Drug problems

Kevin Lewis

March 13, 2017

The Effects of Alcohol Use on Economic Decision Making

Klajdi Bregu et al.

Southern Economic Journal, forthcoming

In a controlled laboratory experiment, we study the causal effect of alcohol on economic decision making. A treatment group was given a dose of alcohol designed to target a blood alcohol concentration (BAC) of 0.08 while the BAC of those in the control group remained 0.00. We investigate the behavior of control and treatment groups in the following types of tasks: math, uncertainty, overconfidence, strategic games, food choice, anchoring, and altruism. Our results indicate that alcohol consumption has little systematic effect on economic behavior, at least for the BAC level considered. Further, there is little evidence that alcohol differentially impacts the choices of male and female subjects.


Substance Use Treatment Provider Behavior and Healthcare Reform: Evidence from Massachusetts

Johanna Catherine Maclean & Brendan Saloner

Health Economics, forthcoming

We examine the impact of the 2006 Massachusetts healthcare reform on substance use disorder (SUD) treatment facilities' provision of care. We test the impact of the reform on treatment quantity and access. We couple data on the near universe of specialty SUD treatment providers in the USA with a synthetic control method approach. We find little evidence that the reform lead to changes in treatment quantity or access. Reform effects were similar among for-profit and non-profit facilities. In an extension, we show that the reform altered the setting in which treatment is received, the number of offered services, and the number of programs for special populations. These findings may be useful in predicting the implications of major health insurance expansions on the provision of SUD treatment.


Electronic Nicotine Delivery Systems and Acceptability of Adult Cigarette Smoking Among Florida Youth: Renormalization of Smoking?

Kelvin Choi, Rachel Grana & Debra Bernat

Journal of Adolescent Health, forthcoming

Purpose: There is a dearth of research into whether electronic nicotine delivery systems (ENDS) promote acceptance of cigarette smoking. Therefore, we aimed to assess the association between ENDS exposure, acceptance of cigarette smoking, and susceptibility to cigarette smoking.

Methods: Data from the 2014 Florida Youth Tobacco Survey with a state representative sample of middle and high school students (n = 68,928) were analyzed. Own ENDS use, exposure to ENDS advertising, living with ENDS users, acceptance of adult cigarette smoking, demographics, and known predictors of cigarette smoking were assessed. Susceptibility to cigarette smoking was assessed among never smokers. Weighted multiple logistic regression models and mediation analyses were conducted, stratified by middle/high school and never/ever smoking. Analyses were conducted in 2016.

Results: Own ENDS use, exposure to ENDS advertising, and living with ENDS users were associated with acceptance of adult cigarette smoking even among never smokers, after accounting for covariates (p < .05). In a mediation analysis, own ENDS use, exposure to ENDS advertising, and living with ENDS users were indirectly associated with susceptibility to cigarette smoking among never smokers through acceptance of adult cigarette smoking (p < .05).

Conclusions: Youth ENDS exposure may contribute to normalizing adult cigarette smoking and may in turn heighten susceptibility to cigarette smoking. If confirmed by longitudinal studies, these findings suggest that ENDS policy interventions may help prevent youth cigarette smoking.


National and State Trends in Sales of Cigarettes and E-Cigarettes, U.S., 2011–2015

Kristy Marynak et al.

American Journal of Preventive Medicine, forthcoming

Methods: Trends in cigarette and e-cigarette unit sales were analyzed using retail scanner data from September 25, 2011 through January 9, 2016 for: (1) convenience stores; and (2) all other outlets combined, including supermarkets, mass merchandisers, drug, dollar, and club stores, and military commissaries (online, tobacco-only, and “vape“ shops were not available). Data by store type were available for the total contiguous U.S. and 29 states; combined data were available for the remaining states, except Alaska, Hawaii, and DC.

Results: During 2011–2015, cigarette sales exhibited a small, significant decrease; however, positive year-over-year growth occurred in convenience stores throughout most of 2015. E-cigarette unit sales significantly increased during 2011–2015, but year-over-year growth slowed and was occasionally negative. Cigarette unit sales exceeded e-cigarettes by 64:1 during the last 4-week period. During 2014–2015, cigarette sales increases occurred in 15 of 48 assessed states; e-cigarette sales increased in 18 states.

