THE EPIDEMIOLOGY OF DRUG ABUSE:

CURRENT ISSUES

Editors:

Louise G. Richards, Ph.D. and Louise B. Blevens

March 1977

NIDA RESEARCH MONOGRAPH 10

Psychosocial Branch

Division of Research

National Institute on Drug Abuse

11400 Rockville Pike

Rockville, Maryland 20852

DEPARTMENT OF

HEALTH. EDUCATION. AND WELFARE

PUBLIC HEALTH SERVlCE

Alcohol. Drug Abuse, and

Mental Health Administration

For sale by the Superintendent of Documents, U.S. Government Printing Office

Washington, D.C. 20402 - Price $2.60

Stock No. 017-024-00571-1
The NIDA Research Monograph series is prepared by the Division of Research of

the National Institute on Drug Abuse. Its primary objective is to provide ciritcal reviews of research problem areas and techniques, the content of state-of-the-art

conferences, integrative research reviews and significant original research. Its

dual publication emphasis is rapid and targeted dissemination to the scientific

and professional community.

Editorial Advisory Board

Avram Goldstein, M.D.

Addiction Research Foundation

Palo Alto, California

Jerome Jaffe, M.D.

College of Physlcions and Surgeons

Columbia University, New York

Reese T. Jones, M.D.

Langley Porter Neuropsychiatnc lnstutute

University of California

San Francisco, California

William McGlothlin, Ph.D.

Department of Psychology. UCLA

Los Angeles, California

Jack Mendelson, M.D.

Alcohol and Drug Abuse Research Center

Harvard Medical School

McLean Hospital

Belmont, Massachusetts

Helen Nowlis, Ph.D.

Office of Drug Education, DHEW

Washington, D.C.

Lee Robins, Ph.D.

Woshington Uniiversity School of Medicine

St Louis, Missouri

NIDA Research Monograph series

Robert DuPont, M.D.

DIRECTOR, NIDA

William Pollin, M.D.

DIRECTOR, DIVISION OF RESEARCH, NIDA

Robert C. Petersen, Ph.D.

EDITOR-IN-CHIEF

Eunice L. Corfman, M.A.

EDITOR

Rockwell Building 11400 Rockville Pike Rockville, Maryland, 20852
FOREWORD

The epidemiology of nonmedical drug use or abuse continues to be

one of the most active research programs in the National Institute on Drug Abuse. It is active in that it has inspired numerous research endeavors, and additionally in meeting continuing

and pressing demands for information. This is one of the subject

areas that responds most frequently to questions from the public,

Congress, and other government agencies. It is also active methodologically. There is no "status quo" in the means of acquiring

this knowledge; few if any are satisfied with the techniques now

at hand. There is much searching, examining, and speculation

about better ways of comprehending the extent and nature of drug

use and abuse.

The presentations and discussions in this publication are a fair

reflection of the state of the art in 1975, its imperfections as

well as its achievements. They should provide an excellent fourdation for improved research in the future.

William Pollin, M.D.

Director

Division of Research

National Institute on Drug Abuse

iii
ACKNOWLEDGMENT

This publication originated as a report prepared

under Contract 8271-75-03224, Task Order 19, by

System Sciences, Inc., 4720 Montgomery Lane,

Bethesda, Maryland 20014.

This monograph is derived from a conference held

November 18 through 19, 1974, in Miami Beach,

Florida.

NIDA Research Monographs are indexed in the Index Medicus

DHEW publication number (ADM) 77-432

Library of Congress catalog card number 77-70239

i v
PREFACE

These papers are edited transcripts from the Conference on the

Current Issues in the Epidemiology of Drug Abuse held in Miami

Beach, Florida, on November 18-19, 1974. The procedural format

of the Conference was informal. A roundtable exchange was encouraged in order to promote the most relevant, stimulating and wideranging examination of the issues involved. Participants were

invited to speak briefly on a particular topic on the agenda.

Their comments in turn became the lead-off remarks for discussion.

The two days’ proceedings were tape recorded in their entirety.

Edited transcripts of presentations were submitted to each speaker

for further editorial review. Discussion sections were edited

as well for clarity and relevance. This final report does not

represent a verbatim transcript but a joint effort of participants

and editors to render an accurate yet concise representation of

the Conference.

The editors wish to thank Joseph Romm, System Sciences’ Project

Director, for his intelligent guidance of the Conference itself

and his careful supervision of the project report to its completion. The contributors are also owed thanks for their conscientious editing of transcripts and tendering of finished manuscripts.

Louise G. Richards, Ph.D.

Chief

Psychosocial Branch

Division of Research

National Institute on Drug Abuse

v
CONFERENCE PARTICIPANTS

Herbert Abelson, Ph.D.

President, Response Analysis

1101 State Road

Princeton, New Jersey 08540

Michael Alexander, M.D.

Fellow in Medical Oncology

Division of Oncology S-025

Stanford University Medical

Center

Stanford, California 94305

Alan Berkowitz, M.D.

Research Psychiatrist

System Sciences, Inc.

4720 Montgomery Lane

Bethesda, Maryland 20014

Carl Chambers, Ph.D.

Executive Vice President

Resource Planning Corporation

16201 S.W. 95th Avenue

Miami, Florida 33157

Ira Cisin, Ph.D.

Professor of Sociology

Social Research Group

George Washington University

2401 Virginia Ave., N.W.

Washington, D.C. 20037

Gail Crawford, Ph.D.

Research Associate

Univ. of Chicago Drug Abuse

Rehab. Prog.

5454 South Shore Drive

Chicago, Illinois 60615

Robert Eichberg, Ph.D.

Project Coordinator, Study of

Adolescent Drug Abuse

Etiologies

UCLA - Dept. of Psychology

405 Hilgard Avenue

Los Angeles, California 90024

Jack Elinson, Ph.D.

