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"Addiction Policy Research Update" Newsletter - Fall 2007

This is the fourth volume of the quarterly news tips from the Substance Abuse Policy Research Program (SAPRP) of the Robert Wood Johnson Foundation—a $66 million program that funds research into policies related to alcohol, tobacco and illegal drugs.

Please contact me at Prabhu_ponkshe@saprp.org if you'd like to follow up on any of the news items below. —Prabhu Ponkshe

ADDICTION  POLICY
Research Update

Fall 2007

 

New Knowledge Assets

Three New Web Resources Available on Tobacco and Opioid Addiction

The Substance Abuse Policy Research Program (SAPRP) has added three new Knowledge Assets to its website (www.saprp.org). This growing body of web-based resources provides policy makers and the media with information on the policy implications of the latest research on issues related to alcohol, tobacco and drugs.

The newest Knowledge Assets are:

Boosting Use of Smoking Cessation Treatments
In 2005 some 40 percent of the 45 million adult smokers in the United States tried to quit. But most of them failed to stay off cigarettes for more than a few weeks. A closer look at why smokers have such a hard time overcoming their nicotine addiction reveals that many do not follow proven smoking cessation treatment strategies, such as those widely recommended by the United States Public Health Service (USPHS).

This Knowledge Asset summarizes the results of SAPRP-funded studies that examine particular policies and programs aimed at helping more smokers to pursue proven tobacco cessation treatments.

Internet Cigarette Sales
A growing number of Internet vendors are selling cigarettes at much lower prices because they avoid charging excise taxes. Also, few Internet cigarette vendors check the age of their customers, making Internet sales an appealing option for underage smokers. The Knowledge Asset on Internet cigarette sales highlights several studies on this topic, which explore the current and potential impact of Internet cigarette sales; the regulations that exist regarding such sales, and whether or not existing regulations are complied with and enforced.

Results of these studies can provide guidance to policymakers and others who are working to maintain and expand the positive impact that increases in cigarette prices have had, both reducing tobacco use and providing support for federal and state budgets.

Treating Opioid Addiction in an Office-based Practice
Opioid abuse and dependence are the cause of a serious and growing public health problem in the United States, but new concerns have arisen with a recent surge in the use of prescription opioids such as Oxycontin, Vicodin and Percocet. The reported increase in abuse of these opioids is occurring in tandem with a rising trend among physicians to prescribe them to treat pain. There is substantial evidence that opioid dependence, whether it involves heroin or prescription drugs, can be successfully treated with methadone and a newer medicine called Buprenorphine. However, there is a gap between treatment effectiveness and treatment access. Since the 1970’s, federal and state regulations have generally restricted methadone availability to specially licensed methadone clinics, effectively preventing most private physicians from offering methadone to treat addiction.

This Knowledge Asset addresses recent interest by many experts in whether more patients could get help if methadone treatment were provided by physicians in a general office-based setting (as opposed to a special clinic), through what are known as “methadone medical maintenance” programs. There is also interest in broadening access to office-based treatment through the use of Buprenorphine.

Each Knowledge Asset summarizes the major research results in lay language and provides the policy implications of the research. Each Knowledge Asset also includes a detailed description of the research results; names of the researchers who were funded in that general area by SAPRP, and additional resources (websites, reports, etc.) that might be of interest to the media and policy makers.

By 2010, SAPRP expects to have produced between 25 and 30 Knowledge Assets on key topics related to substance abuse policy.



State Policies and Naltrexone Use

State Medicaid Drug Policies Impeding Access To Effective Drug For Alcohol Abuse

Many states could more effectively address the huge financial and societal burden of alcohol abuse by changing policies that may be inadvertently impeding access to an inexpensive prescription drug known to reduce problem drinking.

The study by researchers at the University of Wisconsin and Georgetown University examined how state efforts to control spending on Medicaid, the program that provides health care for low-income individuals and families, may be limiting the ability of physicians to treat alcohol addiction with a widely studied generic drug called naltrexone. The research was funded by the Robert Wood Johnson Foundation’s Substance Abuse Policy Research Program (SAPRP).

“States should be keen to quickly deal with this problem because today they are spending on average about $1 of every $7 of their revenues dealing with alcohol-related problems like child neglect and violent crime,” said Carolyn Heinrich, a professor of Public Affairs at the University of Wisconsin-Madison and the study’s lead author. “Naltrexone is certainly not a cure-all, but it can be a powerful therapy, it’s relatively inexpensive and states have the policy levers at hand to increase its availability to alcohol addicts.”

Evidence from clinical trials shows that naltrexone, which blocks a brain receptor associated with a craving for alcohol, makes it easier for alcoholics to stop drinking and stay sober even when the drug is used alone; that is, unaccompanied by counseling or other interventions.

“We know from extensive research that only about 6 percent of people diagnosed as alcohol dependent are getting medication during their treatment and about a third of those who do not get medication cite cost or insurance as the key barrier,” Heinrich said. “Revising certain state policies on prescription drugs is one way to address what is clearly a need for greater access to a clinically-proven and cost-effective treatment.”