Conclusions: Despite overall declines during 2011–2015, cigarette sales in 2015 grew for the first time in a decade. E-cigarette sales growth was positive, but slowed over the study period in assessed stores. Cigarette sales continued to exceed e-cigarette sales, reinforcing the importance of efforts to reduce the appeal and accessibility of cigarettes and other combusted tobacco products.


E-cigarettes and National Adolescent Cigarette Use: 2004–2014

Lauren Dutra & Stanton Glantz

Pediatrics, forthcoming

Methods: Data were collected by using cross-sectional, nationally representative school-based samples of sixth- through 12th-graders from 2004–2014 National Youth Tobacco Surveys (samples ranged from 16 614 in 2013 to 25 324 in 2004). Analyses were conducted by using interrupted time series of ever (≥1 puff) and current (last 30 days) cigarette smoking. Logistic regression was used to identify psychosocial risk factors associated with cigarette smoking in the 2004–2009 samples; this model was then applied to estimate the probability of cigarette smoking among cigarette smokers and e-cigarette users in the 2011–2014 samples.

Results: Youth cigarette smoking decreased linearly between 2004 and 2014 (P = .009 for ever smoking and P = .05 for current smoking), with no significant change in this trend after 2009 (P = .57 and .23). Based on the psychosocial model of smoking, including demographic characteristics, willingness to wear clothing with a tobacco logo, living with a smoker, likelihood of smoking in the next year, likelihood of smoking cigarettes from a friend, and use of tobacco products other than cigarettes or e-cigarettes, the model categorized <25% of current e-cigarette–only users (between 11.0% in 2012 and 23.1% in 2013) as current smokers.

Conclusions: The introduction of e-cigarettes was not associated with a change in the linear decline in cigarette smoking among youth. E-cigarette–only users would be unlikely to have initiated tobacco product use with cigarettes.


Macroeconomic Conditions and Opioid Abuse

Alex Hollingsworth, Christopher Ruhm & Kosali Simon

NBER Working Paper, February 2017

Past research indicates that physical health measures (such as all-cause mortality) improve when economic conditions temporarily deteriorate, but the relationship between economic conditions and behavioral health remain unclear. The pro-cyclicality of mortality has declined in recent years while drug poisoning deaths have trended sharply upwards, suggesting a connection to the rising use of many types of drugs. We contribute new evidence to the literature by examining how severe, adverse outcomes related to use of opioid analgesics (hereafter abbreviated as opioids) and other drugs vary with short-term fluctuations in macroeconomic conditions. We use data on deaths and emergency department (ED) visits related to opioid and other drug poisonings together with information on state and county unemployment rates. We focus on opioids because they are a major driver of the recent, fatal drug epidemic. We use county-level mortality data for the entire U.S. from 1999-2014, and state and county level ED data covering 2002-2014 from a subset of states. We find that as the county unemployment rate increases by 1 percentage point, the opioid death rate (per 100k) rises by 0.19 (3.6%) and the ED visit rate for opioid overdoses (per 100k) increases by 0.95 (7.0%). We also uncover statistically significant increases in the overall drug death rate that are mostly driven by increases in opioid deaths. These results also hold when performing a state, rather than county, level analysis. In most specifications, the results are primarily driven by adverse events among whites. Additionally, the findings are relatively stable across time periods; they do not pertain only to recession years, but instead represent a more generalizable and previously unexplored connection between economic development and the severe adverse consequences of substance abuse.


Effect of a Brief Memory Updating Intervention on Smoking Behavior: A Randomized Clinical Trial

Lisa Germeroth et al.

JAMA Psychiatry, March 2017, Pages 214-223

Importance: Recent research on addiction-related memory processes suggests that protracted extinction training following brief cue-elicited memory retrieval (ie, retrieval-extinction [R-E] training) can attenuate/eradicate the ability of cues to elicit learned behaviors. One study reported that cue-elicited craving among detoxified heroin addicts was substantially attenuated following R-E training and through 6-month follow-up.