Professor, Sociomedical Sciences

Columbia University

630 W. 168th Street #138

New York, New York 10032

Joseph Fitzpatrick, S.J.

Professor of Sociology and

Anthropology

Fordham University

Fordham Road

Bronx, New York 10458

Gloria Francke, Pharm.D.

Chief, Program Evaluation

Alcohol Drug Dependence Div.

Veterans Admin. Central Office

810 Vermont Avenue, N.W.

Washington, D.C. 20420

William Glenn, Ph.D.

Senior Statistician

Research Triangle Institute

P.O. Box 12194

Research Triangle Park,

North Carolina 27709

Louis Gottschalk, M.D.

Professor and Chairman

Dept. Psychiatry and Human

Behavior

Univ. of California - Irvine

College of Medicine

Irvine, California 92664

v i
Mark Greene, M.D.

Medical Epidemiologist

c/o S.A.O.D.A.P.

726 Jackson Place, N.W.

Washington, D.C. 20506

Joseph Greenwood, Ph.D.

Chief Mathematician Statistical Advisor

Drug Enforcement Administration

1405 Eye Street, N.W.

Washington, D.C. 20537

Lloyd Johnston, Ph.D.

Study Director

4007 Institute for Social Research

The University of Michigan

Box 1248

Ann Arbor, Michigan 48106

Eric Josephson, Ph.D.

Associate Professor

School of Public Health

Columbia University

630 W. 168th Street

New York, New York 10032

Denise Kandel, Ph.D.

Adjunct Associate Professor

School of Public Health

Columbia Univ. and Biometrics

Research

N.Y. State Dept. of Mental

Hygiene

100 Haven Avenue

New York, New York 10032

Khalil Khavari, Ph.D.

Director, Midwest Institute

on Drug Use

Univ. of Wisconsin/Milwaukee

Milwaukee, Wisconsin 53201

Morton Kramer, Sc.D.

Director, Div. of Biometry

NIMH Parklawn Building

5600 Fishers Lane

Rockville, Maryland 20852

Dan Lettieri, Ph.D.

Psychologist

National Institute on Drug

Abuse

11400 Rockville Pike

Rockville, Maryland 20852

Irving Lukoff, Ph.D.

Co-Director

Center for Socio-Cultural Re622 W. 113th Street

Columbia University S.S.W.

McVickar Hall

New York, New York 10025

William McGlothlin, Ph.D.

Professor-in-Residence

UCLA - Dept. of Psychology

405 Hilgard Avenue

Los Angeles, California 90024

Lee Minichiello

Institute for Defense Analyses

Science Technology Division

400 Army-Navy Drive

Arlington, Virginia 22202

Joseph Murphy

Chief, Drug Information Section

Drug Enforcement Administration

1405 Eye Street, N.W.

Washington, D.C. 20537

Richard Myrick, Ph.D.

Research Psychologist

National Institute on Drug Abuse

Division of Research

11400 Rockville Pike

Rockville, Maryland 20852

John Newmeyer, Ph.D.

Epidemiologist

Haight-Ashbury Free Medical

Clinics

529 Clayton Street

San Francisco, California 94117

Helen Nowlis, Ph.D.

Director, Div. of Drug Education/

Health and Nutrition

Office of Education, DHEW

400 Maryland Avenue

Washington, D.C. 20202

vii
Philip Person, Ph.D.

Chief, Forecasting Branch

National Institute on Drug Abuse

11400 Rockville Pike

Rockville, Maryland 20852

Louise Richards, Ph.D.

Chief, Psychosocial Branch

Division of Research

National Institute on Drug Abuse

11400 Rockville Pike

Rockville, Maryland 20852

Alex Richman, M.D., MPH

Coordinator Psychiatric Utilization Review Activities

Beth Israel Medical Center

Professor of Psychiatry, Mt.

Sinai School of Medicine

of the City Univ. of N.Y.

M.J. Bernstein Institute

307 Second Avenue

New York, New York 10003

Lee Robins, Ph.D.

Professor of Sociology in

Psychiatry

Dept. of Psychiatry

Washington University Medical School

St. Louis, Missouri 63110

Joseph Romm

Vice President

System Sciences, Inc.

4720 Montgomery Lane

Bethesda, Maryland 20014

Irving Rootman, Ph.D.

Chief, Epidemiology Div.

Research Bureau/Non-Medical

Use of Drugs Directorate

Health and Welfare

365 Laurier Avenue West

Ottawa, Ontario, Canada

Olga Salinas-DeValle, Ph.D.

Insurgentes sur 1991

Edif. B-6 Piso

Mexico 20, D.F.

Mexico

C. James Sample, Ph.D.

Senior Research Economist

System Sciences, Inc.

4720 Montgomery Lane

Bethesda, Maryland 20014

Leonard Savitz, Ph.D.

Professor of Sociology

Dept. of Sociology

Temple University

Philadelphia, Pennsylvania 19122

Saul Sells, Ph.D.