Heinrich and her colleague Carolyn Hill, an assistant professor at Georgetown Public Policy Institute, found that treatment providers are more likely to prescribe naltrexone when states institute policies that encourage the use of generic drugs, include generics on their preferred drug lists and reduce drug costs for Medicaid beneficiaries. Conversely, they found naltrexone is less likely to be adopted in states whose policies allow managed care organizations to restrict access to pharmacy networks or limit prescriptions. Other policies that impede naltrexone’s use include restricting the use of Medicaid funds for substance abuse treatment and establishing restrictive Medicaid preferred drug lists.

State policies related to Medicaid prescription drug benefits are seen as critical to determining naltrexone’s availability because Medicaid funds and related block grants constitute the majority of spending, public or private, on substance abuse treatment. One reason for this dominant role is that most alcoholics tend to be poor and lacking in health insurance and thus are dependent on Medicaid for care.

Heinrich said it’s difficult at any given moment to assess the situation in particular states because Medicaid drug policies are in such constant flux that they can change even from one month to the next. Heinrich and Hill note that a recent search of available state Medicaid preferred drug lists found that California, Florida, Iowa, Maine, Massachusetts and Vermont most actively encourage the adoption and use of naltrexone by including the drug explicitly on their preferred drug list.

But there are limits to the information available for many states. For example, Maine, while encouraging naltrexone adoption for Medicaid enrollees, allows it to be prescribed only in the context of “a formal, structured outpatient detoxification program” even though research shows it can be effective as a stand-alone therapy. Also, not every state has a Medicaid preferred drug list and some lists may not be publicly available while undergoing revision. Other states might be implicitly encouraging naltrexone use through general policies that promote the adoption of generic drugs, but such policy-specific information is not always readily available on a state-by-state basis.

Furthermore, the investigators acknowledge that state policies are not the only impediment to wider use of naltrexone. For example, some alcohol treatment programs oppose the use of drugs to deal with addiction. But Heinrich and Hill say changes in state policies can go a long way toward ensuring that the decision about the appropriate use of naltrexone, based on the best available scientific evidence, will be made by the physician and the patient.

This research was funded by the Substance Abuse Policy Research Program (SAPRP) of the Robert Wood Johnson Foundation. The paper entitled “The Role of State Policies in the Adoption of Naltrexone for Substance Abuse Treatment,” appears in the online version of the journal, Health Services Research. If you would like to speak with the researchers or obtain a copy of the article, please contact Carol Vieira at cvieira@burnesscommunications.com.



Reducing Alcohol Abuse In The Neighborhood

Study Finds It’s Local Bars, Not Liquor Stores, Encouraging Heavy Drinking

Bars and nightclubs, but not liquor stores, are linked with excessive alcohol consumption and heavy episodic drinking in adults who live nearby, according to a new study from the Pardee RAND Graduate School in Santa Monica, California.

“Usually people think that liquor stores define a neighborhood’s alcohol consumption, but we didn’t find any relationship between them and problem drinking among the adult population in California,” says author Khoa Truong, PhD.

Instead, the investigators say that overall, their findings point to so-called “minor-restricted establishments”—adults-only bars and nightclubs--as having the most consistent and sizeable effects on adult problem drinking, even though they accounted for only about 6% of the total number of alcohol retail licenses in the area studied.

After accounting for one’s education level, income, race, and neighborhood sociodemographic characteristics, we found that a higher number of minor-restricted establishments located within one mile from someone’s home is associated with that person’s higher likelihood of binge drinking and consuming excess alcohol,, the authors write.

“If the number of minor-restricted establishments increases, on average, from zero to two in a neighborhood, the prevalence of heavy episodic drinking in the past 30 days would increase from 11.1% to 14.3% among women and from 19.6% to 22.0% among men; and prevalence of riding with a driver who perhaps had too much to drinkin would increase from 2.9% to 4.1% among women and 4.0% to 5.5% among men says Truong.

The investigators were not surprised with the results because bars, taverns, and night clubs, especially those that do not allow minors, are where social and cultural norms are more likely to accept, if not encourage, excess drinking.

This finding raises questions about the effectiveness of policies that target alcohol sales in general, such as a regulation in counties in California that limits the sale of alcohol licenses based on population numbers. For example, California imposes a moratorium on the issuance of alcohol retail licenses when the ratio exceeds one on-sale general license for each 2000 persons and one off-sale general license for each 2500 persons. Truong’s study indicates that limiting the total number of alcohol licenses is not as effective as targeting certain types of licenses, namely those for minor-restricted drinking establishments.

“What’s usually happening is that alcohol outlets are regulated at broader environments. It turns out that the action happens within a micro environment,” says Truong.

This research was funded by the Substance Abuse Policy Research Program (SAPRP) of the Robert Wood Johnson Foundation. The paper entitled “Alcohol Outlets and Problem Drinking Among Adults in California” appears in the November 2007 issue of the Journal of Studies on Alcohol and Drugs. If you would like to speak with the researchers or obtain a copy of the article, please contact Carol Vieira at cvieira@burnesscommunications.com.




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