June 1999
DPRC Celebrates Its 10th Anniversary
D I R E C T O R S ’
M E S S A G E
W
ith this issue of the newsletter, we celebrate the 10th
anniversary of the Drug Policy Research Center’s founding. In 1989, America’s cocaine epidemic was still raging,
illicit-drug use was a major concern of the public, and the nation
had declared “war on drugs.” But so little information was available for policy formulation that wildly different solutions were
being offered by reasonable people. Mandatory minimum sentences were being enacted for the sale and use of drugs and the
death penalty urged against drug kingpins at the same time that
some were calling for legalization.
It was a propitious time for the establishment of an institution
devoted to injecting rigorously conducted, unbiased analyses into
the debate. We did not enter this arena predisposed toward any
particular solution. In fact, we ourselves were interested in getting
some solid answers to policy questions that had, to date, drawn
only opinions. With that goal in mind, we sought to
DPRC codirectors Audrey Burnam and Martin Iguchi
• reframe the debate around broad issues of effectiveness at achieving a goal and the costs
and other drawbacks of doing so
• contribute toward improving the basic data available, along with the tools for analyzing
the data
• foster the development of a broader community of researchers devoted to a similar analytic strategy.
We think we’ve made substantial progress along each of these lines. Over the past 10 years,
for example, the DPRC has contributed to a growing body of empirical research that has
shaped the drug policy debate. Initially, the center explored a very broad range of topics—
from community assessments to international comparisons, from models of coca-growing
in South America to analyses of street markets in U.S. cities. As DPRC matured, the early
descriptive comparisons of international drug policy yielded to frameworks for rationally
weighing different U.S. drug policy goals. Work by Rob MacCoun and Peter Reuter, in particular, exposed the oversimplification inherent in comparisons of U.S. drug policy and trends
with those in other countries such as the Netherlands. Their work showed that it was not just
legal status that influenced drug use but also commercial availability.
Modeling and Gaming
A milestone of integrative analysis was achieved in 1994 with Controlling Cocaine, one of
our most enthusiastically received and widely cited reports. In the early 1990s, it was unclear how programs as different as enforcement, interdiction, and treatment could be
In This Issue
DPRC Celebrates Its 10th Anniversary
Directors’ Message
1
Removing Health Plan Coverage
Limits on Substance Abuse
Services: Is It Affordable?
5
Knowing from Adam:
Improving the National Survey
of Drug Use by Arrestees
5
Shaping Our Nation’s Policy
for Safe and Drug Free Schools
and Communities
6
Collaborating with Phoenix House
on a Treatment Research Agenda
7
New People
8
New Publications
9
Advisory Board
11
compared. Peter Rydell and Susan Everingham found a way to
solve that problem and drew together many discrete research
projects to produce a unified understanding of the cocaine sysRewards and Risks of Selling Drugs in Washington, D.C.
tem. They collaborated with Jonathan Caulkins and others to use
the model in two subsequent studies of approaches to cocaine
Number of street dealers
24,000
control not addressed in the original research—Mandatory MinRegular-seller (at least 1 day per week) equivalents
14,000
imum Drug Sentences and An Ounce of Prevention, a Pound of
Median net monthly drug sale income of those selling
Uncertainty.
Daily
$3,600
Two or more days a week
$1,200
The model also became the engine that drove the computer
simulation in the DPRC’s drug policy game. By the mid-1990s, the
Hourly dealer income from drug selling (median)
$30
limitations of the center’s early stand-alone community assessHourly dealer income from legitimate job (median)
$7
ments had became apparent. Local leaders needed to know not
Portion of drug income spent on drugs for dealer use
28%
just what the data were, but also how to tie them into the deciRisk over a one-year period, for regular sellers, of
sionmaking process, and it took this game to bring the lessons to
Incarceration
22%
Injury
7%
life. As master gamer Jim Kahan is fond of saying, “I heard and I
Death
1.4%
forgot. I read and I remembered. I did and I understood.”
Sequestered from political exposure and routine demands, game
participants explored new policy options, received rapid feedback on their choices, and
In Money from Crime, Peter Reuter and Robert MacCoun conshared experiences with key players in other programmatic areas.
ducted interviews with street-level drug dealers in the nation’s
19 9 0
capital and learned that most were employed and spent more
hours earning legitimate income than selling drugs.
Treatment Research
R & R Railroad
Our cocaine modeling has strongly supported the relative cost-effectiveness of treatment for
reducing drug consumption. Another line of research at the DPRC addresses allocation of
treatment funds and effectiveness of treatment programs. For example, the center conducted a congressionally mandated evaluation of the formula used to allocate block grants for
19 9 2
substance abuse treatment to the states.