Research Professor and Director

Institute of Behavioral Research

Texas Christian University

Fort Worth, Texas 76129

viii
CONTENTS

FOREWORD

PREFACE

CONFERENCE PARTICIPANTS

PROCEEDINGS

INTRODUCTION Louise Richards

I. ISSUES UNDEPLYING INCIDENCE AND PREVALENCE

Status of Operational Definitions Jack Elinson

II. PROBLEMS IN DATA ACQUISITION

Discussion

Concept of Polydrug Use C. James Sample

Surveys

General Populations

Target Populations

Discussion

Special Populations

Longitudinal Studies

Discussion

Relational Studies

Discussion

(Nationwide and State) Ira Cizin

Lee Robins

(Adolescents and Other) Erric Josephson

Lloyd Johnston,

Denise Kandel

Non-Survey Techniques

Observational Techniques

Sub-Cultural Groups

Institutional Sources

Arrests

Discussion

Treatment

Discussion

Indicators

Deaths

Hepatitis

Discussion

Buys

DAWN

Urinalysis Screening

Discussion

GENERAL DISCUSSION

Gail Crawford 73

Joseph Fitzpatrick 78

Leonard Savitz

Saul Sells

Louis Gottschalk

Michael Alexander

John Newmeyer

Philip Person

Alan Berkowitz

iii

v

v i

1

9

10

14

19

33

34

39

46

49

60

66

68

72

84

89

91

96

98

123

126

130

135

138

148

150

ix
III. PROBLEMS RELATED TO APPLYING AND EXTRAPOLATING DATA 153

Survey Sampling

Discussion

William Glenn

Institutional Data

DEA Register

Discussion

Joseph Greenwood

Research Uses of NYC Register Data

Discussion

Irving Lukoff

Ecological Studies of Narcotic Addiction Alex Richman

CODAP C. James Sample

Applications of Indicator Data (Epidemics) Mark Greene

Discussion

IV. CURRENT ESTIMATES, RANGES, AND TRENDS 225

Trends and Projections

Discussion

Carl Chambers 226

V. CURRENT EPIDEMIOLOGY PROGRAM AND RECOMMENDATIONS 237

Current Program Dimensions Richard Myrick

Interpretations and Policy Implications Helen Nowlis

Relationship Between Mental Health

and Drug Abuse Epidemiology Morton Kramer

Program Gaps and Future Directions William McGlothlin

238

244

248

253

CONCLUSION Louise Richards

154

160

162

166

172

173

197

206

214

257

LIST OF MONOGRAPHS 258

x
INTRODUCTION

Louise G. Richards, Ph.D.

With this conference in Miami Beach, the epidemiology of nonmedical drug use and dependence came into its own. A total of

three national meetings had been held specifically on the subject

of the extent and patterns of drug abuse.* In the government’s

classification of research projects, epidemiology had been singled

out as a prime focus. At the time of the meeting, there were

already two active programs of drug abuse epidemiology, one in the

National Institute on Drug Abuse and the other in the Special

Action Office for Drug Abuse Prevention, under the leadership of

Dr. Mark Greene.** Since that meeting, specialized programs and

positions have become firmly established and are now devoted exclusively to drug abuse epidemiology, both in Canada and the United

States.

The purpose of the Miami Beach Conference was to review the state

of research at the time, identify major problems and gaps, and

recommend new directions that should be taken. Geographically, it

was midway between Washington and San Juan. Also, conceptually

its purpose lay at a point between the extremes of the first national meeting on this subject held in San Juan in 1972, and two

later meetings in Washington, D.C. Columbia University’s School

of Public Health was the sponsor of the first meeting. It was

rich in intellectual fare, and created the first community of

scholars for this research area. The proceedings of the San Juan

conference still stand as the definitive conceptual work on the

subject (Josephson and Carroll, 1974). The second and third meetings had practical purposes oriented toward specific plans or projects. Between these extremes, the agenda of the Miami Beach

meeting was devoted to evaluation of progress, reminders of the

hazards in the territory, and discussion of the precautions to observe if further advances were to be made.

*The term "drug abuse" is employed broadly here to include all

non-medical drug use, with recognition of the fact that not all

use results in adverse consequences.

**With the closing of the SAODAP, most of the active projects were

transferred to the N.I.D.A.

1
Because of the emphasis on review and assessment, the group was

small and consisted primarily of those who were actively engaged

in research at the time. They were and still are the leaders in

the field. Full reports of the participants’ research are not included here, but references are given to many of the pertinent

publications available at that time or in the months since.

EIGHT QUESTIONS

Eight sets of questions were offered to the conference participants

as a scaffold for the meeting. These were questions that frequently teased and plagued officials responsible for reporting on drug

abuse in the nation and seemed to cry for answers from the research

community:

1.

2.

3.

4.

5.

6.

7.

8.

The first was an old but still unanswered question: What is

the extent of opiate addiction in the U.S.? How much of it

is hidden? What proportions are treated and untreated? HOW

much use is there at different levels of frequency and regularity, from chipping to hard-core addiction?

How accurate are the sample survey data now abundant? More

specifically, how well do they reflect the actual extent of

use or abuse, in all groups? Can they accurately chart changes

over time?

How can the adverse consequences of drugs be measured as they

occur among users? Specifically, how many accidents result

from drug use? How many hospitalizations, bad trips and

deaths? Can the serious methodological problems be overcome?

How accurate are data on clients in treatment? Can this information be used for national allocation of resources?

Is it possible to predict drug abuse epidemics? Further, can

the next new fad be predicted?

Can states and cities assess their own drug abuse problems

accurately, at a reasonable cost? Is it realistic to try?

Are there indicators of drug abuse accurate enough to assess

incidence or prevalence? Of those currently used, which are

the best?

How can one resolve conflicting estimates of the same phenomenon?

2
OVERVIEW

It is fair to say that the conference participants, if they did

not answer these questions, made valiant attempts to address them.

At the same time, they commented on other developments of a conceptual or philosophical nature, as would be expected of scientists

whose responsibility is to put practical questions in a thoughtful

context.

One conceptual issue was the state of operational definitions in

this field, dealt with by Elinson; another was the term "polydrug

use," covered by James Sample, both in Section I. A number of

philosophical questions raised by Nowlis in Section V gave pause

to the purposes of the entire endeavor, asking whether epidemiological statistics can actually serve the cause of ameloriation of

drug abuse.