Design, Setting, and Participants: This prospective, mixed-design, human laboratory randomized clinical trial took place between December 2013 and September 2015. Participants were recruited in Charleston, South Carolina. Study sessions took place at the Medical University of South Carolina. The participants were 168 screened volunteer smokers, of whom 88 were randomized; 72 of these 88 participants (81.8%) attended all the follow-up sessions through 1 month. The primary eligibility criteria were current nicotine dependence (DSM criteria), smoking 10 or more cigarettes per day, and a willingness to attempt smoking cessation.

Interventions: Participants were randomly assigned to receive either smoking-related memory retrieval followed by extinction training (the R-E group) or nonsmoking-related retrieval followed by extinction training (the NR-E group).

Results: A total of 44 participants were randomly assigned to the R-E group (mean age, 48.3 years; 72.7% male); a total of 44 participants were randomly assigned to the NR-E group, with 43 attending at least 1 training session (mean age, 46.7 years; 55.8% male). The mean craving response to both familiar and novel smoking cues was significantly lower for participants in the R-E group than for participants in the NR-E group at 1-month follow-up (for both cue types: t1225 = 2.1, P = .04, d = 0.44, and Δ = 0.47 [95% CI, 0.04-0.90]). The mean numbers of cigarettes smoked per day at 2 weeks and 1-month were significantly lower for the R-E group than for the NR-E group (treatment main effect: F1,68 = 5.4, P = .02, d = 0.50, and Δ = 2.4 [95% CI, 0.4-4.5]). Significant differences in physiological responses, urine cotinine level, number of days abstinent, lapse, and relapse were not observed between groups (all between P = .06 and .75).

Conclusions and Relevance: Retrieval-extinction training substantially attenuated craving to both familiar and novel smoking cues and reduced the number of cigarettes smoked per day by participants 1 month after treatment relative to extinction training alone. Between-group differences were not observed for physiological responses, cotinine level, number of days abstinent, relapse, or lapse. In summary, R-E training is a brief behavioral treatment that targets smoking-related memories and has the potential to enhance relapse prevention.


Competitive sports participation in high school and subsequent substance use in young adulthood: Assessing differences based on level of contact

Philip Veliz et al.

International Review for the Sociology of Sport, March 2017, Pages 240-259

The objective of this study is to examine how participation in different types of competitive sports (based on level of contact) during high school is associated with substance use 1 to 4 years after the 12th grade. The analysis uses nationally representative samples of 12th graders from the Monitoring the Future Study, who were followed 1 to 4 years after the 12th grade. The longitudinal sample consisted of 970 12th graders from six recent cohorts (2006–2011). The analyses, which controlled for 12th grade substance use, school difficulties, time with friends, and socio-demographic characteristics, found that respondents who participated in at least one competitive sport during the 12th grade had greater odds of binge drinking during the past two weeks (AOR = 2.04; 95% CI = 1.43, 2.90) 1 to 4 years after the 12th grade, when compared to their peers who did not participate in sports during their 12th grade year. Moreover, respondents who participated in high-contact sports (i.e. football, ice hockey, lacrosse, and wrestling) had greater odds of binge drinking (AOR = 1.80; 95% CI = 1.18, 2.72), and engaging in marijuana use during the past 30 days (AOR = 1.81; 95% CI = 1.12, 2.93) 1 to 4 years after the 12th grade when compared to their peers who did not participate in these types of sports during their 12th grade year. Accordingly, the findings indicate important distinctions in sport participation experiences on long-term substance use risk that can help inform potential interventions among young athletes.


The Short- and Long-Run Effects of Smoking Cessation on Alcohol Consumption

Benjamin Ukert

University of Pennsylvania Working Paper, January 2017

This paper examines the short- and long-term effect of quitting smoking on alcoholic beverage consumption using the Lung Health Study, a randomized smoking cessation program. Building on the theory of rational addiction, I estimate the relationship between smoking and alcohol consumption using several different smoking measures. Moreover, I implement a two-stage Least squares estimation strategy utilizing the randomized smoking cessation program as an instrument. The empirical analysis leads to three salient findings. First, self-reported and clinically verified smoking measures suggest that quitting smoking lowers alcoholic beverages consumption by 11.5%. Second, cigarette consumption dating back up to 60 months affects alcohol consumption, and those with the highest average consumption see the largest increase in alcohol consumption. Lastly, the length of abstaining from smoking decreases alcohol consumption, where participants decrease alcohol consumption by up to 20% from baseline levels after five years of smoking cessation. As a result, these findings suggest that the public health and finance benefits are undervalued in smoking cessations treatments.


