Misuse of General Population Surveys: Estimating Heroin Prevalence in the United States Peter Reuter (U. Maryland) Jonathan P. Caulkins (Carnegie-Mellon University) Greg Midgette (RAND Corporation) Lisbon Addictions conference, October 2017 Work in progress Prior users of NSDUH

Credulous reliance on Household Survey for estimates of heroin prevalence in US Official Reports “More than 36 million (13.5 percent) reported using marijuana in the past year, 12.5 million reported misusing prescription pain relievers, and over 300,000 reported using heroin in the past year. “ Surgeon General’s Report 2016 (I-7) Scientific journals “According to national surveillance data (NSDUH), 914,000 people reported heroin use in 2014” (Compton Jones and Baldwin, 2016; 155) NEJM

Credulous reliance on Household Survey for estimates of heroin prevalence in US Official Reports “More than 36 million (13.5 percent) reported using marijuana in the past year, 12.5 million reported misusing prescription pain relievers, and over 800,000 reported using heroin in the past year. “ Surgeon General’s Report 2016 (I-7) Scientific journals “According to national surveillance data (NSDUH), 914,000 people reported heroin use in 2014” (Compton Jones and Baldwin, 2016; 155) Estimates are implausible on their face Ignore well known serious problems with reporting of rare drug behaviors Ignore alternative estimates using a wider variety of data sources Why so little critical curiosity on an apparently important figure?

Many potential sources of error for estimates of rare drug behaviors in population surveys Non-response Under-reporting Ever used frequency Sampling frame restrictions; important exclusions include Homeless Incarcerated Small numbers reduce precision as well Even with 60,000 completed interviews

Past Year Heroin use, 2002-2015, by age

Past Year Heroin use, 2002-2015, by age

Past Year Heroin use, 2002-2015, by age nunweighted 130 132 151 160 152 161 197 175 213 227 238 223

Cell sizes for past-year heroin use are small Age Group 12-17 18-25 26-34 35-49 50 or older Total 2002 35 70 10 13 2 130 2003 32 74 8 16 132 2004 38 79 20 1 151 2005 96 14 18 160 2006 26 89 22 5 152 2007 80 4 2008 93 21 15 6 161 2009 119 24 197 2010 110 25 17 175 2011 124 27 7 213 2012 149 29 12 3 2013 143 41 9 227 2014 99 72 30 238 2015 91 71 223 370 1416 389 246 81 2502

Self-Report vs Urinalysis for Cocaine shows Substantial under-reporting Just show past 7 days and 3 days Source: Harrison et al. 2007

Large incarcerated population with extremely high prevalence rates One day count, 2010 federal and state prisons plus jails ca. 2.4 million Most recent data on drug use in prisons, jails from 2007-2009 Shows large rise in prevalence since 2002-4 No data since sharp increase in heroin/fentanyl overdoses after 2010 Estimates are self-report, so likely lower bounds Perhaps higher willingness to report in community with high prevalence and already subject to stigma of criminal conviction

How easy would it be remove the drug specific lines other than heroin/opiates and cocaine/crack?

Large incarcerated population with extremely high prevalence rates One day count, federal and state prisons plus jails ca. 2.4 million Most recent data on drug use from 2007-2009 Shows large rise in prevalence since 2002-4 No data since sharp increase in heroin/fentanyl overdoses after 2010 Complex to estimate effect on prevalence estimates Heroin use rare in prisons or jails Substantial share of incarcerated population not in household population at any time in past year Crude estimate is 120,000 past-year state and federal prison inmates with low probability of capture in NSDUH

ADAM supplements NSDUH Arrestee Drug Abuse Monitoring program Self-report and urinalysis of arrestees in small number of “booking facilities” Maximum of 42 facilities in 2002; only 10 in 2010 Data collection imperfect Problems tracking and sampling all eligibles But high response rate both for self-report and urinalysis Program now ended Rarely used by researchers or policy makers (national or local) Complex method for extrapolating user estimates from limited ADAM sites using county level treatment admissions, overdose deaths etc. Also generated only systematic estimates of quantity consumed and expenditures

ADAM II: Male Arrestees Testing Positive for Opiates, 2010

ADAM-based estimates of frequent heroin use >5 times NSDUH estimates Show in 2 stages: WAUSID for heroin 2002-2010, with CI Then add NSDUH past month estimates 2002-2010

ADAM-based estimates of frequent heroin use >5 times NSDUH estimates Show in 2 stages: WAUSID for heroin 2002-2010, with CI Then add NSDUH past month estimates 2002-2010

Reconciling higher estimates with other indicia Treatment admissions, Emergency Department admissions consistent with million frequent users in 2010 266,000 Treatment admissions for heroin (not other opiate) in 2010 211,000 Emergency Department visits for heroin Interpretation of OD figures very complicated E.g. high vulnerability of recently released heroin using prisoners implies rising prevalence in incarcerated populations might engender higher population level OD rate

Concluding comments: Why no skepticism about NSDUH estimates? Other population survey (NESARC) estimates even lower than NSDUH Minimal reference to NESARC drug estimates, let alone comparisons ADAM estimates published in Addiction…barely cited Three conjectures (not mutually exclusive) Consensus is more important than accuracy when on a public health crusade Drug epidemiology is a weak field Drug policy makers don’t care about the number Yet prevalence bedrock measure in other fields of substance abuse More research is needed……