The methodological issues covered in Section II reiterated some

perennial difficulties in achieving high return rates and preventing bias, but authors Cisin and Robins also conveyed guarded optimism about the possibility of obtaining high quality data from surveys . Johnston and Kandel spoke on survey problems from experience

in conducting longitudinal studies over several years’ time, commenting on sample attrition, interpretation of changes, and adherence to rules on protection of human subjects. Crawford and

Fitzpatrick related their experiences in looking at extent and nature of drug use from a different angle: the observation of users

on the street. The shortcomings of validity and reliability often

present in household or classroom surveys seem less a problem in

observational methods, though these also fail to meet the ideal because they seldom achieve complete coverage of the population or

employ standard instruments.

Representatives of special indicator data sources commented on

their methodological problems of collection and interpretation.

Savitz discussed one of the oldest sources in use, arrests of drug

law violators. In connection with arrests, Newmeyer proposed the

use of price-and-property data on street drugs, as an important

clue to the state of a drug epidemic. Sells dealt with the problems of designing studies of treatment populations and with the

possibilities of use of such data when available. Gottschalk presented preliminary findings from a comprehensive survey of drugrelated deaths in major cities and Person described the National

Drug Abuse Warning Network (DAWN) from which data on other adverse

consequences such as hospitalizations are available. Alexander

and Minichiello discussing the utility of serum hepatitis figures

for estimating trends in drug use, were alternately pessimistic

and optimistic on the topic. Finally, Berkowitz threw out a serious challenge to the assumption of accuracy in the urinalysis data

used to screen or monitor drug abuse.

3
Once data are collected from a primary source, whether it is drug

users in households, in classrooms, on the street, in physicians’

offices, or in military settings, the estimation of extent and nature of the behavior is not automatic. Statistical manipulations

of various kinds take place to portray the situation in a conventional but technically correct form that can be understood and

used. These problems of relating and extrapolating data were undcrtaken in Section III. Glenn argued that some efforts to produce

point estimates in numbers of persons, characterized in certain

ways, had been misleading because the standard error was not taken

into account. A second presentation by Greenwood pointed out the

possibilities of using addict register data for estimating the

total population of addicts, and Rootman commented on a number of

uses of the Canadian Narcotics Registry. Lukoff was critical of

the procedures used in keeping the New York Narcotics Registry upto-date and recounted the difficulties he encountered in trying to

use the Register for research purposes. Richman, on the other

hand, reported on his successful use of the Register in connection

with attempts to characterize treated addicts in ecological terms.

Sample also described the use of management information on clients

in treatment, in this case the nationwide Client Oriented Data

Acquisition Process (CODAP), as a research tool.

In Section III, Chambers inserted a summary of major trends from

the numerous state surveys conducted by Resource Planning Corporation, as an example of the product of epidemiological research.

He pointed to a number of findings showing concentrations of certain kinds of behavior in special populations, and gave an example

of how such data can engage treatment needs.

The final presentations of the meeting pointed toward possible new

directions for the future as well as toward the accomplishments of

the past. As mentioned earlier, Nowlis asked for a broader look

at drug abuse than the epidemiological framework provides. Kramer

suggested closer collaboration with epidemiological activity in

mental health, and McGlothlin urged the merging of information on

alcohol use with that of drug abuse for greater insight into

trends in substance use. McGlothlin also recommended more longitudinal surveys in this field. Myrick described how the information on government supported research was classified and how one

could find out about the types and amounts of research underway.

NEW INITIATIVES

With the opportunity to look back at accomplishments and expectations in Miami Beach, it is surprising how many of the eight questions are still waiting for answers. However, a number of salutary advances have occurred that bode well for the future of this

enterprise. Taking each question in turn, the following new initiatives either have been completed or are progressing well:

1. A NIDA sponsored conference on heroin epidemiology was held at

Stanford University in February, 1976, the proceedings of

4
which will be available in the near future (Rittenhouse 1976).

Also, a completed study by O'Donnell sheds new light on the

patterns of heroin use in a national sample of the population

at risk in recent years (O'Donnell 1976).

2. The first study measuring validity of the interview method for

incidence and prevalence of non-medical drug use in the general population has been completed (Abelson and Atkinson 1975).

The results do provide confidence in the use of interview questions for most substances, the major exception being the measurement of heroin use. The National Survey of 1975 that followed the validity study made possible a third point in time

for assessment of trends in use (Abelson and Atkinson 1975).

The survey is now on an annual basis with the completion of the

1976 report (Abelson and Fishburne 1976).

3. The research territory of adverse consequences is still in need

of development. A new initiative for developing guidelines and

questionnaire items for measuring drug use consequences has recently been launched in NIDA.

4. The CODAP source of nationwide data on admissions to treatment

has improved its coverage of programs dramatically since the

Miami Beach meeting. Quarterly reports of admissions and other

aspects of treatment are now available from NIDA (NIDA 1976).

5. A method for predicting future drug epidemics or fads is still

primarily a hope and not an expectation, although a number of

investigators have been experimenting with techniques for postdiction. Healthy debate goes on over the feasibility of use of

treatment admissions data for predicting the incidence of heroin use in the community (Richman 1976).

6. As many as thirty states have conducted surveys of drug abuse

to date and undoubtedly as many cities have done so too

(Richards and Glenn 1976). The cost of conducting a reliable

survey is high, and the expectation of obtaining trend data for

local areas is unrealistic, for the most part. Several investigators have explored means of using existing indicator data

for assessing need at the local level, but more development is

needed (Chambers and Hunt 1976). A beginning has been made toward an index of drug abuse employing survey and census data,

but this too needs much more effort devoted to it (Cohen 1974).

7. A good deal of attention has been paid to the question of interrelations among indicators since the meeting (Person 1976). As

yet, there are no conclusive answers on which indicator, if

any, might be the most accurate. This initiative should eventually result in knowledge highly useful to the field.

8. There is still a visible gap in the estimates provided from

drug abuse surveys and from indicators. No one has been able

to link one to the other in a useful way, but it is a worthy

goal.