With a Little Help from My Friends: The Effects of Naloxone Access and Good Samaritan Laws on Opioid-Related Deaths

Daniel Rees et al.

NBER Working Paper, February 2017

In an effort to address the opioid epidemic, a majority of states have recently passed some version of a Naloxone Access Law (NAL) and/or a Good Samaritan Law (GSL). NALs allow lay persons to administer naloxone, which temporarily counteracts the effects of an opioid overdose; GSLs provide immunity from prosecution for drug possession to anyone who seeks medical assistance in the event of a drug overdose. This study is the first to examine the effect of these laws on opioid-related deaths. Using data from the National Vital Statistics System multiple cause-of-death mortality files for the period 1999-2014, we find that the adoption of a NAL is associated with a 9 to 11 percent reduction in opioid-related deaths. The estimated effect of GLSs on opioid-related deaths is of comparable magnitude, but not statistically significant at conventional levels. Finally, we find that neither NALs nor GSLs increase the recreational use of prescription painkillers.


E-Cigarettes and “Dripping” Among High-School Youth

Suchitra Krishnan-Sarin et al.

Pediatrics, forthcoming

Background: Electronic cigarettes (e-cigarettes) electrically heat and vaporize e-liquids to produce inhalable vapors. These devices are being used to inhale vapors produced by dripping e-liquids directly onto heated atomizers. The current study conducts the first evaluation of the prevalence rates and reasons for using e-cigarettes for dripping among high school students.

Methods: In the spring of 2015, students from 8 Connecticut high schools (n = 7045) completed anonymous surveys that examined tobacco use behaviors and perceptions. We assessed prevalence rates of ever using e-cigarettes for dripping, reasons for dripping, and predictors of dripping behaviors among those who reported ever use of e-cigarettes.

Results: Among 1080 ever e-cigarette users, 26.1% of students reported ever using e-cigarettes for dripping. Reasons for dripping included produced thicker clouds of vapor (63.5%), made flavors taste better (38.7%), produced a stronger throat hit (27.7%), curiosity (21.6%), and other (7.5%). Logistic regression analyses indicated that male adolescents (odds ratio [OR] = 1.64), whites (OR = 1.46), and those who had tried multiple tobacco products (OR = 1.34) and had greater past-month e-cigarette use frequency (OR = 1.07) were more likely to use dripping (Ps < .05).


Curbing the DUI offender’s self-efficacy to drink and drive: A laboratory study

Walter Roberts & Mark Fillmore

Drug and Alcohol Dependence, March 2017, Pages 73–79

Method: Adult drivers with (n = 20) and without (n = 20) a history of DUI arrest attended two dose challenge sessions where they received 0.64 g/kg alcohol or placebo, completed a simulated driving task, and provided measures of subjective impairment. They attended a third retesting session where they received feedback that they were impaired by alcohol. They received 0.64 g/kg alcohol and their objective and perceived driving ability was retested.

Results: Both groups showed significant impairment of driving performance following 0.64 g/kg alcohol compared to placebo. DUI offenders rated themselves as less impaired than controls. After performance feedback, self-reported impairment during the alcohol retest increased for DUI offenders but not for controls. There was no effect of performance feedback on objective driving ability.

Conclusions: These results support the notion that under alcohol DUI offenders characteristically perceive themselves as better able to drive than non-offenders. These perceptions can be tempered by performance feedback. To the extent that perceived ability to drive safely after drinking contributes to DUI and its recidivism, feedback geared towards lowering this self-efficacy could reduce willingness to engage in this behavior.


