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Drug policy issues for health
services research
John White, PhD and Thomas Nicholson, PhD
Western Kentucky University
David F. Duncan
Duncan 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 threeyear 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/ICPSRSERIES/00056.xml
TEDS Data




20.5 million
1992-2003
Concatenated dataset
Covers all 50 States and Puerto Rico
Principal Source of Referral
Including Justice
Frequency
Without Justice
Percent
Individual
6,972,312
33.9
Justice
6,777,194
33.0
Care Provider
2,410,257
Other Community Referral
Other HC Provider
Frequency
Percent
6,972,312
53.5
11.7
2,410,257
18.5
1,706,968
8.3
1,706,968
13.1
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
20,548,697
100.0
13,042,836
100.0
Total
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
Frequency
Without Justice
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
20,548,697
100.0
13,042,836
100.0
Total
Income Source
Including Justice
Frequency
Missing
Without Justice
Percent
Frequency
Percent
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
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
Retirement/Pension
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
Frequency
Missing
Without Justice
Percent
Frequency
Percent
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
844,860
4.1
532,523
4.1
20,548,697
100.0
13,042,836
100.0
Medicare/Other
Total
Payment Source
Including Justice
Frequency
Without Justice
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
70,244
0.3
53,383
0.4
20,548,697
100.0
13,042,836
100.0
Medicare, Workman's Comp
Total
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.
Case Mix
Alcohol
Cocaine/crack
Heroin
Marijuana/hashish
Methamphetamine
Missing
Other opiates
None
Other amphetamine
Other
Benzodiazepines
PCP
Hallucinogens
Other sedatives
Inhalants
Non-prescription meds
Barbiturates
Other tranquilizer
Other stimulants
OTC
Total
Including Justice
Frequency
Percent
10,075,419
49.0
3,092,175
15.0
2,889,278
14.1
2,454,902
11.9
698,371
3.4
293,663
1.4
278,874
1.4
272,527
1.3
164,831
0.8
83,244
0.4
56,172
0.3
35,635
0.2
34,091
0.2
27,190
0.1
22,605
0.1
20,019
0.1
16,738
0.1
13,126
0.1
12,276
0.1
7,561
0.0
20,548,697
100.0
Without Justice
Frequency
Percent
5,998,703
46.0
2,194,314
16.8
2,505,617
19.2
1,088,930
8.3
371,682
2.8
152,420
1.2
229,742
1.8
179,432
1.4
92,312
0.7
58,466
0.4
46,333
0.4
17,849
0.1
20,168
0.2
20,301
0.2
14,315
0.1
16,470
0.1
12,706
0.1
9,895
0.1
7,718
0.1
5,463
0.0
13,042,836
100.0
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
3500000
3000000
Individual
Care Provider
Other Provider
School
Community/EAP
Justice
2500000
2000000
1500000
1000000
500000
0
None
One
Two
Three
Four Five +
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.