Several DPRC studies have addressed treatment efficacy. One
Jutland
such
project evaluated the effects of treatment programs on homeNew Elsinore
International
Airport
less people in Los Angeles County. Among persons who adhered
Route 253
to the regimen, treatment was effective at reducing drug use and
Route 32
symptoms of mental illness—but only temporarily, and most
Newton
subjects did not adhere to the regimen. DPRC has also conducted
The
Heights
North
evaluations of the effectiveness of programs treating drugFort
Station
North
Jutland
involved criminal offenders, who commit large numbers of
River
Route 6
crimes. In a major, ongoing series of projects, we are collaborating
City
Park
with methadone clinics to develop and evaluate a methodology for
West
Mid Town
East
City
Side
Parkside
Park
keeping methadone recipients off other drugs. The new approach
West
Route
stresses the importance of focusing on clients’ successes rather
253
Route 53
than their failures, and early results have been promising.
The Pier
Riverside
Downtown
In 1997, DPRC entered into a partnership with Phoenix House,
South
Erving
Station
Arena
a
nonprofit
organization providing drug use treatment, prevenR & R Railroad
Greyhound
tion, and education services in the Northeast, California, and
Station
Highway/Main Road
South
River
Texas. Phoenix House hoped to expand its research agenda and
Side
Railroad
Station
Route 53
enhance the use of data on its clients to understand and improve
their responses to treatment. We at DPRC wanted our staff to reDPRC staff convened a group of Miami community leaders one
ceive more practical exposure to the issues that a service provider faces and to apply our exOctober weekend to help solve the drug problems of the
pertise in a context where we could not only identify problems but help solve them. Both our
fictional city of New Elsinore. Participants in the drug policy
organizations have already made progress toward achieving our joint goals, and we have also
game appreciated the opportunity to work together instead of
begun an ambitious agenda of cooperative research funded by third parties.
just meeting together and the chance to explore what-ifs.
Players included Janet Reno, future U.S. Attorney General.
Prevention Research
Above we mentioned An Ounce of Prevention, a Pound of Uncertainty, our recent report on the
cost-effectiveness of model school-based drug prevention programs. One such program is Project ALERT, which was designed and evaluated by a team of researchers led by Phyllis Ellick-
2
19 9 4
300
250
Cocaine Consumption
(metric tons)
son. This intervention program is now being expanded from
a middle-school curriculum to one that lasts through the 11th
grade. The new program, Project ALERT Plus, seeks to sustain the reductions in cigarette and marijuana use observed
at the 8th-grade level among Project ALERT participants.
Project ALERT generated a database that we continue to
use to better understand substance abuse among adolescents and to support the formulation of new prevention
strategies. We have verified, for example, that alcohol misuse among teenagers is a major problem in the United States
and have recommended prevention programs that target alcohol misuse, not just initiation or experimentation.
Heavy Users
200
150
200
Light Users
50
0
1977
1982
1987
1992
Improving the Data
1972
Many drug policy analyses are hampered by the absence of
reliable data on existing programs. Hence, we have devoted
a considerable fraction of our effort to improving data and
the use of data by policymakers. Our activities have included
The Proportion of Cocaine Consumption by Heavy Users Has Increased
Cocaine Use Trends and Control Strategies.
Dissemination
Percent continuing in program
• assisting the Office of National Drug Control Policy in increasing the policy relevance of
national drug indicators, and the California Department of Alcohol and Drug Programs
in improving data and analysis to support decisionmaking
• analyzing the drug control budgets of the various federal agencies to assess the comparability of expenditure categories
• undertaking several efforts to improve the use of data by communities (for example, we
helped a coalition of organizations in Houston take steps toward a decision support system to match treatment supply and demand)
• helping standardize data describing illegal-drug markets and
revising estimates of the responsiveness of drug consumption to
100
price changes.
In Controlling Cocaine, Peter Rydell and Susan Everingham
constructed a model of cocaine use careers and the cocaine
market. The model showed that although the number of users
was falling, total use was holding steady because heavy users
were accounting for a greater portion of cocaine consumers.
19 9 5
80
60
Although research is central to the DPRC’s mission, it does little
40
good to conduct research without communicating the findings. We
Resident
communicate results to policymakers and researchers through re20
ports, books, and research summaries published by RAND. ReNonresident
0
search is also communicated to the research and practitioner com10
30
5
15
20
25
0
munity through such scholarly journals as Science, Addiction, and the
Total Program-Weeks
American Journal of Public Health.
Forty percent of clients referred to each treatment program
We have held press conferences on newsworthy findings at the
did not attend a single session, and another 10 to 20
time of publication to ensure that they reach the widest possible
percent attended for two weeks or less. These disappointing
results are similar to retention rates reported elsewhere for
audience. Release of reports such as Controlling Cocaine and
the treatment of persons with severe mental illness and
Mandatory Minimum Drug Sentences was followed by articles and
substance abuse.
editorials in many newspapers including The New York Times and
on CNN, C-SPAN, the ABC evening news, and NPR.
DPRC researchers have personally reported findings to a broad
Treating the Dually Diagnosed Homeless.
spectrum of audiences, from community organizations to such key leaders as the director
A research team led by Audrey Burnam found that a treatment
of the Office of National Drug Control Policy. Several DPRC staff members have testified
program for mentally ill substance abusers among the homebefore Congress; members of congressional staffs attended a half-day forum we held in
less had no effect. The result was not surprising, considering
Washington, D.C.
that many of those enrolled did not stick with the program long
As a result of these efforts, DPRC research now figures prominently in debates about drug
(as shown in graph above). But even among those who stayed,
policy. Quotes from our reports have been copied directly into national drug control strateffects had dissipated within nine months. The researchers conegy reports, and, at a summit of drug policy czars in San Diego, 7 of 10 references to drug polcluded that the homeless might need permanent housing
icy studies were to RAND work.
before their substance abuse could be successfully addressed.
