Catching up

Here are several articles I've been meaning to post about but have fallen behind:

Substance Abuse Benefits: Still Limited After All These Years

In 2005, approximately 22.2 million Americans age twelve or older were "dependent" on or "abused" illicit drugs or alcohol. Alcoholism alone is one of the ten leading U.S. causes of disability. Illicit drug users commit more than 60 percent of serious adult violent and property crimes in this country. In 2003, medical spending for substance abuse (SA) treatment constituted an estimated $20.7 billion--1.3 percent of health care spending.

More than 90 percent of people with SA problems do not seek medical attention, a figure that has changed little in recent years. Of the 37.5 percent of those who sought treatment and were unable to get it in 2002, cost was the key reason for not obtaining care.

Since the early 1990s, the public sector has assumed an increasing share of medical spending for substance abuse, while private payers' share has declined. From 1991 to 2003, all medical payments by private insurers (of which nearly 90 percent were for employer-based coverage) grew from 33 percent to 35 percent of national health care spending. In contrast, private insurance spending for SA services declined from 22 percent in 1991 to 10 percent in 2003. Yet about three of every four Americans with a drug or alcohol dependency were employed either full or part time in 2005.

Much of the decline in private insurance SA spending was concentrated in inpatient and residential services, although it also affected outpatient spending. Private insurance spending in all settings has declined, although the decline in inpatient spending has been longer and more substantial (Exhibit 1). It resulted in a falling share of inpatient, residential, and outpatient SA spending coming from private insurance between 1991 and 2003.

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About 88 percent of insured employees had at least some coverage for SA treatment in 2006. To provide historical perspective, we compared 2006 data for workers in private firms who had health care coverage with similar historical information from the BLS. For 2000-03, 93-94 percent of workers in all private firms were enrolled in a plan with SA benefits, similar to the 93 percent recorded in our survey results for 2006. Earlier figures for 1995 and 1997 covering medium and large private establishments were only slightly higher (98 percent), in part because small private establishments, which typically provide less rich benefits, are not included. Concurrently, the use of limits on coverage of SA services became more pervasive: In 1989, 56 percent of employees with SA benefits had limits that were different from those applying to medical-surgical benefits. In 2006, 81 percent of covered employees belonged to plans that limit hospital inpatient days or office visits for SA treatment.

Patients' cost-sharing requirements for SA benefits remain higher than those for medical-surgical benefits--and it is well established that higher cost sharing reduces the use of services. In 2006, deductibles were 46 percent higher for SA services than for medical-surgical benefits (Exhibit 5). Employees are more likely to be subject to coinsurance as opposed to copayments for SA services than for medical-surgical services. According to the data presented in this paper, when employees face copayments, they are higher, on average, for SA benefits. When workers are subject to coinsurance, rates also are higher for SA than for medical-surgical services. Perhaps most important, plans that limit employees' out-of-pocket liability for medical-surgical services do not apply this protection for 44 percent of the employees with SA benefits.

Court ordered treatment reduces offending:

A new study from a team of researchers at the University of Kent and King's College London shows that court-ordered treatment for drug dependence can be effective in reducing offending and drug use.

The study, published this week in the British Journal of Criminology, suggests that, although treatment is effective in reducing offending by drug users, it can be equally effective for people who enter treatment as an alternative to imprisonment, leading to reductions of almost three quarters in the average frequency of offending.

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Alex Stevens explained: 'Our research has shown that people on Drug Treatment and Testing Orders (DTTOs) were as likely to reduce their offending and drug use as people who entered treatment 'voluntarily'. On average, those sentenced to a DTTO reported a 71% reduction in the frequency of offending between the time of arrest and 18 months after they started treatment. The sharpest fall in offending occurred in the first six months of treatment. There were similar reductions in the frequency of drug use and in the money they spent on drugs.'

Experts Warn About Powdered Alcohol

They look harmless enough, the inconspicuous packets often next to the cashier at gas stations, convenience stores, beverage stores and bars. But according to consumer protection officials, that's what makes them all the more dangerous, since the powder inside contains alcohol, and a lot of it -- about 4.8 percent by volume. That is the equivalent of one to one-and-a-half glasses of liquor.

Vancouver mayor to lead campaign for injection site

Vancouver Mayor Sam Sullivan plans to lead an aggressive campaign to lobby for the continued operation of the country's only injection site for drug users.

In contrast to the last round of lobbying to keep the site open, where Sullivan used a quieter, back-door approach, the mayor said he plans to mount a public campaign that brings together injection-site supporters from every sector of the city.

He said that's because having the injection site open is key to bringing in the new kind of drug-treatment approach he has been advocating since he took office.

That approach, which he has labelled Chronic Addiction Substitution Treatment, will see legal substitutes for cocaine and heroin given to addicts.

