The COMPA Bulletin
Volume I, Issue 6 September 6, 2001
Welcome to the Sixth Issue of the COMPA Bulletin
Contents:
COMPA’s New Executive Director
This past Tuesday, September 4th Henry Bartlett stepped into his new role as Executive Director and ushered in a new era for COMPA. As COMPA is now an independent free-standing organization, Henry’s first task will be to set up basic office procedures and operations before he begins to address the challenge of implementing COMPA’s Business Plan which was recently mailed to the membership. In accordance with our long term plans, Henry will also be developing a presence in Albany, and for the time being, John Coppola and ASAP have been kind enough to make an office available. Henry can be reached by calling 518-281-8965 or 212-447-6682.
JCAHO Accreditation Workshop
On Friday, September 28th COMPA, in cooperation with the Beth Israel Medical Center, will sponsor a day long workshop focused on the JCAHO accreditation process, the JCAHO standards that have been developed for opiate treatment programs, and what programs should be doing to prepare for accreditation surveys. Sharon Dow, director of the opioid treatment accreditation project of the Joint Commission will be the primary presenter. The workshop will be held in the 2nd Floor Conference Room at the Beth Israel Medical Center Phillips Ambulatory Care Center on 14th Street, Union Square in Manhattan from 9:00 to 4:00 pm. and refreshments will be provided. The cost of the session is $25 for participants from member organizations and $50 for those who are not. Due to space limitations, registration will be limited to 100 individuals. Registration forms are available from the COMPA Office.
Due to requests from a number of member organizations, we are also attempting to set up a similar session with representatives from CARF.
CSAT To Select Accrediting Entities Shortly
According to Robert Lubran, Director of the Center for Substance Abuse Treatment’s (CSAT) Office of Pharmocologic & Alternative Therapies, four applications have been received thus far from entities looking to become certified as accreditation bodies for opioid treatment programs. Applications have been submitted by JCAHO, CARF, the Council on Accreditation for Children and Family Services, and the State of Washington and Mr. Lubran expects to announce the selection of accrediting bodies prior to the National Methadone Conference in October. Once this announcement is made, programs will then have 90 days to select one of the approved entities to perform an accreditation survey over the next two years.
We also understand from Commissioner Miller that OASAS is seriously considering submitting an application to become an accrediting body. COMPA has formally recommended against OASAS becoming an accrediting body. Concerns that have been expressed which led to the decision to oppose OASAS becoming an accrediting body, included:
State Association Calls Field to Action
The following memo was sent to providers by John Coppola, executive director of the Alcoholism and Substance Abuse Providers of NYS
The Governor’s budget was not a good one for our field. The barebones budget, passed by the Senate and Assembly is much worse. It is more than $180 million dollars BELOW the Governor’s proposal. The "barebones" budget eliminates all re-appropriations (unspent funds from last fiscal year proposed for use in the new fiscal year) and some new initiatives proposed by the Governor. The barebones budget is not what the Senate, Assembly, or the Governor wants. It would hurt many interest groups.
If a budget, containing the re-appropriations, does not pass by September 15, more than $180 million in OASAS re-appropriations (more than $130 million in capital, more than $50 million in federal funds for services) and much more elsewhere in the state budget might not be available for its intended purpose. If the Governor, the Senate, and the Assembly do not come to an agreement and if we have to live with this barebones budget, it will be disastrous for our field.
ASAP’s message to the field is: Call your Senator (Senate switchboard: 518-455-2800) and your Assemblyperson (Assembly switchboard: 518-455-4100) TODAY. Call again in a couple of days and keep calling till this is over. Increase your voice by getting staff, Board, and friends to do the same. If everyone makes these calls, it WILL make a difference.
In a conference call last week with two of our Long Island members and their Senator, I heard firsthand the benefits of such phone calls. The Senator said, "We need to hear from the field. We need to know what cuts could mean locally". Let’s tell our Senator and Assemblyperson that the Governor’s budget and the barebones budget are unacceptable. Tell them that the budget must contain $10 million more than the Governor proposed so that OASAS can get the same 2.5% COLA proposed by the Governor for OMH and OMRDD.
"Just do it" for the field. Thank you. It will make a difference.
Analysis: Budget War in Albany Pits Pataki Against All
by Richard Pérez-Peña and James C. McKinley Jr.; New York Times; August 22, 2001
As summer began, the Capitol was mired in its annual budget deadlock. The battle lines were drearily familiar: Gov. George E. Pataki and the Republican-led Senate versus the Democrat-controlled Assembly. Today, there is nothing familiar about this fight. A partisan struggle between Republicans and Democrats has turned into an institutional one, pitting the governor against the Legislature. The Senate majority leader, Joseph L. Bruno, and his troops joined forces with the Assembly Democrats and, over Mr. Pataki's objections, adopted a budget shot full of holes, hoping to force the governor to the negotiating table.
The tactic seems to have worked, for now. The governor and legislative leaders held their third budget negotiation today, discussing new sources of revenue, like Indian casinos, video gambling machines at race tracks, or joining the multistate Powerball lottery, that could offset education spending sought by the Legislature. Mr. Bruno and the Assembly speaker, Sheldon Silver, left the session today sounding optimistic that a deal could be near. Mr. Pataki did not. "I'm continuing to make it plain to them these are difficult economic times," he said.