3
Building the Research Community
19 9 7
0
20
40
60
80
Weekly drinking
Problem drug use
Any cocaine use
Minor delinquency
Felony delinquency
Drug selling
Dropping out
Low academic orientation
Poor mental health
Early pregnancy
■ Multiple, persistent violence
■ No violence
Percentages of Violent and Nonviolent High-School Seniors
and Drop-Outs Engaging in Drug-Related Activities
Data collected during RAND’s Project ALERT have continued to
support analyses of youth behavior. Phyllis Ellickson, Hilary
Saner, and Kimberly McGuigan recently demonstrated a
connection between youth violence and a number of other
problems (those relating to drugs are shown above). The
findings suggest that violence will have to be addressed in
concert with these other problems.
• Individual staff within the DPRC have organized
symposia on drug policy at professional conferences, given presentations at such symposia, and
edited special volumes in journals that do not
traditionally focus on drug issues.
• The center has sponsored seminars at RAND and
in conjunction with UCLA.
• We hosted a week-long summer institute that
brought together drug policy experts from across
the country and from overseas to analyze and
debate fundamental trends and objectives of
drug policy.
A week is long enough to share experiences but
not to collaborate on research. Therefore, the DPRC has sponsored visiting scholars. And we
have paid special attention to developing the careers of young drug policy researchers
through our support of Ph.D. dissertations, other graduate-student work, and postdoctoral fellowships. These young scholars have gone on to university or federal-government positions. Of course, there are local benefits of our efforts to improve a nationwide community
of researchers: We believe that our seminars, conferences, hosting of visiting scholars, and sponsorship of students have contributed greatly to the intellectual environment of the DPRC and
to the quality of our work.
• • •
The drug policy debate seems to have inched toward greater rationality over the past 10
years, and we like to think that we have contributed. As the new millennium approaches
and policymakers and insurers press for greater accountability, issues of cost and effectiveness are becoming all the more important. We hope to continue our efforts to conduct
research, disseminate our findings, and build a researcher corps in this most fractious of
public policy arenas.
Audrey Burnam
Martin Iguchi
DPRC Staff May 1999
4
100
In the past 10 years, we have made progress in contributing to the development of a community of
drug policy analysts. The few people conducting research in this area tend to be isolated and do not
benefit from collegial interaction to the extent that
researchers in other policy fields do. Our approaches
to strengthening the community of drug policy researchers include the following:
Removing Health Plan Coverage
Limits on Substance Abuse Services:
Is It Affordable?
In 1996, Congress passed the Mental
Health Parity Act, which prohibits dollar
limits on mental-health benefits offered
by insurance plans, including managedcare plans. Substance abuse, however, was
explicitly excluded from the act’s provisions. Almost all employer-sponsored
health plans limit the type or quantity of
substance abuse services for which members are eligible. The principal reason for
these limits is uncertainty about costs—
the fear that removing limits will result in
a dramatic increase in use of substance
abuse services and a concomitant rise in
the costs of the plan.
At the time that mental-health parity
legislation was under consideration by
Congress and state legislators, RAND
economist Roland Sturm conducted a
study that served as an impetus to its passage.1 The study demonstrated that establishing parity would not, as some feared,
greatly increase health plan costs. Sturm
and his associates then turned their attention to substance abuse. The new study 2
was funded principally by The Robert
Wood Johnson Foundation and the National Institute on Drug Abuse, with additional support from DPRC and the
UCLA/RAND Center on Managed Care
for Psychiatric Disorders. It showed,
again, that concerns about big cost increases appear to be unfounded.
A principal reason why such fears have
proven wrong is that they have been overtaken by events. They were based on old
data from an era when fee-for-service
plans dominated the behavioral-health
field. Now, most of the privately insured
U.S. population receives mental-health
1Roland Sturm, “How Expensive Is Unlimited
Mental Health Care Coverage Under Managed
Care?” The Journal of the American Medical Association, Vol. 278, No. 18, November 12, 1997, pp.
1533–1537.
2Roland Sturm, Weiying Zhang, and Michael
Schoenbaum, “How Expensive Are Unlimited Substance Abuse Benefits Under Managed Care?” The
Journal of Behavioral Health Service & Research, Vol.
26, No. 2, May 1999, pp. 203–210.
and substance abuse services through
managed-care arrangements with companies specializing in this field. These
“carve-out” arrangements typically involve preauthorization and intensive concurrent utilization review.
Sturm and his colleagues took a
straightforward approach. They obtained
1996–1997 beneficiary-level expenditure
data on 25 plans managed by a large
carve-out company. They selected plans
that offered a comprehensive array of
substance abuse services, required low copayments (e.g., $10 or less per outpatient
session), and had no annual coverage limits. They calculated how much was spent
in excess of annual coverage limits in
common usage by other plans (e.g.,
$10,000 for the more generous plans and
$1,000 for the less generous). The excess
total was then divided by the number of
enrollees to obtain a per-capita cost of
eliminating these coverage limits.