5
The examples of progress outlined above are satisfying indeed, but

the unanswered questions do not allow relaxation of efforts to improve the state of the science.

THE "NUMBERS" CRITICISM

Throughout the Miami Beach meeting and at other meetings on the

epidemiology of drug abuse, the theme of "number numbness" frequently appears. The theme is expressed in questions of why numbers seem important, and whether they lead to real understanding

or merely serve to satisfy reporters and politicians. These

queries led to some provocative discussion, and undoubtedly deserved a larger portion of the agenda. Since the time was not sufficient to expand on the theme at the meeting, some comments are

offered here.

Non-medical use and abuse of psychoactive substances continue to

evoke curiosity, fear and uncertainty, and continue as a topic for

political debate. Thus, requests and demands for numbers representing the size and scope of the phenomenon have not abated. The

need for numbers has been real and constant and admittedly constituted one impetus for the Miami Beach meeting. It is a legitimate need and the research community is a legitimate source of such

information. The objection seems to be that the desire for numbers

does not go far enough in providing an understanding of what the

phenomenon of drug abuse means for individuals, the society and the

culture. The implication is that numbers alone may short-change

the contribution that research could and should make to public understanding.

Undoubtedly there is danger in blind acquiescence to requests for

simple numbers representing the extent of drug use or abuse or

changes over time. Often the consumers of such statistics are not

interested in further explanation but only wish to comprehend size.

Yet the projects designed for epidemiological purposes are seldom,

if ever, limited to a few estimates of size. The surveys commissioned by the government, for example, always include as many explanatory variables as feasible and always report results by sociodemographic correlates, at the least. Providers of estimates

should routinely offer adjunctive information along with numbers

to serve subtly as a kind of consumer education.

Even the numbers themselves can improve understanding, if couched

in the proper language. Numbers never stand completely alone -

they are always presented in a semantic context; that is, they are

always numbers of something. In earlier years of the current drug

abuse period (since 1965), numbers of drug abusers were almost always reported as those who had "ever used" a substance, a reflection of lifetime experience. Experts with intimate knowledge of

drug abuse knew that those numbers were an exaggeration of the actual "problem." Since then, there has been a slow, but definite

movement toward reporting current use along with lifetime experience, and reporting of new users or other measure of incidence

6
along with prevalence figures. In addition, the reporting from

DAWN and other monitoring systems complements the survey data on

non-medical use by emphasizing only the "abusive" features. Thus,

the types of numbers chosen for reporting and the accompanying

terminology in and of themselves, have improved general understanding. It should be the practice of scientists to report as much as

possible of this context or qualifying data along with the simple

numbers requested by others.

The fact that the epidemiology of drug abuse has come into its own

does not mean that it is the whole story of the drug abuse phenomenon. Many psychosocial and clinical studies employing a myriad of

variables have been completed or are in progress and these will

ultimately have more elucidative importance than studies of the extent and nature of the behavior. Nevertheless, science has always

proceeded from description to explanation, and the description is

essential. The Miami Beach Conference has helped a number of

scientists do a better job of description in the ensuing years.

REFERENCES

Abelson, Herbert and Ronald Atkinson. Public Experience with

Psychoactive Substances. Response Analysis Corporation, Princeton,

New Jersey, 1975.

Abelson, Herbert and Patricia Fishburne. Nonmedical Use of Psychoactive Substances. Response Analysis Corporation, Princeton, New

Jersey, 1976.

Chambers, Carl and Leon Hunt. Alternative approaches to incidence

and prevalence studies. Proceedings of the Annual Meeting of National Association of Drug Abuse Program Coordinators, Sparks,

Nevada, June 7-11, 1976, NASDAPC, Washington, D.C.

Cohen, Reuben. An Index of the Number of Drug Abusers in States

and Major Urban Areas. Response Analysis Corporation, Princeton,

New Jersey, 1974.

Josephson, Eric and Eleanor Carroll, Eds. Drug Use: Epidemiological and Sociological Approaches. Washington, D.C.: Hemisphere

Publishing Corporation, 1974.

National Institute on Drug Abuse. Statistical Series: Quarterly

Report. Rockville, Maryland, 1976.

O’Donnell, John. Young Men and Drugs - A Nationwide Survey. NIDA

Research Monograph 5, Rockville, Maryland, 1976.

Person, Philip, Robert Retka and J. Arthur Woodward. Toward a

heroin problem index - an analytic model for drug abuse indicators.

Technical paper. National Institute on Drug Abuse, 1976.

7
Richards, Louise and William Glenn. Recent Surveys II. National

Institute on Drug Abuse. Monograph in preparation.

Richman, Alex. The contribution of treatment data to epidemiologic

perspectives of narcotic addiction. The Epidemiology of Heroin and

Other liarcotics: Use, Abuse and Addiction. Proceedings of the

Task Force Meeting. (J. Rittenhouse, Ed.) Stanford Research Institute, Menlo Park, California. Monograph in preparation. 1976.

Rittenhouse, Joan, Ed. The Epidemiology of Heroin and Other Narcotics: Use, Abuse and Addiction. Proceedings of the Task Force

Meeting. Stanford Research Institute, Menlo Park, California.

Monograph in preparation. 1976.

8
I. ISSUES UNDERLYING INCIDENCE

AND PREVALENCE ESTIMATES
Status of Operational Definitions

Jack Elinson, Ph.D.

One of those "nuts and bolts" conferences that Louise Richards referred to took place about a year ago. One of the "nuts" present,

namely myself, felt that in the discussion about some of the general problems affecting survey research in this field -- specification of the population, sampling schemes, response rates -- the

question was raised as to whether there was any agreement on certain definitions of terms used in survey research on drug use.

The group agreed that there was no agreement on the way in which

sample surveys of general populations defined "drug usage." It

was felt that it might be useful to create an ad hoc committee to

work toward the possibility of achieving more comparable usage in

survey research, such that the knowledge gained could be more cumulative than it is now.