At its core, this year's conflict is an intensification of a long-running power struggle between Mr. Pataki and the Legislature. The governor has repeatedly tried to assert greater control over the budget process and tie the hands of a Legislature that he believes has overstepped its bounds and reflexively spends too much. This year, he made his firmest stand yet, and the Legislature pushed back like never before, prompting the governor to ask the courts to settle the matter once and for all. "The governor's lawsuit has less to do with this year's budget than with future budgets," said the leader of the Assembly's Republican minority, John J. Faso, who is close to Mr. Pataki. "A large part of the governor's motivation is to establish the authority of the office."
Even if this year's impasse is resolved, the governor's aides say the lawsuit and the more fundamental struggle it represents will continue. Several aggravating factors helped bring the fight to a head this year, including a slowing economy that prompted Mr. Pataki to dig in his heels. Most important, Mr. Bruno and the Senate Republicans, who had long been frustrated by dealing with the Democrats, grew equally impatient with the governor. Unlike the experience of previous years, they were unable until last week to coax Mr. Pataki into negotiation and compromise, and saw in his actions a lack of respect for the Legislature and its role. "The governor acts as though the Senate is just there to do his bidding, he has this take-it-or-leave-it attitude, and Joe got tired of it," said a lobbyist who is close to Mr. Bruno. Aides to Mr. Bruno said he became particularly irked when Mr. Pataki began sending the Legislature emergency spending bills to keep the government running a week at a time, rather than two or three weeks. That forced the Legislature to return to Albany every week, long after the scheduled end of this year's legislative session in June. Meanwhile, the governor was criss-crossing the state, cutting ribbons and criticizing the Legislature, but would not meet legislative leaders to discuss the budget.
Mr. Pataki took the position that his job was done when he proposed a budget in January, and that he should not negotiate budget details with the Legislature. For most of this year, Mr. Bruno agreed, joining the governor in assailing the Democrats and calling on them to begin budget conference committee meetings. The Republicans even held mock conference sessions and lectured Democrats in absentia, before an audience of reporters, for not attending. "Joe was incredibly frustrated that the process wasn't moving," said a Republican senator. "He thought Shelly's approach was wrong, but he understood it."
Under a 1998 law passed at Mr. Pataki's insistence, legislators go unpaid after the April 1 start of the fiscal year if there is no budget. By mid-summer, irritation with the governor was running high in both houses, and lawmakers were pressuring Mr. Bruno and Mr. Silver to get paychecks issued again. August loomed as a deadline. Most school districts outside New York City have to send out their property tax bills before Sept. 1, and without the expected increase in aid from Albany, those bills would rise. It was a smaller issue to the Assembly Democrats, but Senate Republicans feared blame for higher taxes. Ultimately, it was Mr. Bruno who proposed last month that they pass a stripped-down budget, aides in both houses said. In announcing the deal in late July, Mr. Bruno repeatedly stressed that the Legislature was "an equal partner" in the process, wording that his aides say was aimed at the governor.
From the 1970's until 1997, budgets were negotiated by governors and legislative leaders. Then, in 1998, the Assembly and Senate abandoned that method and drafted a budget in public conference committees without directly involving the governor. Mr. Pataki, not tied to the deal, vetoed 1,300 spending items worth $1.6 billion. He also pushed the boundaries of how the line-item veto power had been used in the past, leading to a still-pending lawsuit by Mr. Silver. The Democrats concluded from 1998 that the governor had to be a party to the budget deal — the outlines, if not the specifics — or he would veto their pet programs at will. But since then, Mr. Pataki has resisted negotiations. The negotiated budgets of the past, his office argues, were a legislative power grab in defiance of the state Constitution, which gives governors the most control over budgets. Mr. Pataki and his aides insist that he was always willing to discuss broad parameters, but that the Assembly's spending demands were so high — more than $2 billion above the governor's proposed $83.6 billion — that there was no point in talking. They note, rightly, that the governor's call for a 5 percent spending increase was hardly austere, and that independent fiscal monitors applauded his restraint. "When the speaker says the governor won't negotiate, what he's really saying is the governor won't cave in to my demands to spend more," said Michael McKeon, a spokesman for the governor.
But the gap between Mr. Silver and Mr. Pataki was less stark than it appeared. Each year, the Assembly seeks billions more than the governor, but it is a bargaining position, later abandoned. And as much as a month ago, in private talks, Mr. Silver cut his demands by more than $1 billion, leaving him at roughly the same level as the Senate. The governor rejected even that as too much, helping push the Senate toward turning its back on Mr. Pataki. He and his aides acknowledge that the governor has been more rigid than usual this year about not increasing spending much above his proposal, but they say that is due to his fears about the economy, not to a desire to have his way.