The researchers found that the total
cost of substance abuse services in these
very generous plans amounted to $5.11
per year per covered individual—only a
tenth of the $49 the plans pay for all behavioral-health services. The cost with
various coverage limits in place would be
as shown in the table. The difference between any of those amounts and $5.11 is
the cost per plan member of removing
that limit. Even companies enforcing a
relatively low $1,000-per-year coverage
limit would incur an additional cost of
only $3.39 per plan member, or about 0.2
percent of the $1,500 a company might
pay a health maintenance organization
for all medical services. The effects of removing a $10,000 limit would probably
not even be noticed.
Costs of Substance Abuse Services
with Different Coverage Limits
Annual
Coverage Limit
Annual Cost
Per Member ($)
None
5.11
$10,000
5.05
$5,000
4.33
$1,000
1.72
While the no-limit plans’ cost per
member is small, the benefit for many individuals needing substance abuse services is quite large. Forty-three percent of
these individuals incurred annual costs
over $1,000. The average excess amount
incurred, i.e., the average amount for
which the patient was responsible, was
approximately $2,600. Had a $1,000 limit
been in place, these people would not
have been compensated by their employer’s plan for what were presumably
medically necessary services (given their
approval within an intensively managed
system). They would probably not have
paid the $2,600 out of pocket; either they
would have turned to the public sector or
gone without the needed treatment.
Sturm and his colleagues concluded
that, in contrast to the common belief
that unlimited substance abuse benefits
will break the bank and are not a realistic
policy option, “parity” in employersponsored health plans is affordable
under comprehensively managed care.
They conceded that tight management
could affect the most severely ill patients.
However, they had little doubt that
parity-level benefits under managed care
would increase continuity of treatment
and reduce dumping of severely ill patients into the public sector compared
with the present situation in which those
patients exceed coverage limits. ■
Knowing from Adam:
Improving the National Survey
of Drug Use by Arrestees
DPRC’s mission of analysis in support of
drug policymaking cannot be achieved
without good data; therefore, one of
DPRC’s principal objectives is to improve
the data available. The National Institute
of Justice (NIJ) is reviewing its Arrestee
Drug Abuse Monitoring (ADAM) program and asked DPRC what changes
might make the system more useful to analysts seeking to construct reliable models
of drug careers, markets, and control
strategies. In response, a team headed by
Susan Everingham identified topics on
which additional information potentially
obtainable through ADAM would be
5
most helpful to these modeling efforts.
The researchers also suggested ways in
which ADAM’s capabilities could be expanded within current funding levels.
Under ADAM, once every three
months, a sample of arrestees booked into
jails in participating cities are given a
questionnaire focusing on their drug use
and on associated conditions and behaviors (such as drug dependency and criminal activity). This series of surveys allows
policymakers and analysts to track use
trends among a population with high use
rates that is not sampled well in other nationwide surveys, such as the National
Household Survey of Drug Abuse.
The DPRC team began by reviewing
ADAM’s dual roles of supporting both
monitoring and modeling. They noted
that, in practice, the modeling function
has been somewhat neglected and argued
that more attention be paid to it for two
reasons. First, modeling is a valuable
technique for understanding and predicting future drug use and the effects of policy changes. Second, modeling can support monitoring. As an example, they
pointed to the exponential growth in the
number of crack users in the 1980s, which
led to draconian responses from policymakers fearing a crack epidemic in the
general population. Forecasting models,
using data gathered from the ADAM population, could have revealed that crack
was indeed growing exponentially among
heavy users of other expensive drugs but
not among the population in general. Because the total numbers of such users are
limited, the plateau in the crack growth
curve could have been anticipated and
more appropriate policies adopted.
The DPRC team acknowledged the
great utility of ADAM’s current questions
to modelers but identified several topics
about which little is currently known, for
which more information would be particularly helpful in answering modelers’
questions, and for which ADAM is in an
especially good position to provide additional data. These include information regarding the following:
• Heavy users—how many are there,
how much do they use and when, how
6
dependent are they on their drugs, and
how long are their drug-using careers?
• Drug markets—how do they operate,
where do they operate (e.g., indoors or
out), how does money flow through
them, how available are drugs, and how
much time does it take to find them?
• Enforcement—what do drug buyers
and sellers know about enforcement
and what do they perceive to be the
risks of getting caught and punished?
Everingham and her colleagues also
suggested ways to improve linkages between ADAM and other data sets and to
correct for the current deviance of
ADAM’s sample of arrestees from a truly
random sample. The goal of these and
other recommendations from the DPRC
team is to make ADAM, already a useful
tool for some within the drug policy community, even more broadly valuable. ■
New Projects
Shaping Our Nation’s Policy for
Safe and Drug Free Schools and
Communities
The Safe and Drug Free Schools and
Communities (SDFSC) program represents one of the nation’s largest investments in reducing substance abuse and
violence among American youth and in
providing young people with a school environment that is conducive to learning.