Intergenerational Consequences of Adolescent Substance Use: Patterns of Homotypic and Heterotypic Continuity

Emily Nadel & Terence Thornberry

Psychology of Addictive Behaviors, March 2017, Pages 200-211

Does substance use run in families? In this article, we examine both homotypic continuity in substance use—the impact of a parent’s adolescent substance use on their child’s adolescent substance use — and heterotypic continuity — the impact of a parent’s adolescent substance use on their child’s involvement in other adolescent problem behaviors. The analysis is based on data from the Rochester Youth Development Study (Thornberry, Lizotte, Krohn, Smith, & Porter, 2003) and its intergenerational component, the Rochester Intergenerational Study (Thornberry, 2009). The initial study began with a representative sample of 7th and 8th grade students followed until Age 31, and the intergenerational study is currently following their oldest biological child from childhood through adolescence. The final sample size in the current analysis consists of 341 parent–child dyads. For fathers, their adolescent substance use predicts both homotypic and heterotypic outcomes of their child. For mothers, however, there is no evidence of intergenerational continuity for either homotypic or heterotypic outcomes. In contrast, when the parent’s adult substance use is examined, the opposite pattern emerges. The mother’s adult substance use is a more consistent predictor of child behavioral outcomes, but there is little evidence that the father’s adult behavior matters. Thus, it appears that the answer to the question of whether or not substance use runs in families is more nuanced than typically thought. Based on these results, continuity depends both on the sex of the parent and when in the parent’s life-course substance use occurs.


Brain substrates of reward processing and the μ-opioid receptor: A pathway into pain?

Frauke Nees et al.

Pain, February 2017, Pages 212–219

The processing of reward and reinforcement learning seems to be important determinants of pain chronicity. However, reward processing is already altered early in life and if this is related to the development of pain symptoms later on is not known. The aim of this study was first to examine whether behavioural and brain-related indicators of reward processing at the age of 14 to 15 years are significant predictors of pain complaints 2 years later, at 16 to 17 years. Second, we investigated the contribution of genetic variations in the opioidergic system, which is linked to the processing of both, reward and pain, to this prediction. We used the monetary incentive delay task to assess reward processing, the Children's Somatization Inventory as measure of pain complaints and tested the effects of 2 single nucleotide polymorphisms (rs1799971/rs563649) of the human μ-opioid receptor gene. We found a significant prediction of pain complaints by responses in the dorsal striatum during reward feedback, independent of genetic predisposition. The relationship of pain complaints and activation in the periaqueductal gray and ventral striatum depended on the T-allele of rs563649. Carriers of this allele also showed more pain complaints than CC-allele carriers. Therefore, brain responses to reward outcomes and higher sensitivity to pain might be related already early in life and may thus set the course for pain complaints later in life, partly depending on a specific opioidergic genetic predisposition.


The Effect of Prescription Drug Monitoring Programs on Opioid Utilization in Medicare

Thomas Buchmueller & Colleen Carey

NBER Working Paper, February 2017

The misuse of prescription opioids has become a serious epidemic in the US. In response, states have implemented Prescription Drug Monitoring Programs (PDMPs), which record a patient's opioid prescribing history. While few providers participated in early systems, states have recently begun to require providers to access the PDMP under certain circumstances. We find that "must access" PDMPs significantly reduce measures of misuse in Medicare Part D. In contrast, we find that PDMPs without such provisions have no effect. We find stronger effects when providers are required to access the PDMP under broad circumstances, not only when they are suspicious.


Prescription Drug Monitoring Programs Produce a Limited Impact on Painkiller Prescribing in Medicare Part D

Courtney Yarbrough

Health Services Research, forthcoming

Data Source: 2010–2013 physician-level Medicare Part D prescribing data released by the Centers for Medicare and Medicaid Services and Propublica.

Study Design: Using difference-in-differences models with physician-level fixed effects, the study compares prescribing in states with and without PDMPs for opioid and nonopioid analgesics, oxycodone, hydrocodone, and opioids by controlled substances Schedules II–IV.

Principal Findings: Prescription drug monitoring programs were associated with a 5.2 percent decrease in days supply prescribed per physician for oxycodone in addition to smaller reductions for hydrocodone and opioids overall (2.8 percent and 2 percent, respectively) and a small increase in prescribing for Schedule IV opioids. PDMPs were not associated with changes for nonopioid analgesics or other opioids in Schedules II and III. The effects of PDMPs were negated in states where statutes explicitly did not require use of the PDMP.

Conclusions: Prescription drug monitoring programs have a modest effect targeted at the high-profile drug oxycodone among the Medicare Part D population and an even smaller effect for hydrocodone and opioids in general. The findings suggest some substitution toward lower schedule opioids. Substantially addressing the widespread opioid abuse problem will require enhancing existing PDMPs or implementing new policies.

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