A more basic dispute stems from the way Mr. Pataki writes his budgets, and the fact that the state Constitution puts strict limits on what the Legislature can do to his appropriations bills. With each passing year, the governor has inserted into his appropriations bills more and more text containing changes in state law on how money is spent. He has also increasingly lumped many projects together as a few large, general line items. With those changes, he has sought to give himself the maximum power to alter state law and decide how money is used, with minimal input from the Legislature.
Legislators began complaining about this trend a few years ago, and this year they tried to reverse it by amending some of the governor's budget bills. In his suit, Mr. Pataki, said that step violated the state Constitution. Mr. Silver and others countered that the governor's bills themselves were unconstitutional. Legal experts say it is not clear who is right. Mr. Pataki's aides say they are confident he will not be hurt politically by the mess, citing polls showing that most New Yorkers blame the Legislature. Legislators, in turn, express similar confidence, and some predict that ultimately, as state services suffer, so will the governor. In any case, both sides argue, the stakes for control of state budgets are high enough to run those risks.
(As we go to publication Governor Pataki has called the legislators back to Albany for a special session to address budgetary issues.)
Department of Education Pressured to Modify Financial Aid Restrictions
From the Drug Reform Coordination Network Week Online, August 17, 2001
According to an article in this week's Chronicle of Higher Education, Rep. Mark Souder (R-IN), the author of the Higher Education Act's anti-drug provision, has met with officials at the Department of Education, seeking to have the scope of the law's applicability narrowed to not punish those whose convictions occurred prior to their enrolling in college and receiving federal aid. The law as it is currently interpreted takes away college aid privileges from would-be students with drug convictions for periods of time ranging form one year to indefinitely.
According to the latest Department of Education data, 35,326 would-be college students have been fully or partially denied financial aid by the DOE this year -- with 25% of applications remaining to be processed -- because they reported drug convictions on their aid applications.
It is unclear whether the law can be narrowed in this way without an act of Congress. Though Rep. Souder professes that it was not his intention to take away opportunities from those who have put their legal troubles behind them, the law as written specifies no such exemption. Even if passed, however, such a compromise would do little to slow the growing momentum of the campaign to overturn the law in its entirety. Terry Hartle, vice president of government relations for the American Council on Education told the Chronicle, "It would obviously make a bad idea more palatable, but it will still be a bad idea." DRCNet Executive Director David Borden added, "We're happy that some would-be students with past convictions will now be allowed to move on with their lives. But this so-called 'reform' addresses none of the crucial issues that our coalition has been raising, and the law in its proposed new form will still discourage tens of thousands of students every year from completing their college careers. Anyone who thinks that will reduce drug abuse needs a new 'anti-drug.'"
A wide variety of organizations, including the NAACP, the American Public Health Association and the United States Student Association have charged that the HEA drug provision is an extra-
judicial second punishment inflicted only on the poor and middle class, and that it imposes racial disparities on the education system because of unsolved criminal justice problems including
racial profiling.
New Drug Enforcement Agency Administrator Asa Hutchinson spoke out on this issue two weeks ago, telling the Los Angeles Times that he would support allowing drug offenders to remain eligible for college financial aid. Hutchinson said that many drug offenders who wish to further their education find themselves barred from receiving student aid "even though they've turned their lives around." Allowing such people to receive financial aid would help them "get back to leading useful, productive lives" Hutchinson's opposition to the student aid ban is a response to guidance he received from education experts. In May, 13 leading education associations representing admissions officers, community and state colleges, financial aid administrators and students groups, sent a letter to the newly nominated Hutchinson, calling the HEA drug provision a "fundamentally flawed piece of legislation".
Key Findings From the 2000 DAWN Report
The Drug Abuse Warning Network (DAWN) is a nationally representative survey of hospitals with emergency departments conducted annually by the federal Substance Abuse and Mental Health Services Administration (SAMHSA). The survey is designed to capture information about emergency department visits that are induced by or related to the use of an illegal drug or the nonmedical use of a legal drug. Because up to four drugs can be reported for each emergency department visit, there are more "mentions" than "episodes".
In 2000, there were an estimated 601,776 drug-related emergency department visits in the continental United States with 1,100,539 mentions of a particular drug (on average, 1.8 drugs per visit). There was no statistically significant change between 1999 and 2000 in the number of emergency department visits or the number of drugs mentioned.
ONDCP uses the emergency department data from DAWN as a key indicator of the consequences of drug abuse. Estimates of the consequences of drug abuse are essential to the PME system, specifically as the measure for Goal 3, Impact Target 1 (Reduce the health and social costs to the public of illegal drug use.).
DAWN measures the health consequences of drug abuse that are reflected in visits to hospital emergency departments, not prevalence. The estimates may increase or decrease for reasons unrelated to the size or characteristics of the drug-using population. For example, the number of visits reported to DAWN is not equivalent to the number of individual patients, because one person may make repeated visits to an emergency department. Changes may be due to changes in the use of drug combinations; patterns of drug use, such as route of administration; amount of drug used per administration; drug purity; or drug price. For example, a decrease in the purity of cocaine or heroin/morphine could result in fewer users experiencing unexpected reactions and overdoses.
