muskie school of public service reducing substance abuse ...detox provider • more than half of all...

Muskie School of Public Service Cutler Institute for Health and Social Policy

Reducing Substance Abuse in


Reducing Substance Abuse in Rural America

David Hartley, PhD, MHA

Maine Rural Health Research Center

National Conference of State LegislaturesNational Conference of State LegislaturesUpdate on Rural Health Policy

April 8, 2010p

Muskie School of Public Service Cutler Institute for Health and Social PolicyMuskie School of Public Service Cutler Institute for Health and Social Policy

OverviewOverviewPrevalence of drug and alcohol gabuse

Trends

P tiPrevention

TreatmentTreatment


Exploring Rural Substance Abuse

• Rural areas may lack the continuum of services needed to assess, diagnose, treat, and evaluate substance , g , ,abuse patients.

• Lower use of most substances in rural areas; however,Lower use of most substances in rural areas; however, use of alcohol, oxycontin, and methamphetamine is higher for rural youth than urban (Hartley, Gale, and Lambert, 2008).

• Substantial regionalization in drug-of-choice – opiates in the northeast, mid-Atlantic and California; cocaine in the , ;South and Midwest; amphetamines in the West; and marijuana in the northern border states (McAuliffe and Dunn, 2004).


What substances are we talking b ?about?

Substance Large Urban Small Rural gAlcohol 62% 59%Marijuana 17% 15%Methamphetamine .5% 1.1%Methamphetamine .5% 1.1%Oxycontin 1% 1%Inhalants 2.1% 2.3%Bi D i ki 25 2% 24 9%Binge Drinking 25.2% 24.9%Binge Drinking age 12-17 9.7% 12.3%DUI 14.5% 15.2%DUI age 12-17 3.8% 6.6%

2008 data from NSDUH


Past Year Methamphetamines and OxyContin Use by aPast Year Methamphetamines and OxyContin Use by a Five-Tiered Measure of Rurality(2002-2004)

9

10

6

7

8

ge

MetroRural Adjacent

4

5

6

Per

cent

ag Rural AdjacentLarge RuralMedium RuralSmall Rural

0.6 0.50.8 0.61.3

0.80.9 0.80.5 0.31

2

3 Small Rural

0Methamphetamines OxyContin (2004 only)


Past Year Alcohol Use Among Urban andPast Year Alcohol Use Among Urban and Rural Youth (2002-2004)

81 890

100

78.2 76.581.8

74.2

60

70

80

90

Metro

33.7 36.3 37 37.740

50

60 MetroRural AdjacentLarge RuralMedium and Small Rural

10

20

30

(2004 only)0

Alcohol Use Age 12-17 Alcohol Use Age 18-25


Past Year OxyContin Use by Urban andPast Year OxyContin Use by Urban and Rural Youth (2004)

9

10

6

7

8

9

e Metro

2 8 2 84

5

6

Perc

enta

ge

MetroRural AdjacentLarge RuralMedium and Small Rural

0.7

1.71.2

1.81.2

2.8

0.5

2.8

1

2

3

(2004 only)0

Age 12-17 Age 18-25

Muskie School of Public Service Cutler Institute for Health and Social PolicyMuskie School of Public Service Institute for Health Policy

Past Year Methamphetamine Use by UrbanPast Year Methamphetamine Use by Urban and Rural Youth (2002-2004)

9

10

6

7

8

9

e Metro

2 7 2 94

5

6

Perc

enta

ge

MetroRural AdjacentLarge RuralMedium and Small Rural

0.71.5

0.9

2.2

1.2

2.7

1.2

2.9

1

2

3

0Age 12-17 Age 18-25


P li i C l iPreliminary Conclusions:• Lower use of most substances in rural• Lower use of most substances in rural

areasP tt f th diff t• Patterns for youth are different– Alcohol age 12-17 increases with rurality– Oxycontin age 18-25 increases with rurality– Meth increases with rurality for age 12-25