For more than a decade, the program has
provided some half billion dollars to
states, school districts, and schools in support of drug and violence prevention and
safety programs that recipients believe
best serve their needs.
A confluence of important developments at a variety of levels has spurred
government interest in improving the effectiveness of the SDFSC program. First,
there are the concerns of high-level policymakers regarding recent incidents of
drugs and violence in schools, coupled
with the decision to reauthorize this significant federal government appropriation. Second, the SDFSC program office is
focusing more on accountability, effectiveness, and pursuing research-based
prevention programs. Third, progress in
school reform over the past decade has
generated many lessons to help identify
programs that are not only effective on a
small scale, but remain so when scaled up
and extended over time—essentially becoming part of the institution.
In recognition of the DPRC’s major
contributions to preventing adolescent
drug use, the Department of Education
has funded a DPRC proposal to provide
guidance on refining the SDFSC program. To pursue this objective, Peter
Reuter and Michael Timpane are organizing a small conference this July 22–23 in
Wye, Maryland. The conference will
bring together nationally prominent
researchers, policymakers, and practitioners from drug- and violence-prevention
programs, behavior modification programs conducted in school settings, and
school reform programs. Presentations
and discussion will focus on
• placing greater emphasis on joint, community-based work among federal
agencies—particularly the departments
of Education, Justice, and Health and
Human Services
• providing the states with information
and analysis that would be useful if
they were to receive greater discretion
over SDFSC funds
• developing a strong, focused researchand-evaluation approach for the program’s activities, to provide empirically
based policy guidance for an area in
which collecting reliable data has been
notoriously difficult and expensive
• modifying program policy or procedures to encourage greater support
within, and integration into, the
school-based reforms that are becoming both more numerous and more
dominant in shaping the educational
landscape.
The organization of this conference
offers an exciting opportunity for the
DPRC to apply experience from seminal
work on related projects—such as Project
ALERT and ALERT Plus. It also provides
yet another chance to demonstrate how
research and policy analysis can play a
critical role in informing national policies.
Collaborating with Phoenix House
on a Treatment Research Agenda
Two years ago DPRC entered into a partnership with Phoenix House, a nonprofit
organization providing drug use treatment, prevention, and education services
for adults and juveniles in several states. A
primary goal of our collaboration has
been to develop a program of treatment
research and secure outside funding for it.
Two successful ventures along these lines
have been initiated.
Comparing Substance Abuse Treatments
for Adolescent Probationers
Adolescent abuse of alcohol and other
drugs is prevalent, costly, and a growing
public health problem. In part, these costs
are exacerbated by the fact that adolescents with the most severe problems often
do not receive treatment until they come
under the supervision of juvenile courts.
In California, for instance, almost half of
all teenagers receiving drug treatment services were referred by the court system.
Unfortunately, by the time drug-using
adolescents reach the criminal justice system, they tend to be alienated from their
families and extensively involved in truancy and delinquent behavior, violence,
and other dangerous or destructive activities. As such, they are in grave need of
treatment services that do more than
eliminate substance abuse; treatments
must challenge teenagers to accept greater
responsibility for their lives and help
them to better address the problems contributing to their drug use.
Recognizing the obvious importance of
understanding the need for adolescent
treatment programs and evaluating their
outcomes, the federal Center for Substance Abuse Treatment (CSAT) has
awarded DPRC over a million dollars to
study the effects of “suitable placements,”
or group treatment homes, on the treatment outcomes of adolescent probationers who have a history of drug use. This
RAND Adolescent Outcomes Project is
led by principal investigator Andrew Morral and survey director Pat Ebener. It is
being carried out in cooperation with the
Los Angeles Juvenile Courts, the Los
Angeles County Department of Probation,
the Phoenix Academy of Lake View Terrace, and six other adolescent group
homes in Los Angeles County.
The RAND research team will interview 400 drug-using adolescent probationers before, during, and after they
receive rehabilitation services either at
Phoenix Academy or at comparison group
homes. Questions cover a range of issues
such as drug use, school performance,
criminal behavior, family and living environment, and psychosocial functioning
and productive activity. To ensure a complete and effective evaluation, the experiences of probationers who drop out of the
programs will also be evaluated. The
dropout problem is not inconsequential:
Attrition rates at some group homes are
expected to be well over 50 percent.
DPRC believes the results of this study
will shed light on a number of critical
questions with respect to improving adolescent substance abuse programs:
• What types of adolescents are most
helped by extensive social rehabilitation, such as that provided at Phoenix
Academy? What problems are likely
to be most amenable to this type of
therapeutic-community treatment?
• Are there important differences
among group homes? What program
characteristics are most beneficial to
probationers?
• What are the relative benefits of
shorter versus longer stays in homes?
Most treatment lengths now average
one year, but there is growing pressure
on the providers of residential programs for adolescents to provide
shorter treatments.
The RAND Adolescent Outcomes
Project represents the largest externally
funded project that has yet resulted from
the RAND–Phoenix House partnership
begun just two years ago. Both organizations hope to build on this collaborative
effort toward improving adolescent drug
use treatment and prevention.