Estimates of drug-related emergency department visits could also increase or decrease over time for reasons that affect reporting patterns. For example, some possible factors are greater awareness of these problems by hospital staff who therefore report drug use more carefully on medical charts, changing patterns of use of emergency departments by drug users, and different emergency department usage patterns by population subgroups.
Since 1988, DAWN emergency department data have been collected from a representative sample of eligible hospitals located throughout the continental U.S., with over-sampling in 21 metropolitan areas and a National Panel of hospitals sampled from locations outside these areas. Hospitals eligible for DAWN are non-Federal, short-stay, general hospitals that have 24-hour emergency departments.
In 2000, 466 hospitals participated in the DAWN emergency department survey. Data collected from these hospitals are weighted to produce estimates representing all emergency department drug visits and drug mentions in the continental U.S. and in the 21 metropolitan areas. Data for the 21 metropolitan areas are pooled with data from the National Panel to produce the national estimates.
The new DAWN report includes estimates based on a national panel of hospitals as well as results specific to 21 metropolitan areas of the United States.
Key findings include:
TOTAL DRUG-RELATED EPISODES
In 2000, there were an estimated 601,776 drug-related ED episodes and 1,100,539 ED drug mentions (1.8 drugs per episode) in the coterminous U.S. Nationally, the number of ED episodes and mentions remained relatively stable from 1999 to 2000.
The 4 drugs mentioned most frequently in ED reports in 2000 were alcohol-in-combination (204,524 mentions), cocaine (174,896), heroin/morphine (97,287), and marijuana/hashish (96,446).
ED mentions of cocaine, LSD, and marijuana/hashish were statistically unchanged from 1999 to 2000, but there were increases in amphetamine (35%, from 11,954 to 16,189), PCP/PCP combinations (32%, from 4,969 to 6,583), methamphetamine/speed (29%, from 10,447 to 13,513), and heroin/morphine (15%, from 84,409 to 97,287).
Adjusting for population, males (with 259 episodes per 100,000 population) and young adults age 18 to 25 (with 426) had the highest rates of ED drug episodes in 2000 among the demographic subgroups.
Males had the highest rates of cocaine mentions (95 mentions per 100,000 population), heroin/morphine mentions (54), and marijuana/hashish mentions (52) in 2000.
Adjusting for population, adults age 26 to 34 had the highest rate of cocaine mentions (155 mentions per 100,000 population) and the highest rate of heroin/morphine mentions (73) in 2000. However, younger adults age 18 to 25 had the highest rate of marijuana/hashish mentions (with 105) among the age subgroups.
Among drug-related ED episodes in 2000, dependence (217,224, or 36% of episodes) and suicide (193,061, or 32%) were the most frequently cited motives for taking the substances.
In 2000, overdose was the most common reason for ED contact (264,240, or 44% of episodes). Between 1999 and 2000, patients seeking detoxification increased 24 percent, and patients visiting the ED because of overdose increased 14 percent.
Among the 21 metropolitan areas over sampled in DAWN, 7 had significant increases in drug-related ED episodes from 1999 to 2000: Seattle (32%, from 8,426 to 11,116), Boston (28%, from 11,669 to 14,902), Los Angeles (22%, from 20,678 to 25,288), Miami (20%, from 7,128 to 8,560), Chicago (16%, from 26,158 to 30,330), Minneapolis (12%, from 4,643 to 5,198), and Phoenix (9%, from 8,293 to 9,072). Drug related ED episodes decreased in Baltimore (19%, from 14,172 to 11,505) and San Francisco (12%, from 8,930 to 7,857).
LONG-TERM TRENDS 1990 TO 2000
From 1990 to 2000, total drug-related episodes increased 62 percent, from 371,208 to 601,776.
Mentions of the four major illicit drugs increased from 1990 to 2000 as follows: marijuana/hashish (514%, from 15,706 to 96,446), heroin/morphine (187%, from 33,884 to 97,287), methamphetamine/speed (158%, from 5,236 to 13,513), and cocaine (118%, from 80,355 to 174,896).
COCAINE
Cocaine-related episodes constituted 29 percent (174,896) of all ED drug episodes in 2000, more than any other illicit substance measured by DAWN. Mentions of cocaine were statistically unchanged from 1999 to 2000.
Although cocaine mentions did not increase from 1999 to 2000 overall, increases were evident for Hispanics (16%) and for patients age 35 and over (9%).
From 1999 to 2000, cocaine mentions increased significantly in 6 of the 21 metropolitan areas in DAWN: Los Angeles (35%, from 6,772 to 9,111), Seattle (32%, from 2,520 to 3,338), Atlanta (19%, from 5,236 to 6,229), Boston (15%, from 3,560 to 4,101), Chicago (11%, from 13,399 to 14,871), and Miami (9%, from 4,018 to 4,381). Decreases in cocaine mentions were observed in 4 of the 21 metropolitan areas: Baltimore (29%, from 6,921 to 4,943), Newark (13%, from 3,124 to 2,726), Washington, DC (10%, from 3,150 to 2,830), and New Orleans (7%, from 2,140 to 1,998).
HEROIN/MORPHINE
Heroin/morphine was mentioned in 16 percent of ED drug episodes in 2000. From 1999 to 2000, heroin/morphine-related episodes increased 15 percent (from 84,409 to 97,287 mentions).