Among the several questions posed by Louise Richards, this committee addressed the one on the utility of sample survey data. Utility might be increased if definitions were more comparable. It

also addressed the issue of conflicting estimates, which has to do

not only with definition, but also with other things. These then

are the two major questions being addressed by this committee.

Some of those present there -- about ten people -- expressed a

special interest in forming themselves into an ad hoc committee

which has met now about three times. What is being given to you

here today is a report of these three meetings, and the extent of

work so far.

At the first meeting of this group -- five or six of whom are here

today -- the entire day was spent just discussing what drugs ought

10
to be paid attention to and what drugs should we be worried about,

without coming to agreement on that one day. Before the second

day’s meeting, which took place some months later, it was felt that

perhaps a review of existing studies (survey research in recent

years) that have dealt with the issue of drug use research be done

and be placed before the committee for an overview of the way in

which terms are actually used. Accordingly, a research associate

and I, and two students, reviewed some 50 studies which met certain criteria: for example, the study had to do with survey research; it had to do with populations of a general sort -- not too

special; it had to do with a survey of both users and non-users;

these non-users had to be very prominently featured in the population studied; and it had to have resulted in some publication of

an open variety, whether in printed form or in progress reports to

a government agency (that is, available to the general scientific

community, not merely inhouse or agency reports). Some fifty of

these met the criteria. You will notice the principal exclusion

were studies which dealt with known drug addicts. Definition of

terms required in studies of known drug addicts was much more specific, much more refined, and much more detailed than could be

applicable to general populations. It was felt that another committee, another group, should be concerned with that highly important population of drug addicts or drug users in treatment, and

ways of approaching some comparability. In point of fact there

have been such efforts.

Approximately 15 concepts were identified. These were:

User, ever

Frequency/quantity

Onset of use

Recent or current use

Interest in trying, maintaining, or changing use

Typology of use

History of use

Polydrug use

Methods of use

Conditions of use

Reasons for use

Reasons for non-use

Effects

Pathology

Availability

These fifty studies were reviewed with regard to their use of these

concepts and terms. Just to show by way of illustration the variation that exists in even the most objective of these concepts,

namely "ever use" the following are some of the ways in which some ,

of the studies refer to it.

naire phrasings: "Did you ever use (selective) drugs?" "Do you

These are among the various questionnow or have you ever used, or do not use now (selective) drugs?"

"Which drugs have you taken at least once when they were not prescribed for you by a physician or received during medical treatments, but you use larger doses or more frequently than directed

11
and that you use with a specific intention of getting high?" (These

are all different surveys, not in the same survey.) "Up until today, how many times have you used marihuana in any of its forms --

grass, pot, hash, etc.?" In another phrasing: "Have you ever used

this drug or class of drugs?" And an agree/disagree type of statement: "During my lifetime I have used the following drugs without

a medical prescription," etc. This report, entitled the 0perational

Definition of Terms of Drug Use Research, is merely a compilation

and an examination of the different ways in which terms have been

used in recent survey research.

Following the presentation of this report at the second meeting

various members of the ad hoc committee were assigned the task of

taking one of these concepts and working up "recommended" ways of

approaching it, with some rationale. The people who were involved,

just for the record, were: Denise Kandel on measurement of "ever

use" and frequency/quantity, Lee Robins on history of drug use,

John O’Donnell on effects of drug use, Charles Winick on typologies

of drug use, and Gail Crawford on conditions of drug use. Subsequent ly , the following were added: Louise Richards on measurement

of currency or recency, Lloyd Johnston on measurement of polydrug

use, and Mildred Bateman and Roger Meyer on a functional taxonomy

of drugs.

We have working papers from the group on these subjects and the next

meeting (the third) of the ad hoc committee, was supposed to deal

with reviewing these papers and coming to some recommendations.

Maybe you can anticipate what happened. We were able to deal with

only one of the papers in one day, namely the functional taxonomy

of drugs. These individualistic investigators undertook their

assignment in the way they do their work -- instead of coming up

with recommendations, they analyzed the problem further, looked at

the way things were conceptualized and suggested other ways of conceptualization. The analysis was full of qualifications, limitations, problematics and so on, which leads us a long, long way from

the accomplishment of arriving at some, not "standard," but even

some recommended, comparable use of terms in this field.

Prior to the meeting I ended the little report that we did on the

operational definitions of drug use with this paragraph which I

think still fits even after the meeting: "It is clear that in the

current stage of socio-cultural and socio-psychological research on

drug use, there is little consensus among investigators as to operational definition of the same concepts and terms. There is of

course more agreement with respect to some terms than others."

Still, I think Denise Kandel showed us in reviewing the more objective ones, such as frequency of use, that among ten or so investigators there were not two who used exactly the same frequency-ofuse vocabularies, although some were transposable into the others.

Even in the case of objective experiences, it was remarkable how

many different ways concepts or terms are reported. It would seem

that at least in such cases a greater degree of consensus among the

investigators could be relatively easily achieved without sacrificing either concepts or findings. That is the optimistic statement.

12
In other cases, especially those which attempt to get at motivation, it is fairly obvious that a consensus would be more difficult to achieve.

We are now preparing for another meeting next month. This time

we are allowing two whole days in which we have six more concepts

to concern ourselves with. I think we still agree that we do not

yet have agreement.

(Editorial Note: The working papers referred to in Elinson’s

presentation have been published as Operational Definitions in

Socio-behavioral Drug Use Research, Jack Elinson and David Nurco,

eds., National Institute on Drug Abuse Research Monograph Series 2,

Rockville, Maryland, 1975.)

AUTHOR

Jack Elinson is Professor, Sociomedical Sciences, Columbia University, New York, N.Y.