How Well Are Juvenile Drug Treatment
Programs Doing?
prosecutors, and probation officers in the
juvenile justice system have little empirical
evidence on which to assess treatment
options. Phoenix House and RAND are
collaborating to address this need in a
study funded by the National Institute of
Justice under its Juvenile Accountability
Incentive Block Grant program. The new
study will identify
• what kinds of offenders benefit from
what kinds of services
• how long and how well offenders engage in different programs
• what kinds of outcomes should be expected, given differences in adolescents, services, and costs
• how those outcomes can be measured.
In the last six months, the DPRC project team, led by Patricia Ebener, has conducted a large-scale trial of Phoenix
House’s system for tracking treatment
process and outcomes from the time juveniles are admitted to a program through
posttreatment follow-up. Working from
data on 120 youths referred to Phoenix
House in Los Angeles and Yorktown,
New York, the project team has
• developed preliminary profiles of applicants and identified characteristics
that predict admission to treatment
and retention
• developed and tested tools for measuring the treatment process and
monitoring outcomes.
The next step will be to use the data to
assess the validity of juvenile offenders’
self-reported criminal history. Since criminal status is a principal outcome measure
for youths in drug treatment, it is important to determine whether the information they provide about themselves
through routine monitoring is reliable.
This research will help Phoenix House
understand and improve its clients’
responses to treatment and demonstrate
program effectiveness to potential funders. We also hope that research results
will provide a model that other treatment
providers can adapt to their needs. ■
Although young drug offenders have
increasing access to treatment, judges,
7
New People
Ricky Bluthenthal joined RAND as
an associate sociologist in September
1998 shortly after receiving his Ph.D. in
sociology from the University of California, Berkeley. His research interests
include innovative HIV prevention
strategies for injection drug users, especially syringe exchange programs; access
to drug treatment for illicit-substance
users; and the relationship among race,
poverty, and health in low-income
minority populations. Ricky is currently
involved in two studies. He is co–
principal investigator on a Robert Wood
Johnson Foundation–funded study of
how treatment on demand affects longterm injection drug users. He is also the
site director of a study, funded by the
National Institute on Drug Abuse
(NIDA), on the diffusion of benefits
from syringe exchange programs. In
addition to his appointment at RAND,
Ricky is an assistant professor in the
Department of Psychiatry and Human
Behavior at Charles R. Drew University
of Medicine and Science, and the associate director of the Prevention and Treatment Services Core of the Center for HIV
Identification, Prevention, and Treatment Services at UCLA.
Kara Riehman is working at RAND as
part of her postdoctoral research fellowship at the UCLA Drug Abuse Research
8
Center. Kara received her Ph.D. in sociology from Florida State University in 1998.
Her research has focused on evaluation of
HIV interventions, drug use and HIV risk
behavior, and social and contextual influences on substance abuse behavior and
treatment outcomes. She worked for five
years as a research assistant and data
manager on an HIV intervention study
funded by the National Institutes of
Health and targeting low-income women
at risk of HIV. She also served as a consultant to the World Bank for a policy research report on AIDS in developing
countries. At RAND, Kara is working
with Andrew Morral and Martin Iguchi
on an NIDA-funded study of methadone
detoxification treatment employing contingency management intervention. As
part of this project, she will soon begin a
pilot study examining the influence of dynamics within couple relationships on
treatment retention and outcomes.
Psychiatrist Katherine Watkins joined
the DPRC research team last year after receiving her master of science degree in
health services from the UCLA School of
Public Health, where she studied for two
years as a Robert Wood Johnson clinical
scholar. She received her M.D. from the
University of Pennsylvania and did her
residency in the UCLA Department of
Psychiatry, where from 1995 to 1996 she
was chief resident of the Dual-Diagnosis
Ward at the Brentwood Veterans Administration facility. Katherine’s research interests include the access and delivery of
care to individuals dually diagnosed with
mental illness and substance abuse, with a
special focus on women with mental illness and substance abuse problems and
how gender affects service delivery and
access. In her current projects, she is assessing the effect on health of recent legis-
lation terminating Social Security disability benefits to substance abusers and measuring the equity of mental health care
under managed care. Katherine is also the
director of mental health services at Prototypes Women’s Center, a residential
treatment facility for substance-abusing
women and their children.
Rosalie Liccardo Pacula came to
RAND from the University of San Diego,
where she was an assistant professor
teaching health economics and statistics
in the School of Business. She received
her Ph.D. in economics at Duke University in 1995, where her doctoral work examined the relationship among demands
for cigarettes, alcohol, and marijuana in
youth—i.e., the so-called gateway hypothesis. Much of Rosalie’s subsequent
research has focused on drug policy, risky
adolescent behavior, and the evaluation
of health care policies. Before coming to
RAND, she spent a year on leave at the
University of Illinois at Chicago working
on a project to develop a system surveying
state and local policy and prevention programs targeted at alcohol, tobacco, and
illicit-drug use among youth. Since coming to RAND in September 1998, Rosalie
has worked on a number of different projects, including an evaluation of state
mental-health mandates on the cost and
utilization of mental health services, the
development of the risky-youth-behavior
module for the LA Family and Neighborhood Study, and an evaluation of NIJ’s
ADAM survey instrument and its usefulness for modeling purposes (see article in
this issue). ■
New Publications
䊳 Jonathan P. Caulkins, C. Peter
Rydell, Susan S. Everingham, James
Chiesa, and Shawn Bushway, An
Ounce of Prevention, a Pound of
Uncertainty: The Cost-Effectiveness
of School-Based Drug Prevention
Programs, Santa Monica, Calif.:
RAND, MR-923-RWJ, 1999.