The increase in heroin/morphine mentions from 1999 to 2000 was evident in several demographic subgroups, with increases for patients age 18 to 25 (22%), patients age 35 and over (11%), females (15%), males (13%), and whites (20%).
Eight of the 21 metropolitan areas had increases in heroin/morphine mentions between 1999 and 2000. They were: Miami (58%, from 921 to 1,459), New Orleans (50%, from 664 to 996), Boston (35%, from 2,874 to 3,888), Buffalo (31%, from 525 to 687), Chicago (29%, from 9,725 to 12,564), Detroit (26%, from 2,678 to 3,369), Atlanta (17%, from 432 to 507), and Minneapolis (14%, from 207 to 237. Heroin/ morphine mentions decreased in Baltimore (23%, from 7,013 to 5,414) and San Francisco (10%, from 3,074 to 2,773).
METHAMPHETAMINE/SPEED
Overall, methamphetamine/speed was mentioned in 2 percent of drug-related episodes in 2000. From 1999 to 2000, methamphetamine/speed mentions increased 29 percent (from 10,447 to 13,513), but estimates for this drug are notable for their volatility from year to year.
Looking across the 21 DAWN metropolitan areas, the vast majority (81%) of estimated ED mentions of methamphetamine/speed in 2000 came from 5 cities in the western United States: Los Angeles (1,375 mentions), San Diego (747), Phoenix (600), San Francisco (591), and Seattle (540).
Among the 10 metropolitan areas with at least 100 mentions of methamphetamine/ speed in 1999 or 2000, significant increases from 1999 to 2000 were evident in 6: Phoenix (76%, from 341 to 600), Seattle (53%, from 353 to 540), Los Angeles (51%, from 910 to 1,375), Dallas (35%, from 100 to 135), Atlanta (31%, from 83 to 109), and San Diego (28%, from 584 to 747). Methamphetamine/speed estimates were stable in San Francisco (591 mentions in 2000), St. Louis (162), Minneapolis (153), and Denver
(110).
OTHER ILLICIT DRUGS
ED mentions of PCP/PCP combinations increased 32 percent (from 4,969 to 6,583) from 1999 to 2000.
No significant changes occurred in LSD mentions from 1999 to 2000 (5,126).
Considering ED visits involving club drugs, mentions of MDMA (Ecstasy) increased 58 percent (from 2,850 to 4,511) between 1999 and 2000.
No significant changes were evident for GHB, Ketamine, and Rohypnol from 1999 to 2000. Mentions of GHB, MDMA, and Ketamine have increased dramatically since 1994, but the apparent increase in Rohypnol mentions is not statistically significant.
NON-MEDICAL USES OF LICIT DRUGS
Not all cases involving prescription or over-the-counter (OTC) drugs are reportable to DAWN. DAWN cases do not include accidental ingestion or inhalation of a substance with no intent of abuse, or adverse reactions to prescription or OTC medications taken as prescribed. Accidental overdoses of OTC or prescription drugs taken as directed are reportable when used in combination with an illicit drug. Alcohol is reportable only when used in combination with another drug.
Mentions of alcohol-in-combination occurred in 34 percent (204,524) of ED drug episodes in 2000. Mentions of alcohol-in-combination were stable from 1999 to 2000.
From 1999 to 2000, DAWN estimates of ED episodes involving prescription and OTC drugs show: Increases in mentions of the narcotic analgesics containing oxycodone (68%) and hydrocodone (31%) but no significant changes in the narcotic analgesics acetaminophen with codeine or d-Propoxyphene; increases in cyclobenzaprine (a muscle relaxant, 44%), OTC sleep aids (33%), and the non-narcotic analgesics ibuprofen (24%), aspirin (22%), and acetaminophen (19%). These findings should not be attributed to any particular brand of these drugs.
Cocaine and Heroin Emergency Department Mentions in NYC
|
1993 |
1994 |
1995 |
1996 |
1997 |
1998 |
1999 |
2000 |
|
|
Cocaine |
21,085 |
20,214 |
19,724 |
21,592 |
20,202 |
19,549 |
14,799 |
14,250 |
|
Heroin |
11,351 |
11,185 |
10,728 |
11,167 |
9,491 |
9,244 |
9,331 |
11,028 |
The complete report may be found at: http://www.whitehousedrugpolicy.gov/
Drug Prices and Emergency Department Mentions
By Jonathan P. Caulkins, PhD; Published in September 2001, Vol 91, No. 9 | American Journal of Public Health 1446-1448
ABSTRACT
Objectives. In this report, the author illustrates the historic relation between retail drug prices and emergency department mentions for cocaine and heroin.
Methods. Price series based on the Drug Enforcement Administration's System to retrieve information From Drug Evidence database were correlated with data on emergency department mentions from the Drug Abuse Warning Network for cocaine (1978–1996) and heroin (1981–1996).
Results. A simple model in which emergency department mentions are driven by only prices explains more than 95% of the variation in emergency department mentions.
Conclusions. Fluctuations in prices are an important determinant of adverse health outcomes associated with drugs.