13
DISCUSSION

Dr. Richards: I should be corrected on the use of the word "Standard" in connection with Elinson’s Committee. That was wishful

thinking more than anything else. What advice do you have for people who might be in the business of constructing a questionnaire or

initiating research in this field? You gave a gloomy conclusion

from the work up to this point. Do you have any advice?

Dr. Elinson: The first bit is just to be aware of what others have

done. That is partially covered in this document in which someone

looked at approximately fifty other studies and put it down --

awareness is first. The second thing -- I am not so gloomy about

it as you think because this is really early stuff, as far as epidemiology goes in the field. I have previously worked in the field

of cardiovascular disease where it took an international commission

perhaps ten years to arrive at some international definitions which

people might repair to. The question really is, as I see it,

whether or not this is a field in which one ought to strive toward

serious research such as that of vascular disease, in which case it

will take some time and effort to arrive at some consensus. Is it

worth that much? Or should it stay primarily pretty much where it

is -- the field of journalistic polling, the sociological fashions

in research? I mean this is what’s going on in these years. Of

course, the answer may be someplace in between; that’s about where

I stand.

Dr. Robins: One of the problems we were hassling with was the problem of "current?" The definition varies between two weeks to a

year. Some people when they speak of a "user" are talking about

use within the last year. Some are talking about anytime in their

lifetime. Some are talking about a shot of something in the last

48 hours. These obviously are not comparable. The problem is comparability from one study to another.

Dr. Kramer: You don’t get involved in dosage or level of use and

so on?

Dr. Robins: That is another problem. That is more refined than

the one concerning use within an amount of time. The amount of

time is never the same from one study to the next.

34
Dr. Johnston: If you are trying to address a particular question

and standard measures that exist are not going to do that, obviously you are going to develop measurements appropriate for that.

On the other hand, I think that a lot of people develop measures

and really do not care much whether it is measure A, B or C; they

all sort of address the same general point the person wants to get

at. A provision that a set of standards be recommended in the

field would allow, for example, a number of studies all using "A"

to do a better job on integrating their findings. What the committee is trying to do is come up with recommendations that I think

make sense as general measures, where it is possible, and I suspect

in some of those areas we will conclude it is not possible, that

is, the investigators will have two different kinds of purposes.

Dr. Richman: In regard to the question of "abuse" in our New York

City area -- "use" brought low response; "try," "have you taken" --

brought high response. Surveys should employ verbs other than

"use."

Dr. Robins: We had the same experience. We scratched out "use"

every time we used it. Quite often this is misunderstood. "Taken"

is still innocuous; however, next month that may not work.

Dr. Richards: I remember a really nice illustration of this softness in definitions in a study of marihuana taking or use, about

1968, which asked about people who had used it one or more times --

those people fell into the "ever used" group, of course. This included some experimenters, and some with more frequent use. Then a

couple of years later, someone did a study which, because marihuana

use had increased so much, categorized people who had used it once

or twice as the "non-user" group. This shifting may not be going

on extensively now, but you feel that you are walking on eggs when

you compare these kinds of results.

Dr. Sells: I would like to make a few comments about some other

variables that might be relevant to a study of standard definitions.

One is the use of a manual of jargon that may accompany interview

questionnaires where the language varies widely. A second question

involves the method of data collection, e.g., self-report questionnaires; they may yield results quite different from interviews.

And finally I would like to ask Dr. Elinson what criteria he uses

for deciding on the appropriate definitions to adopt.

Dr. Elinson: On the issue of a manual of jargon, I think this useful for educational purposes for the investigator. Such a manual

can get rather thick, especially if you go into other languages,

and other localities and over time. We have been having trouble

trying to adapt an English questionnaire which we use in the U.S.

to Puerto Rico, then back from Puerto Rico to high schools in New

York City where there are Puerto Ricans, Dominicans and Cubans. The

word for a pack of cigarettes becomes an issue worthy of an academy

of Spanish language. If it's for educational purposes, I say fine.

Let people be at least aware of the different kinds of jargon.

15
On the business of self-report versus interviews, we will be coming

out with a report shortly on just this issue, at least in high

schools where we are concerned with the same question.* We thought

we were getting much higher yields of use of drugs in self reports

and questionnaires and honest questionnaires in classrooms in high

schools than we were in the interviews as reported in household interviews around the country for people in this age group. It turns

out however, that when we tried it out in the same city using the

same population, the same sample, and these two different methods,

at least with the questions that we used at that level, there were

no significant differences.

On the issue of criteria, i.e., how are criteria in science developed for selection of measures? How did one finally decide to use

a platinum meridian bar tested at a certain temperature located in

Paris to be a measure of length of a defined sort? It came about

through an authoritative scientific body with consensus of that

scientific body. We are nowhere near that. That is why I differ

from Dr. Richards’ characterization: that is, it is pessimistic.

It is just a start and whether it’s worthy of this amount of effort,

is a question I put before all of you.

It’s not the accuracy that we are dealing with so much as comparability where one investigator says that there is a relationship between A and B, and the second person says there is not. We would

be able to look at these two statements and appraise them in terms

of the fact that they are both talking about "A" and they are both

talking about "B," whereas if the second one is talking about "A"

and "B" then they are both true. Go back and solve Dr. Sell’s criterion’in which you look at the data of each and every investigation, and it becomes an epic in itself, a poem, a piece of art, a

piece of sociological interpretation, a journalistic report. Each

is judged on its own merits, and everyone somehow arrives at a belief in what is, or an understanding of what is going on. By lack

of cumulation, the basic scientific question is lost in the terms

of a unique phenomenon. If we can move toward cumulation, we need

to see some kinds of things that we can say are comparable. They

can be equally inaccurate. Precision should only be precise for a

purpose. You want also to avoid creating straightjackets, standards, dogma. We don’t want this to become something which every

applicant or grant application must use or else they won’t get their

grants.