䊳
Anglin, M. Douglas, Douglas Longshore, and Susan Turner, “Treatment Alternatives to Street Crime: An Evaluation
of Five Programs,” Criminal Justice and
Behavior, in press.
Reviews the evolution over the last
quarter-century of a model for managing
criminal offenders involved with drugs.
Reports findings from an evaluation
of five programs—two randomized
controlled trials and three quasiexperimental—that were designed and
implemented under this model. Finds
favorable effects of the model on service
delivery and offenders’ drug use. Reports
mixed, difficult-to-interpret findings
on criminal recidivism. Concludes with
recommendations for improving the
model and similar programs within the
criminal justice system.
䊳
Bluthenthal, Ricky N., Alex H. Kral,
Elizabeth A. Erringer, and Brian R. Edlin,
“Drug Paraphernalia Laws and InjectionRelated Infectious Disease Risk Among
Drug Injectors,” Journal of Drug Issues,
Vol. 29, No. 1, 1999, pp. 1–16.
Tests the hypothesis that state laws
prohibiting injection drug users from
possessing syringes deter these users
from carrying syringes and thus promote
syringe-sharing. Finds that 35 percent of a
sample of northern California injection
drug users report concern over being arrested while carrying drug paraphernalia.
Finds also that those so concerned are
more likely than other injection drug
users to share syringes and injection supplies. Suggests that such risky behaviors
would probably be reduced by decriminalizing syringes and needles.
䊳
Booth, Robert E., Carol Kwiatkowski,
Martin Y. Iguchi, Francesca Pinto, and
Debbie John, “Facilitating Treatment
Entry Among Out-of-Treatment Injection Drug Users,” Public Health Reports,
Vol. 113, Supplement 1, June 1998,
pp. 116–128 (available from RAND as
RP-743).
Reports preliminary results following
the first two years of a five-year study.
DPRC’s latest study of the costeffectiveness of drug control measures
has just been published in book form
by RAND. Previous studies addressed
the cost-effectiveness of treatment and
various enforcement strategies.* The
current study focuses on school-based
drug prevention programs that have
proven effective in formal evaluations.
The authors infer effectiveness at reducing cocaine consumption from effectiveness at reducing marijuana initiation.
They account for spillover effects on those not participating in the program, which
is important, as it is rarely considered and makes up most of prevention’s effect on
cocaine reduction. Given substantial uncertainties in all pertinent factors, the costeffectiveness estimation framework is constructed to permit easy substitution of
alternate values at reader preference or as more information becomes available.
The authors conclude that prevention can reduce lifetime cocaine consumption by
2 to 11 percent. Although these effects are small, prevention programs are inexpensive, so the associated cost-effectiveness values are comparable with those of a
range of enforcement strategies. Treatment, however, still appears to be the most
cost-effective approach. The authors also evaluate the cost and effectiveness of implementing model school-based prevention programs nationwide. They conclude
that such an effort would cost only a tiny fraction of what the United States now
spends on drug control, but its effect on the cocaine-using population would be
modest and slow to accumulate.
*C. Peter Rydell and Susan S. Everingham, Controlling Cocaine: Supply Versus Demand Programs,
Santa Monica, Calif.: RAND, MR-331-ONDCP/A/DPRC, 1994; Susan S. Everingham and C. Peter
Rydell, Modeling the Demand for Cocaine, Santa Monica, Calif.: RAND, MR-332-ONDCP/A/DPRC,
1994; Jonathan P. Caulkins, C. Peter Rydell, William L. Schwabe, and James Chiesa, Mandatory Minimum Drug Sentences: Throwing Away the Key or the Taxpayers’ Money? Santa Monica, Calif.: RAND,
MR-827-DPRC, 1997.
Tests the success of motivational interviewing at moving injection drug users
from the streets into treatment. Finds
that this technique is no more successful
than a counseling technique already in
use. Finds also that, regardless of motivational technique used, more injection
drug users enter treatment if it is provided for free than if they have to pay
for it.
䊳
Caulkins, Jonathan P., Edward H.
Kaplan, Peter Lurie, Thomas O’Connor,
Sung-Ho Ahn, “Can Difficult-to-Reuse
Syringes Reduce the Spread of HIV
Among Injection Drug Users?” Interfaces,
Vol. 28, No. 3, May–June 1998, pp. 23–33
(available from RAND as RP-689).