INTRODUCTION
Most US drug control spending seeks to restrain supply,1 which—unless it makes drugs physically scarce—affects use primarily through prices.2 Hence, a key question concerns the extent to which drug prices affect use, particularly heavy or problematic use.3 If use is not related to price, this focus on supply factors, and much of the literature on controlling drug markets, may be misguided.4
Economists take it as an article of faith that use responds to price changes; they even have a term for quantifying the concept. The price elasticity of demand is the percentage change in consumption associated with a 1% increase in price. Other economists are more skeptical, believing that there may be an elasticity of demand for conventional goods, and perhaps even marijuana, but not for cocaine and heroin.
I am not an economist, but I have some sympathy for economists' view in this case. The purpose of this report is to show some figures that might help a noneconomist understand intuitively that price variations may be related to drug use and associated health consequences, at least at the aggregate level.
For cocaine and heroin, the figures presented here correlate retail prices, numbers of emergency department (ED) mentions, and numbers of mentions one might expect if prices were the only thing that affected ED mentions. Such correlations are not a significant contribution to the economics literature. Besides offering the usual admonition that "correlation does not imply causality," an econometrician would note that prices and measures related to consumption are simultaneously determined, so price is an endogenous variable. To quantify the effect of price on consumption, one must "identify" the system with some "instrumental variable." This is routine work for econometricians, and a growing literature empirically estimates elasticities of demand for addictive substances.5 This literature generally finds that consumption of drugs such as cigarettes, alcohol, marijuana, and cocaine is surprisingly responsive to price changes.
Econometric studies can, however, be bewildering to the uninitiated. In my experience, citing these studies to an audience skeptical that prices influence drug use is of little value. Nevertheless, simple descriptive plots, even if they offer no quantitative estimate of the elasticity of demand, can persuade skeptics of the basic point that price matters.
METHODS
The unit of observation was annual data for the United States. Price data were derived from undercover purchases recorded by the Drug Enforcement Administration's System to Retrieve Information From Drug Evidence (STRIDE) database.6 Data for 1981 through 1996 were obtained from the Office of National Drug Control Policy.7,8 I extended the cocaine series back to 1978 with data from prior work.9 Prices were converted to constant dollars with the consumer price index.
Counts of ED mentions were taken from Drug Abuse Warning Network data.10,11 The Drug Abuse Warning Network monitors drug-related ED episodes by retrospectively examining ED records in a sample of nonfederal, general care, short-stay hospitals that operate a 24-hour ED. Its data have been criticized,12–15 but they remain the standard source of information on drug-related morbidity.
The third pair of data series was the number of mentions one would expect if ED mentions were determined only by prices through a constant price elasticity. By definition, a constant elasticity relation is log linear. Choosing the scaling constant and exponent to minimize the sum of the squared difference between the actual and the expected number of mentions yields the following relations: 1.cocaine ED mentions = 5.85 x 107 x P–1.30 2.heroin or morphine ED mentions = 2.73 x 107 x P–0.84, where P = price.
The apparently strong relation between use and price suggested by the exponents is consistent with cocaine elasticity estimates derived from youth surveys,16 cocaine and heroin estimates based on arrestee urinalysis results,17 and the observation that heroin prices are inversely related to the size of the methadone dose needed to stabilize persons addicted to heroin.18
RESULTS
Figure 1 plots retail price and the annual number of ED mentions for cocaine) and heroin (1981–1996). A clear negative correlation is seen between prices and ED mentions, but it is difficult to judge its strength because it is an inverse loglinear correlation. To present the correlation visually, Figure 2 plots the actual and expected number of ED mentions. If price were all that determined the number of ED mentions (and did so through a constant elasticity), the 2 pairs of lines would coincide, which they nearly do. The correlation between actual and expected mentions is 0.987 for cocaine and 0.975 for heroin. Thus, price changes can explain 97.5% of the variation in ED mentions for cocaine and 95% of the variation for heroin. This is striking, considering the imperfections in price and ED data and the fact that the model omits factors such as changes in the number and age of users, the availability of health insurance, the purity and availability of the drugs, and enforcement risks for users. Furthermore, the biggest discrepancies have a ready explanation. When prices spike, the actual number of ED mentions responds less than would be predicted by the constant elasticity relation. That makes sense if, as one would expect, ED mentions are less responsive to short-term price spikes than to longer-term price trends.
DISCUSSION
The preceding analysis shows that drug prices can explain a large proportion of the variation in national time series for the number of ED mentions for cocaine and heroin. The purpose in showing this is not to argue that other factors are unimportant or to quantify precisely the strength of the relation, but rather to give a visual, intuitive basis for understanding more obscure analyses of the relation between prices and drug use. Inasmuch as one believes that prices affect drug use and drug-related morbidity, it makes sense for policymakers to track price trends, to use price as a performance measure, and to think explicitly about how valuable it is to keep prices high and how best that can be accomplished.19
Acknowledgments
This material is based on work supported in part by the National Science Foundation (grant SBR-9357936). Any opinions, findings, and conclusions or recommendations expressed in this material are those of the author and do not necessarily reflect those of the National Science Foundation.