• Rural young adults are high risk group for meth, oxycontin and alcoholy

Methamphetamine and Oxycontin

Drug

2004

Large

2004Non-metro

2008

Large

2008Non-metroDrug

AgeLargeMetro

metroMed/Small

LargeMetro

metro Med/Small

Meth 0.7% 1.2% 0.5% 0.7%12-17Meth18 25

1.5% 2.9% 0.8% 2.1%18-25Oxy

12-170.7% 0.5% .7% 1.1%

12 17Oxy

18-251.7% 2.8% 1.5% 2.1%

Driving Under the Influence by AgeDriving Under the Influence by Age2004 2004

Non-2008 2008

Non-

Age Metro

Nonmetro

Med/Small Metro

Nonmetro

Med/Small

Total 14.3% 11.8% 15.5% 15.2%

12-17 3.7% 7.2% 3.8% 6.6%

18-25 25.9% 26.6% 26.4% 26.4%


H d t b t b ?How do you prevent substance abuse?

Need to change intervening factors:

Individual characteristics??Individual characteristics??or

E i t l i fl ??Environmental influences??


Environmental PreventionEnvironmental Prevention

W t t h

But to see real lasting changeWe can try to change

conditions withineach individual

lasting change we need to change conditions in the shared environment

“Holding youth solely responsible for underage drinking is like blaming fish for dying in a polluted stream.” –Laurie Lieber, Marin Institute

Need both individual and environmental strategies f ff ti h i h b tfor an effective comprehensive approach – but

what is the most cost-effective balance?

Individual strategies: When the right strategies

Environmental strategies:Easier to implement When the right strategies

reach the right individuals, the potential payoff in reduced

pbecause don’t have to target specific individuals, have potential to impactpayoff in reduced

problems is substantialBut, difficult to target and

reso rce intensi e (ma

have potential to impact whole population

But, the environmental factors resource intensive (may also need environmental change to support

)

seem to have more influence on the behavior of those at lower risk thanprogress) of those at lower risk than at the highest risk


Some factors highly correlated with binge d i ki (b d 2004 MYDAUS)drinking (based on 2004 MYDAUS)

MYDAUS question Odds ratioMYDAUS question Odds ratio (controlling for gender)

My parents think it is not wrong or a little wrong for me to drink

4.6wrong for me to drinkMy parents wouldn’t catch me if I drank w/out permission

4.4p

I do dangerous things b/c somebody dares me to

4.3

It would be easy to get alcohol if I wanted to

4.2

Adults in my neighborhood think it’s not 3 2Adults in my neighborhood think it s not wrong for kids my age to drink

3.2

Same set of factors consistently d i h PARP* b 2 %emerged with PARP* above 25%

Lik lih d f b i R b lli• Likelihood of being caught by police

• Ease of access

• Rebelliousness• Friends who use• Siblings who useEase of access

• Parental attitudes• Likelihood of being

• Siblings who use• Know adults who’ve used

or sold drugs in past yeargcaught by parents

• Community adult attitudes

g y• Engaged in other

prohibited behaviors or have friends/siblings whoattitudes

• Perception of social benefits (cool factor)

have friends/siblings who do

( )* population-attributable risk percent (= % of substance users reduced in population if exposure to factor eliminated)


Piscataquis County MainePiscataquis County MaineFrontier status - <6 persons per square mile.p p qEnvironmental prevention focused on two factors:Likelihood of being caught by policeParental AttitudesParental Attitudes

Intervention: Zero tolerance coordinated police ffintervention. No one gets off. Parents always involved.

Result: increased perception of likelihood of being caught p p g gby police. Increased involvement of parents. Reduced drinking.


Prescription MonitoringPrescription MonitoringMany states have a prescription monitoring program that y p p g p g

reports all filled prescriptions for all controlled substances.

A few states, including Maine, are using this database to identify physicians who over-prescribe, and individuals who use multiple physicians and emergency rooms to obtain controlled substances

One goal for such programs is to assure that the pharmacist looks up the patient in this database before filling the prescriptionfilling the prescription.


