1. 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

2. 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 (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

3. 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, 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?

4. 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

5. Past Year Heroin use, 2002-2015, by age

6. Past Year Heroin use, 2002-2015, by age

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

8. 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

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

10. 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
Shows large rise in prevalence since
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

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

13. 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
Shows large rise in prevalence since
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

14. 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

15. ADAM II: Male Arrestees Testing Positive for Opiates, 2010

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

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

18. 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

19. 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……