the ability to move funds from one program to another.  Of those that did, more districts transferred funds out of SDFS programming (16%) than into it (2%).  States endorsed more of the authorized prevention activities as high priority than did local school districts.

In addition to receiving smaller amounts of SDFS funds, small districts may opt to consolidate funds under the Small Rural Achievement Program, which allows them to combine funding from SDFS, innovative programs, and education technology to meet locally determined education needs. The authors suggest that this may further reduce their incentive for administering evidence-based drug prevention programs.

If you would like to speak with the researchers or obtain a copy of the article, please contact Carol Vieira at cvieira@burnesscommunications.com.

Underage Drinking Laws Reduce Fatal Accidents, Saving 732 Lives Per Year

165 More Could Be Saved if All States Adopted Use & Lose Laws

State laws that prohibit people under the age of 21 from purchasing or possessing alcohol, and from driving with any alcohol in their system save 732 lives a year in the United States, according to a study released today that has examined 23 years of research on the subject. The study further shows that if every state adopted ‘use and lose’ laws—suspending the license of anyone under 21 cited for possession, consumption or attempt to purchase alcohol—an additional 165 lives would be saved.

The study appeared in the April 7, 2009 online version of the journal Alcoholism: Clinical and Experimental Research (ACER). It was funded by the Substance Abuse Policy Research Program of the Robert Wood Johnson Foundation.

Researchers analyzed data from 1982 through to 2004, using the Alcohol Policy Information System (1998-2005); the Digests of State Alcohol-Highway Safety Related Legislation (1983-2006); the Westlaw database; and the Fatality Analysis Reporting System data set (1982-2004).  They looked at six key underage drinking laws and four general impaired-driving and traffic safety laws, and found the most significant impact came from four underage laws.

Three of the four more general laws that target all drivers also were effective in reducing drinking driver crash deaths for all ages, the study found. These included laws that make it illegal to drive with over .08 blood alcohol content (BAC); suspend a license for exceeding the .08 BAC while driving; and enable a police officer to pull over a driver who was not wearing a seatbelt. While the direct effects of laws targeting drivers of all ages on adult drinking drivers aged 26 and older were similar, the results were of a smaller magnitude compared to the findings for those aged 20 and younger.

“These results provide substantial support for the effectiveness of under age 21 drinking laws and point to the importance of key underage drinking and traffic safety laws in efforts to reduce underage drinking-driver crashes,” says James C. Fell, M.S., of the Pacific Institute for Research and Evaluation (PIRE) in Calverton, Maryland.

Another important finding from the study was that beer consumption per capita across all ages in states has a direct relationship with underage drinking and driving. The authors discovered that the higher the beer consumption per capita, the higher the youth crash rate.

“This could be because adult alcohol consumption is correlated with youth consumption,” Fell says. “The Centers for Disease Control and Prevention (CDC) found that if the adult binge drinking rate is high, it is also high for youth.”

Two underage drinking laws—registering kegs and graduated licensing—were found to have almost no impact on fatality rates, according to the study.

“We didn’t find that laws mandating that beer kegs be registered to the purchaser made any difference in reducing underage drinking and driving fatal crashes. In fact with this particular law, we saw 12 percent more drinking-related traffic fatalities amongst those under 21,” says Fell.

He said possible reasons may be that the law was not well enforced, or that in states that adopted keg registration laws, to circumvent the issue of registering beer kegs, young people choose instead to bring their own beer or liquor to underage parties, and as a result become more intoxicated from consuming their own booze than if a beer keg was the only source of alcohol.

Forty-four states have laws that restrict young drivers with an intermediate license from driving late at night, but Fell says this had no demonstrable effect on preventing underage drinking-related fatalities. The authors did not account for the start times of the night restrictions, instead focusing on whether a state had this law.

“So it could be that restrictions that start at 9:00 p.m. may have an effect, but the ones starting at 1:00 a.m. are very unlikely to make an impact because they begin too late,” says Fell.

Last year, Fell and colleagues found that laws making it illegal to possess or purchase alcohol by anyone under the age of 21 had led to an 11 percent drop in alcohol-related traffic deaths among youth; secondly, they found that states with strong laws against fake IDs reported 7 percent fewer alcohol-related fatalities among drivers under the age of 21.

 “People who want to lower the minimum drinking age say that the positive effects of raising it to 21 only took place in the 1980s and has since lost its impact,” Fell says. “But we looked at these numbers over a 23-year period. This study shows the impact is still strong, and is keeping the numbers of underage drinking and driving deaths down—more so than if the drinking age is lowered.”

If you would like to speak with the researchers or obtain a copy of the article, please contact Carol Vieira at cvieira@burnesscommunications.com.

Enforcing Bans on Cigarette Sales to Kids Reduces Youth Smoking