1. Drug policy issues for health services research John White, PhD and Thomas Nicholson, PhD Western Kentucky University David F. Duncan Duncan and Associates

2. 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;

3. 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.

4. 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.

5. 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.

6. 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

7. TEDS Data  20.5 million  1992-2003  Concatenated dataset  Covers all 50 States and Puerto Rico

8. Principal Source of Referral Including JusticeWithout Justice FrequencyPercentFrequencyPercent Individual6,972,31233.96,972,31253.5 Justice6,777,19433.0 Care Provider2,410,25711.72,410,25718.5 Other Community Referral1,706,9688.31,706,96813.1 Other HC Provider1,442,1867.01,442,18611.1 Missing728,6673.5 School260,9401.3260,9402.0 Employer/EAP250,1731.2250,1731.9 Total20,548,697100.013,042,836100.0

9. 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.

10. 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.

11. Living Arrangements Including JusticeWithout Justice FrequencyPercentFrequencyPercent Independent Living9,859,03848.06,153,45147.2 Missing5,432,95226.43,495,83626.8 Dependent Living3,380,09916.41,837,10614.1 Homeless1,876,6089.11,556,44311.9 Total20,548,697100.013,042,836100.0

12. Income Source Including JusticeWithout Justice FrequencyPercentFrequencyPercent Missing10,393,62750.66,640,32050.9 Wages/Salary3,708,08418.01,900,76714.6 Public Assistance1,380,6836.71,109,6378.5 Retirement/Pension505,1462.5358,7202.8 Other2,129,05410.41,439,85211.0 None2,432,10311.81,593,54012.2 Total20,548,697100.013,042,836100.0

13. 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.

14. Health Insurance Including JusticeWithout Justice FrequencyPercentFrequencyPercent Missing10,899,72653.07,292,88355.9 None6,139,54029.93,374,30925.9 Private1,342,5776.5824,1606.3 Medicaid1,321,9946.41,018,9617.8 Medicare/Other844,8604.1532,5234.1 Total20,548,697100.013,042,836100.0

15. Payment Source Including JusticeWithout Justice FrequencyPercentFrequencyPercent Missing14,331,85569.79,356,74571.7 Self-pay1,937,8779.41,002,6567.7 Other Government1,497,3247.3804,9286.2 Medicaid823,0564.0601,4954.6 No Charge794,3213.9512,2963.9 Blue Cross/Blue Shield548,7462.7355,3672.7 Other545,2742.7355,9662.7 Medicare, Workman's Comp70,2440.353,3830.4 Total20,548,697100.013,042,836100.0

16. 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.

17. Including JusticeWithout Justice FrequencyPercentFrequencyPercent Alcohol10,075,41949.05,998,70346.0 Cocaine/crack3,092,17515.02,194,31416.8 Heroin2,889,27814.12,505,61719.2 Marijuana/hashish2,454,90211.91,088,9308.3 Methamphetamine698,3713.4371,6822.8 Missing293,6631.4152,4201.2 Other opiates278,8741.4229,7421.8 None272,5271.3179,4321.4 Other amphetamine164,8310.892,3120.7 Other83,2440.458,4660.4 Benzodiazepines56,1720.346,3330.4 PCP35,6350.217,8490.1 Hallucinogens34,0910.220,1680.2 Other sedatives27,1900.120,3010.2 Inhalants22,6050.114,3150.1 Non-prescription meds20,0190.116,4700.1 Barbiturates16,7380.112,7060.1 Other tranquilizer13,1260.19,8950.1 Other stimulants12,2760.17,7180.1 OTC7,5610.05,4630.0 Total20,548,697100.013,042,836100.0 Case Mix

18. 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.

19. 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.

20. 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

21. Prior Admissions

22. 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).

23. 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.