Footnotes
1. Office of National Drug Control Policy (ONDCP). The National Drug Control Strategy: 2000 Annual Report. Washington, DC: The White House; 2000.
2. Reuter P, Kleiman MAR. Risks and prices: an economic analysis of drug enforcement. In: Tonry M, Morris N, eds. Crime and Justice: An Annual Review of Research. Vol 7. Chicago, Ill: University of Chicago Press; 1986:289–340.
3. Caulkins JP, Reuter P. The meaning and utility of drug prices. Addiction.1996;91:1261–1264.[Medline]
4. Caulkins JP. Measurement and analysis of drug problems and drug control efforts. In: Duffee D, McDowall D, Green Mazerolle L, Mastrofski SD, eds. Criminal Justice 2000, Volume 4: Measurement and Analysis of Crime and Justice. Washington, DC: National Institute of Justice; 2000:391–449.
5. Chaloupka FJ, Pacula RL. Economics and anti-health behavior: the economic analysis of substance use and abuse. In: Bickel W, Vuchinich R, eds. Reframing Health Behavior Change With Behavioral Economics. Hillsdale, NJ: Lawrence Erlbaum Associates; 2000:89–111.
6. Frank RS. Drugs of abuse: data collection systems of DEA and recent trends. J Anal Toxicol.1987;11:237–241.[Medline]
7. Office of National Drug Control Policy (ONDCP). The National Drug Control Strategy, 1997: Budget Summary. Washington, DC: The White House; 1997.
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9. Caulkins JP. Developing Price Series for Cocaine. Santa Monica, Calif: Rand Corp; 1994.
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COMPA General Membership Meetings Scheduled for Fall
General membership meetings have been scheduled for the Fall in both downstate and upstate locations. Come meet our new Executive Director, listen to what you can expect from COMPA in the future, hear the latest regarding accreditation and other key issues, share your thoughts and concerns as we look towards the future, and meet your colleagues.
Friday September 7th, 10-12 noon
Greenwich House, 55 Fifth Avenue, 18th Floor, Manhattan
Friday, November 2
Greenwich House, 55 Fifth Avenue, 18th Floor, Manhattan
Wednesday, November 7th 10-12 noon
Crouse Memorial Hospital, Syracuse
During the upcoming months COMPA will be working closely with OASAS to convene several forums intended to begin a dialogue regarding how best to establish good community relations and deal with chronic resistive patients who contribute significantly to the stigma facing methadone treatment. These working forums will seek to identify key issues and problem areas, and then focus on developing recommendations for solutions. Schedules will be announced in a future issue of the COMPA Bulletin.
Methadone Treatment: The Hope for a New Life
COMPA’s new video, Methadone Treatment: The Hope for New Life is an informative documentary focused on the role of methadone in saving lives and benefiting society. Presenting the real story of opiate addiction and its devastating effect on both the user and the community, the video examines the disease of addiction, addresses the question of who becomes an addict, and highlights the role of treatment in rebuilding the lives of users.
This 30 minute presentation, which is ideal for new staff as well as those unfamiliar with methadone treatment, is built around interviews with several patients as well as some of the key researchers and practitioners in the field, including Dr. Vincent Dole, Dr. Mary Jean Kreek, Dr. Beny Primm, Dr. Edward Salsitz and many others.
The video may be purchased from COMPA for $90 each. Discounts are available for quantity purchases: $75 for 4 – 10 copies; $60 for 11 or more. Please add $5 shipping and handling for the first copy and $2 for each additional video. To order, mail your request to COMPA at 250 Fifth Avenue, Suite 210, New York, NY 10001. Please include either a check payable to COMPA or a purchase order with your order.
GRANT OPPORTUNITIES
The NYS Department of Health AIDS Institute has released a Request for Application to award State and Federal funds for HIV Prevention and Care Services for Substance Abusers Who are In and Out of Treatment. Funds are available in the following categories: HIV Prevention Services to Substance Users in Drug Treatment and Their Sexual and Drug Sharing Partners; Outreach and Prevention Services to Active Users and Consortium Based capacity Building Models for Providing HIV Prevention services to Recovering Users in Treatment; HIV Primary Care services for HIV Infected Substance Users in Drug Treatment; and Transitional Case management Services to Assist Active Injection Drug Users. Proposals must be received by the AIDS Institute by the close of business on September 28, 2001. The RFA may be obtained from the AIDS Institute by calling 212-268-6111.
CONFERENCE AND TRAINING OPPORTUNITIES
2001 AMTA Conference
The American Methadone Treatment Association Conference 2001, Opioid Treatment in the 21st Century – Implementing the Vision is scheduled for October 7– 10, 2001 at the Millennium Hotel in St. Louis, Missouri, with CSAT and NIDA supported pre-conference sessions beginning on October 6, 2001.
According to conference chair Keith Spare, "The conference represents a unique and highly effective partnership, among the American Methadone Treatment Association and the National Institute of Drug Abuse, the Center for Substance Abuse Treatment, the Office of National Drug Control Policy, and the Drug Enforcement Administration." Plenary sessions will feature treatment professionals as well as government officials, including Missouri’s governor Bob Holden.