Presents a mathematical model describing how the proportion of drug use
injections that potentially transmit HIV is
9
affected by introducing difficult-to-reuse
syringes. Finds that introducing a certain
number of difficult-to-reuse syringes and
simultaneously reducing the consumption of regular syringes will increase, not
decrease, the proportion of infectious injections. Concludes that there is little justification for substituting the difficult-toreuse syringes, which are more expensive,
for regular ones.
䊳 Ellickson, Phyllis, “School-Based Substance Abuse Prevention: What Works,
for Whom, and How?” Chapter 4 in
Snehendu B. Kar, ed., Substance Abuse
Prevention: A Multicultural Perspective,
Amityville, N.Y.: Baywood Publishing,
1999, pp. 101–128.
Reviews which drugs are most prevalent among adolescents and how prevalence varies by race, ethnicity, and gender.
Discusses what factors influence adolescent drug use, how those factors vary by
race and ethnicity, and which factors can
be addressed by prevention. Reviews evaluations of the effectiveness of schoolbased prevention programs. Suggests that
programs need to be sensitive to developmental changes in a child’s vulnerability
and take family and school attachments,
along with peer pressures, into account.
Wenzel, “Utilization of Mental Health and
Substance Abuse Services Among Homeless Adults in Los Angeles,” Medical Care,
Vol. 37, No. 3, 1999, pp. 306–317.
Reports on a sample of homeless
adults, two-thirds of whom were chronically dependent on substances and 22
percent of whom experienced chronic
mental illness (with large overlap between
the two conditions). Finds that only onefifth of those in each group had been
treated for their condition within the previous two months. Use of mental-health
services was dependent mostly on needrelated factors; in contrast, use of substance abuse services was also dependent
on location and knowledge of the system,
reflecting supply constraints.
䊳 Longshore, Douglas, Peter Reuter, Jack
Derks, Martin Grapendaal, and Patricia
Ebener, “Drug Policies and Harms: A
Conceptual Framework,” European Addiction Research, Vol. 4, 1998, pp. 172–182.
Reports on a study conducted in
conjunction with RAND Europe and the
Netherlands Ministry of Justice. Proposes
key dimensions of drug policy and harm
on which different jurisdictions might be
rated, in support of obtaining linkages
between policy elements and harm
variations.
䊳
Iguchi, Martin Y., “Drug Abuse Treatment as HIV Prevention: Changes in Social Drug Use Patterns Might Also Reduce
Risk,” Journal of Addictive Diseases, Vol.
17, No. 4, 1998, pp. 9–18; also in Edward
Gottheil and Barry Stimmel, eds., Effects
of Substance Abuse Treatment on AIDS
Risk Behaviors, Binghamton, N.Y.: Haworth Press, 1998, pp. 9–18.
Reports the effects of a methadone
detoxification treatment regimen on frequency and location of opiate use, patterns of social drug use, and number of
potential HIV exposures. Finds dramatic
decreases in rates and amounts of use
during treatment and large-scale changes
in the frequency of use with others. Discusses implications of these observations
for HIV transmission.
䊳
Koegel, Paul, Greer Sullivan, Audrey
Burnam, Sally C. Morton, and Suzanne
10
䊳
MacCoun, Robert, and Peter Reuter,
“Drug Control,” in Michael Tonry, ed.,
The Handbook of Crime and Punishment,
New York: Oxford University Press, 1998,
pp. 207–238 (available from RAND as
RP-731).
Presents an analytic framework for
thinking about how drug policy affects
drug use and related problems and what
the elements are of drug policy. Describes
American drug policy and assesses the
principal programs. Briefly reviews Western European policies. Discusses the future of drug problems and policies in the
United States and what might constitute
more effective drug policy. Recommends
that the traditional focus of U.S. drug policy on reducing the number of users be
balanced by attention to the level of drugrelated harm.
䊳
Morral, Andrew R., Martin Y. Iguchi,
and Mark A. Belding, “Reducing Drug
Use by Encouraging Alternative Behaviors,” Chapter 10 in Stephen T. Higgins
and Kenneth Silverman, eds., Motivating
Behavior Change Among Illicit-Drug
Abusers: Research on Contingency Management Interventions, Washington, D.C.:
American Psychological Association,
1999, pp. 203–220.
Reviews methadone maintenance
studies in which attempts are made to
reduce the use of “target drugs” (e.g.,
heroin) by reinforcing clients for
behaviors other than the one typically
reinforced—providing drug-free urine
samples. Focuses on studies in which
clients are reinforced for behaviors
directed toward improving family life,
economic functioning, and physical
health. Finds that some such contingency
management approaches reduce the use
of target drugs and suggests ways they
might be improved.
䊳
Turner, Susan, Peter Greenwood,
Terry Fain, and Elizabeth Deschenes,
“Perceptions of Drug Court: How Offenders View Ease of Program Completion, Strengths and Weaknesses, and the
Impact on Their Lives,” National Drug
Court Institute Review, in press.
Reviews the implementation of a postsentence drug court for first-time felony
probationers convicted of drug possession or use in Maricopa County, Arizona.
Reports the results of interviews with 29
drug court participants regarding their
perceptions of the difficulty of completing
program requirements, the program’s
strengths and weaknesses, and its helpfulness in attaining their goals. ■
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11
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