Montana Meth ProjectMontana Meth ProjectThe Montana meth project is a large-scale prevention p j g p

program aimed at significantly reducing first-time meth use through public service messaging, public policy and community outreachcommunity outreach.

Environmental prevention focused on:Access to anhydrous ammonia and pseudoephedrineSocial marketing to change public perceptions

Individual prevention focused on:Perception of risksPerception of social benefitsPerception of social benefits


Montana Meth ProjectMontana Meth Project

Meth_Proj_Just_once_Large.mov

tel_EverythingElse.movy g


Montana Meth ProjectMontana Meth ProjectPerception of Risks & Benefits p

– Teens now view Meth as more dangerous than heroin. – Few teens of any age see a benefit in taking Meth.

More than 80% of teens believe there are substantial risks in– More than 80% of teens believe there are substantial risks in taking meth

Awareness and Dialog– 96% of parents say they have discussed the subject of Meth with

their teen in the past year,

more than half the time TV ads prompted these conversations– more than half the time TV ads prompted these conversations63% reduction in teen meth use

62% reduction in meth-related crime


Other Meth Project StatesOther Meth Project StatesArizonaArizonaColoradoG i

http://www.montanameth.org

GeorgiaHawaii

http://www.methproject.org

IdahoIllinoisIllinoisWyoming


TreatmentTreatmentDetox – it often starts hereDistribution of Treatment C tCentersModels

McCann Treatment Center (Bethel Alaska)Alaska)

Montana Corrections System


DetoxDetox• Often the best time for an intervention

• 82% of rural residents live in a county without a detox providerp

• More than half of all rural detox providers serve a 100 mile radius Travel distances are a barriera 100 mile radius. Travel distances are a barrier to outpatient detox models.

R f l ti t b t b t t t• Referral options to substance abuse treatment are limited, especially in isolated rural areas.


Detox in Rural AreasDetox in Rural Areas


National Survey of Substance Abuse yTreatment Services, 2004

• N-SSATS is conducted annually by the Substance Abuse and Mental Health Administration.

• The data is collected to describe the nature and extent of services, analyze trends in treatment, and generate a directory and online locator of treatment facilities.

• Data is collected on multiple variables including ownership, operating characteristics, primary focus of treatment services, core services, type of care by setting, opioid treatment programs, and accepted forms of paymentaccepted forms of payment.

• Limitations: no prisons, limited inclusion of solo practitioners, and no data on need.


Key Findings• The vast majority -- 91 percent – of substance abuse

treatment facilities are located in urban or rural, adjacent areasareas.

• Local, state, and tribal governments as well as the federal Indian Health Service represent a large share of owners in rural areasowners in rural areas.

• Rural treatment infrastructure has a greater reliance on solo practice facilities as well as facilities with a general medical care focus.

• Rural areas have fewer facilities offering more intensive services, such as residential care, inpatient care, andservices, such as residential care, inpatient care, and opioid treatment programs.

• The key question remains: does the distribution of substance abuse treatment meet the needs of thosesubstance abuse treatment meet the needs of those needing care?


McCann Treatment CenterBethel, Alaska

• Youth ages 10-18Youth ages 10 18 • Specializes in inhalant abuse

A ti f ll ti Eld l• Active full-time Elder counselor• Traditional cultural practices (food

gathering, crafts, pride in native culture)combined with evidence-based treatment practices


Montana CorrectionsMontana Corrections• Net decrease in incarcerated populations p p

2006-2008• Pre-trial assessment for all crimesPre trial assessment for all crimes

associated with substance abuse or mental healthmental health

• 7 treatment centers are part of corrections system – 2 specializing in methsystem – 2 specializing in meth

• 6 pre-release centers (include chemical dependency treatment)dependency treatment)


ConclusionsConclusions• Alcohol is the greater threat – especially g p y

for teens • Regional variations dictate regionalRegional variations dictate regional

solutions• Environmental prevention is usually a• Environmental prevention is usually a

better investment Coordinated pre ention programs ha e a• Coordinated prevention programs have a measurable impact


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