The conference, jointly sponsored by the American Methadone Treatment Association and the American Society of Addiction Medicine, has traditionally attracted more than 1,600 participants from throughout the nation as well as 25 other nations. Missouri hosts are the Missouri Department of Mental Health - Division of Alcohol and Drug Abuse and the Missouri Methadone Treatment Association.
The conference will feature major presentations on public policy, legislation, research, and state-of-the-art treatment interventions for opiate dependence. The increasing public discussions on health care, welfare reform, and criminal justice systems highlight the importance of the positive impact methadone treatment offers to individuals in need of such care and the public. This conference serves as a national focal point for treatment providers, researchers, patient advocates and government officials, demonstrating the effectiveness of opioid treatment as a foundation for sound public health policy.
For additional details on the conference, or for registration information, call (856) 423-7222, extension 360, or visit www.americanmethadone.org.
ASAP Fifth Annual Treatment and Prevention Conference
"Advancing the Conversation" has been selected as the theme of this year’s Alcoholism and Substance Abuse Providers of NYS (ASAP) conference, which will be held in Saratoga Springs from October 21 – 24, 2001. Conference information can be obtained by calling 518-426-3122 or through the ASAP web site at www.asapnys.org.
OASAS and ASAP have also joined forces to offer five Julio A. Martinez Professional development Scholarships to support non-administrative staff development. Each scholarship is for $1,000 and is intended for individuals working in the field who wish to pursue CASAC or Prevention credentials. Nominations are due September 14th and further information and nomination forms may be obtained from ASAP.
The State of the Art in Addiction Medicine – From Molecules to Managed Care
The American Society of Addiction Medicine has announced a three day conference highlighting the most recent findings in addiction research. The conference will be held November 1-3, 2001 at the Omni Shoreham Hotel in Washington, DC. For more information call 301-656-3920 or www.asam.org.
Review and Preparation for Oral CASAC Examination
Cicatelli Associates has announced a review and preparation class for the September 2001 oral CASAC Examination. The class is designed to help strengthen test taking confidence, practice oral case presentations, review clinical language, and clarify concepts related to AOD treatment. The class will be held at Cicatelli Associates in midtown Manhattan on Saturday, September 15th, from 9:00 to 5:00 pm. Registration fee $75. For further information call Brigid Betancourt at 212-594-7741 x 226.
ABOUT COMPA
The Committee of Methadone Program Administrators of New York State is a not-for-profit coalition representing New York State’s methadone treatment system which serves over 46,000 individuals suffering from opioid addiction and other substance abuse disorders.
Opioid addiction is a chronic, relapsing medical disorder, with serious consequences related to public health and safety. Methadone treatment has proven to be the most effective means of treating this disorder.
COMPA’s mission is to further the treatment of opioid addiction and other substance abuse disorders in order to address the medical, social and psychological consequences of use, prevent the spread of HIV and other infectious diseases, reduce criminal behavior, promote employment and self-sufficiency, and support the return to a healthy and productive lifestyle.
In order to support this mission, COMPA and its member organizations are committed to the promotion and expansion of methadone treatment through education of elected officials, providers, consumers, and the public at large. COMPA advocates for expanded models of service delivery, co-located services and consumer empowerment to provide increased access to treatment. COMPA supports enhanced services, a comprehensive continuum of care, the provision of high quality treatment and ongoing professional staff development. COMPA encourages the involvement of membership in the development of public policy, standards of care, and regulatory oversight.
COMPA Board of Directors
Peter Coleman, NYC Health and Hospitals Corporation, President
Ira Marion, AECOM-Montefiore, Vice President
Johanne Morne, Whitney Young MMTP, Secretary
Richard Woytek, Long Island Jewish MMTP, Treasurer
Herbert Barish, Lower Eastside Service Center
Willard Campbell, Suffolk County Division of Alcohol and Substance Abuse Services
Robert Krauss, Long Beach Hospital MMTP
Robert Sage, A.R.T.C.
Sheila Tierney, Crouse Hospital
Ira Wolfe, St. Luke’s Hospital
COMPA Executive Director
Henry Bartlett
COMPA has established this newsletter to ensure that New York State providers of opioid treatment services have an effective mechanism of communication which facilitates the dissemination of information and encourages dialogue. The COMPA Bulletin includes information regarding best practices, research, demonstration projects, accreditation, training opportunities, conferences, and other items of interest to the field and will be distributed via email on a monthly basis. COMPA encourages readers to submit news, articles, research, and other items of interest for possible inclusion. Submissions should be titled "COMPA Bulletin Submission" and directed to info@compa-ny.org.
Please send us your email address. Addresses should be titled "Subscription List" and directed to info@compa-ny.org as well.
Past issues of the COMPA Bulletin are available on our web site www.compa-ny.com.
The COMPA Bulletin is compiled, written and distributed by:
The Committee of Methadone Program Administrators of NYS Inc.
250 Fifth Avenue, Suite 210
New York, N.Y. 10001
212-447-6682
or
518-281-8965
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