"The CASTproject does require the supervised injection site as a site for recruitment. We are going to need to aggressively pursue this project," he said.

Sullivan's drug plan isn't the better way

As a former beat cop who spent more than seven years working in the Downtown Eastside, it was nice to see Jonathan Fowlie's article.

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I can recall on many occasions when denizens of the poorest postal code in the country would approach me and say they wanted desperately to get into treatment and leave the drug life behind them.

However, adequate treatment didn't exist or there was a waiting list. When an addict reaches out for help, he or she must be removed from the Downtown Eastside and placed in a treatment facility immediately.

Supreme Court to review crack cocaine sentences

The Supreme Court agreed for the first time yesterday to reconsider the long prison terms meted out to the mostly black defendants who are convicted of selling crack cocaine.

At least 25,000 defendants per year are sent to federal prison on crack-cocaine charges, and their prison terms are usually 50 percent longer than drug dealers who sell powder cocaine.

This disparity, with its racial overtones, has been controversial for two decades since Congress ramped up the "war on drugs" in response to a crack-cocaine epidemic that was sweeping many cities.

Crack was targeted for stiffer penalties because it was viewed as more potent and dangerous than powder cocaine.

At the time, lawmakers set mandatory minimum prison terms for drug sellers based on the quantity of drugs sold. A sale of 5 grams of crack cocaine triggers the same five-year prison term as selling 500 grams of powder cocaine, even though they are the same substance.

Critics have said this 100-to-1 disparity is unfair and racially biased because dealers in crack cocaine are more often black, while powder cocaine is said to be sold more often to whites and by whites.

Put the Gangs Out of Business: Legalize Drugs

The street gang and associated drug trade problem in Canada won't be solved by a get-tough, criminal-justice-system response, nor should we expect young homies to just say no. Look to the United States for proof of this. Over the past 30 years, the U.S. has employed the most aggressive and expensive anti-drug and -gang measures ever conceived. In the process, 800,000 street gangsters under the age of 21 have been created. Moreover, more than two million Americans now call prison home, the majority of which are young black and Hispanic men. About half of them are serving time for relatively minor drug offences. Today, things are so bad that the FBI has made street gangs and the underlying drug trade their number one priority, even over domestic terrorism. The failure in this campaign is a testament to the abject failure of the U.S. war on drugs and gangs.

Canada has the opportunity, but perhaps not the courage, to employ a different approach on street gangs. To be sure, we must tackle the underlying socioeconomic causes of the street-gang problem, including poverty, income inequality and persistent discrimination. At the same time, we must equip our police agencies with the resources they need to take out the hardcore 20% or so of all street gangsters who are responsible for the majority of Canadian street violence. We must spend much more money on early prevention and diversion, because this is not a problem that we can arrest our way out of.

Finally, we need to embark upon drug legalization, which will starve gangs of their principal oxygen supply and serve to upset the attractive risk-reward proposition that every new gangster now faces.

Marlboro Snus: What is it?

Yesterday Philip Morris USA, the tobacco company that has around 50% of the total market for cigarettes in the USA, announced the launch a new product: “Marlboro Snus,” in a test market in the Dallas/Fort Worth area. So what type of product it this?

As this particular brand of snus won’t be launched until August we can’t yet tell much of the details of the product (e.g. how much nicotine it delivers or how much it will cost) so lets talk about what “snus” is generally, and why the biggest cigarette manufacturers in the US are test marketing an entirely different type of product.

Snus (pronounced “snooss”) is the Swedish word for snuff, and is a form of moist ground smokeless tobacco, that is usually sold in “sachet” form – each sachet looking like a small tea-bag. Each sachet is placed in the mouth (usually under the upper or lower lip) for about 30 minutes and the nicotine and tobacco taste is absorbed via the lining of the mouth. The main difference between snus products and other smokeless tobacco already available in the United States, is that snus is produced using a process like pasteurization in which it is heated with steam. This kills most of the microbes that can produce cancer-causing chemicals in tobacco. Traditional smokeless products like Skoal and Copenhagen are not pasteurized but are fermented - a process that facilitates the development of cancer-causing chemicals. So snus does not appear to cause oral cancer. Clearly smokeless products also don’t cause lung cancer or respiratory diseases like emphysema either. That’s not to say that snus is entirely safe. Long term use can cause white patches to appear on the lining of the mouth and erosion of the gum where it is placed, and decades of use may increase risks of pancreatic cancer and cardiovascular disease (e.g. stroke and heart attacks). The nicotine from this product will also harm the unborn baby when used by a pregnant woman. So neither snus nor any other form of smokeless tobacco is recommended for anyone who currently doesn’t smoke. But because the health risks from snus are much lower (about 90% lower) than from smoking this may be a step in the right direction for the smoker who wants to keep using tobacco but wants to avoid most of the health risks.