Drug policy issues for health services research

John White, PhD and Thomas Nicholson, PhDWestern Kentucky University

David F. DuncanDuncan and Associates

Major Alternative Policy Schemes

Medicalization would allow currently illegal drugs to be prescribed by a physician for use by addicts (or perhaps even by recreational users);

Decriminalization would reduce the penalties for possession and use of illegal drugs to an offense (comparable to a traffic violation) rather than a felony or misdemeanor;

Schemes cont’d

Depenalization would eliminate all penalties for possession or use of illegal drugs but would retain penalties for production and trafficking in them;

Legalization would permit the currently illegal drugs to be sold and used like any other commodity, subject to such limits as the legislature might apply – for instance, age limits.

Any of these alternative approaches might be taken with any one or all of the currently illegal drugs.

Impact of Schemes

The current prohibition scheme has an important impact on the patient populations served by drug abuse treatment programs. The adoption of any of the alternative schemes would have major implications for the number of admissions, payer mix and case mix for treatment programs.

Data Source

To explore impact of these various schemes on drug treatment services we analyze data from the TEDS data set

We focus on referral patterns, payer mix, and other operational data.

Treatment Episode Data System

Is a continuation of the former Client Data System (CDS) that was originally developed by the Alcohol, Drug Abuse and Mental Health Services Administration

The TEDS data collection effort began in 1989 with three-year development grants to states.

Treatment providers that receive any state agency funding are expected to provide TEDS data for all clients admitted to treatment, regardless of the source of funding for individual clients.

http://webapp.icpsr.umich.edu/cocoon/ICPSR-SERIES/00056.xml

TEDS Data

20.5 million 1992-2003 Concatenated dataset Covers all 50 States and Puerto Rico

Principal Source of Referral

  Including Justice Without Justice

Frequency Percent Frequency Percent

Individual 6,972,312 33.9 6,972,312 53.5

Justice 6,777,194 33.0

Care Provider 2,410,257 11.7 2,410,257 18.5

Other Community Referral 1,706,968 8.3 1,706,968 13.1

Other HC Provider 1,442,186 7.0 1,442,186 11.1

Missing 728,667 3.5

School 260,940 1.3 260,940 2.0

Employer/EAP 250,173 1.2 250,173 1.9

Total 20,548,697 100.0 13,042,836 100.0

Impact on Admissions

One-third of all treatment admissions are generated directly by the criminal justice system. If all of the currently illegal drugs were to be decriminalized, depenalized or legalized, then all or most of these criminal justice system referrals would cease.

Furthermore, it is likely that some substantial portion of the patients entering the system as self-referrals is actually motivated by a desire to avoid prosecution for a drug offense. The same is likely to be true of some referrals by healthcare providers or other community sources.

Thus, drug policy reform could reduce patient numbers by more than one-third.

Increased Admissions?

On the other hand, the prohibitionist approach of the current “war on drugs” stigmatizes drug users and abusers as criminals. This may be discouraging many persons in need of treatment from seeking it.

It is conceivable that taking a new approach might produce an increase in self-referral patients as large as or larger than the decrease in coerced patients.

Living Arrangements

  Including Justice Without Justice

Frequency Percent Frequency Percent

Independent Living 9,859,038 48.0 6,153,451 47.2

Missing 5,432,952 26.4 3,495,836 26.8

Dependent Living 3,380,099 16.4 1,837,106 14.1

Homeless 1,876,608 9.1 1,556,443 11.9

Total 20,548,697 100.0 13,042,836 100.0

Income Source

  Including Justice Without Justice

Frequency Percent Frequency Percent

Missing 10,393,627 50.6 6,640,320 50.9

Wages/Salary 3,708,084 18.0 1,900,767 14.6

Public Assistance 1,380,683 6.7 1,109,637 8.5

Retirement/Pension 505,146 2.5 358,720 2.8

Other 2,129,054 10.4 1,439,852 11.0

None 2,432,103 11.8 1,593,540 12.2

Total 20,548,697 100.0 13,042,836 100.0

Impact on SES

Elimination of all criminal justice referrals would have very little effect on the distribution of either income sources or living arrangements in the patient care population. The greatest change would be an increase of roughly three percent in the proportion of patients who were homeless and of about two percent in the proportion who were receiving public assistance. These estimates are again hampered by a large amount of missing data on the variables.

Health Insurance

  Including Justice Without Justice

Frequency Percent Frequency Percent

Missing 10,899,726 53.0 7,292,883 55.9

None 6,139,540 29.9 3,374,309 25.9

Private 1,342,577 6.5 824,160 6.3

Medicaid 1,321,994 6.4 1,018,961 7.8

Medicare/Other 844,860 4.1 532,523 4.1

Total 20,548,697 100.0 13,042,836 100.0

Payment Source

  Including Justice Without Justice

Frequency Percent Frequency Percent

Missing 14,331,855 69.7 9,356,745 71.7

Self-pay 1,937,877 9.4 1,002,656 7.7

Other Government 1,497,324 7.3 804,928 6.2

Medicaid 823,056 4.0 601,495 4.6

No Charge 794,321 3.9 512,296 3.9

Blue Cross/Blue Shield 548,746 2.7 355,367 2.7

Other 545,274 2.7 355,966 2.7

Medicare, Workman's Comp 70,244 0.3 53,383 0.4

Total 20,548,697 100.0 13,042,836 100.0

SES of Clients

Health Insurance coverage and Payment Source demonstrate the potential impact of a change in drug policy schemes on the payer mix for patients undergoing treatment for drug abuse. The large amount of missing data on these variables in the T.E.D.S. database limits our ability to draw any conclusions

Elimination of criminal justice referrals would result in an increase in the proportion of patients whose care is paid for by Medicaid and a decrease in the proportion of self payment and of payment by government programs other than Medicaid or Medicare.

Such shifts in source of payment for care would have major impacts on the administration of treatment services, including changes in the types and amounts of treatment provided.

  Including Justice Without Justice

Frequency Percent Frequency Percent

Alcohol 10,075,419 49.0 5,998,703 46.0

Cocaine/crack 3,092,175 15.0 2,194,314 16.8

Heroin 2,889,278 14.1 2,505,617 19.2

Marijuana/hashish 2,454,902 11.9 1,088,930 8.3

Methamphetamine 698,371 3.4 371,682 2.8

Missing 293,663 1.4 152,420 1.2

Other opiates 278,874 1.4 229,742 1.8

None 272,527 1.3 179,432 1.4

Other amphetamine 164,831 0.8 92,312 0.7

Other 83,244 0.4 58,466 0.4

Benzodiazepines 56,172 0.3 46,333 0.4

PCP 35,635 0.2 17,849 0.1

Hallucinogens 34,091 0.2 20,168 0.2

Other sedatives 27,190 0.1 20,301 0.2

Inhalants 22,605 0.1 14,315 0.1

Non-prescription meds 20,019 0.1 16,470 0.1

Barbiturates 16,738 0.1 12,706 0.1

Other tranquilizer 13,126 0.1 9,895 0.1

Other stimulants 12,276 0.1 7,718 0.1

OTC 7,561 0.0 5,463 0.0

Total 20,548,697 100.0 13,042,836 100.0

Case Mix

Case Mix Impacts

The case mix in terms of primary drug of abuse would be effected in a number of small but potentially important ways by drug policy reform.

If all criminal justice referrals were eliminated, then the proportion whose primary problem was heroin addiction would increase by five percent (from 14.1% to 19.2%)

Those reporting a primary problem with marijuana would decrease by more that three percent (from 11.9% to 8.3%).

Alcohol remains the primary substance abuse problem at admission.

Marijuana Impacts

Decriminalization, depenalization or legalization is most likely to come first for marijuana. Patients with a primary problem with marijuana constituted 2,454,902 patients during the period 1992 thru 2003, or about a quarter of a million per year.

Elimination of criminal justice referrals would mean that about 136,000 fewer patients would enter care for marijuana abuse annually.

Revenue Implications

Using costs estimates from the ADSS Cost Study the lowest cost per admission reported was for outpatient treatment without methadone ($1,433)*

This suggests an annual loss of $194,888,000 in revenue per year if marijuana initiatives are successful

*Source: http://www.oas.samhsa.gov/2k4/costs/costs.htm

Prior Admissions

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500000

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1500000

2000000

2500000

3000000

3500000

None One Two Three Four Five +

Individual

Care Provider

Other Provider

School

Community/ EAP

Justice

First Time Admissions

Criminal justice referrals are more often persons who are entering treatment for the first time.

Eliminating criminal justice referrals would reduce the proportion of patients who were first time patients from 36.6% to 31.1% (3,213,316 fewer first time patients).

Impact of Scheme Changes

Drug policy reforms could be expected to result in a patient population that: Is smaller by one-third Includes a larger proportion of patients on Medicaid Includes a larger proportion of patients who are homeless or on

welfare Includes a larger proportion of heroin addicts Includes a smaller proportion of marijuana abusers Includes a larger proportion of patients with a history of relapse

Such changes in patient population would present treatment agencies with greater clinical challenges than the current state of the system.