Dr. Kramer: Since you are dealing with epidemiologic issues, there

are a few epidemiological indicators we are talking about. I think

these must be defined so you know what you are getting and comparing and what these measures in two different populations might indeed mean. If I might put the three or four terms on the board it

might help clarify some of the issues involved, because this problem of "ever use" or "ever tried" is comparable to the concept that

*Anne Zanes and Euthenia Matsoukas. Comparison of reported drug

use in self-administered questionnaires at home and school. Article submitted for publication, 1976.

16
was introduced into psychiatric epidemiology which is called lifetime prevalence. Then you also have the other forms of prevalence

which would be the point prevalence and we have another concept

called interval prevalence. All of these things are functions o f

the rate at which the thing that you are looking at will occur,

which is called incidence. They are also related to a variable

called duration. Lifetime prevalence simply means, just generally

speaking, how many people have ever had a history of doing something. If you go into a population as of today, you would ask how

many people had used a given drug. It is a function of the incidence and the duration which is also a function of mortality in a

population. I was trying to think of a drug that might have a zero

lifetime prevalence in a live population -- cyanide is one. Go into a population and ask how many people have ever used sodium cyanide or potasium cyanide and you’ll find a zero prevalence. Here

you get into the concept of mortality, because in certain populations you may find that people are dying off more rapidly than in

another population for a variety of reasons -- whether using drugs

or not -- so this duration does have an effect. Also if you are

looking at institutional populations versus the general population

you have another problem. Because if you have everybody who has

ever used a drug in prison and you are doing a population survey,

you would never find a lifetime prevalence in the general community. The same thing is true of any kind of condition that has a

very high fatality rate. If you go into a population where anybody who had developed an abnormality was killed off, you would

find a zero prevalence in that particular population. Point prevalence means how much do you have as of a given point in time?

And that would mean -- are you looking for people who are actually

using the drug as of today or used it in some prior interval, etc.

So as of a given point in time, interval means what it says -- how

many people were doing something within that interval? That could

be one year, six months, one day or whatever it may be. It depends

on the question you are asking. Incidence would mean the rate at

which people are first using a compound or whatever it may be within some defined interval of time, Duration gets involved in any of

these things because it relates to how long are you interested in

studying this, due to the fact that prevalence is a function of

interval times duration. I do not see how you can get away from

raising the question of what it is you really want to measure. If

you’re measuring it in two different groups, and you get lifetime

prevalence, you want to determine whether it is due to differences

in incidences or duration and also take into account the fatality

rate. So I do think you have to define which epidemiological indicator you want to use and why you want to use it in order to get

comparable measures. I think it’s important to keep these measures

in mind because they have led to a lot of confusion in psychiatric

epidemiology. If you get into societies where people have a very

high fatality rate, for any reason -- for example in dealing with

Putting people in institutions and institutional care being terrible, and people dying off very rapidly -- you are getting into that

kind of a comparison. So I do urge you to think through the kinds

of measures you are trying to get in order to determine what you

want to do in terms of standardizing your definitions.

17
Dr. Greenwood: I am interested in both of these problems of prevalence and incidence and I think I understand what you have been

saying. And, I would like to tell you my definition. Prevalence:

in a given, stated interval of time it is the number of people who

have that property sometime during that interval. Incidence is the

same, practically: it is the number of new ones who come in during

that interval. That is unequivocal, too. Both of the past investigations I have done have been based on the theory of probability; it is basically the probability that a given person with a

property will do so and so, e.g., get arrested, etc. The basic assumption is equal probability in equal time for all addicts.

Dr. Gottschalk: I want to address myself also to the question of

definitions. What is a drug? Is alcohol a drug? What is abuse?

Was the drug prescribed? Was the prescription made out to the person or someone else? Are drugs to be limited to the illegal which

in my opinion are just a small portion of the problems related to

abuse. There needs to be some clarification of what constitutes

drug abuse.

Dr. Elinson: This Committee has not dealt with the issue of abuse

but we hope to be able to say something about the medical or nonmedical conditions under which drugs are used. One further question with reference to a given concept: Even after agreement has

been reached on its definition, how do you operationalize it?

Again, this practical issue varies from investigator to investigator and the need for consensus exists.

18
Concept of Polydrug Use

C. James Sample, Ph.D.

Charged with the responsibility to present a paper on polydrug use

following a paper by Dr. Elinson on Operational Definitions, I had

hoped for some assistance in defining what is meant by the term

polydrug use. Currently used definitions of polydrug use or abuse

cover a wide range, with no real consensus favoring any one definition. These definitions range from the NIDA treatment definition

of use of an illegal drug or drugs other than the opiates to a definition more common to the literature reflecting use of many drugs

without necessarily a strong preference for any particular drug.

At the risk of adding still another definition to the long list, I

will use the term polydrug abuse to mean the use of more than one

drug, excluding heroin, which are used simultaneously and with a

frequency of use of at least once per month. Regular use of heroin,

regardless of how many other drugs are also used will not be classified as polydrug use for my purpose here. It is recognized that

this definition is no better or worse than many others. The definition of polydrug use will vary depending on the subject matter

and purpose for which it is being used. The intention of this paper is to establish the trends in polydrug use as defined above,

utilizing as many data sources as possible.

Other than various surveys that have been done, there is no currently available data source that accurately or appropriately addresses polydrug use. The Drug Abuse Warning Network (DAWN), for

example, may be the only data source with the potential to accurately reflect trends in polydrug use. However, because of the concentration on drug mentions rather than episodes, it is not possi19
ble to obtain recurring information on the combinations of drugs

being used. Medical Examiner reports from the DAWN system showed

that of the 933 drug related deaths during April, May and June of

1974, 69 percent involved use of more than one drug. These data

are consistent with reported drug abuse treatment data reported

below, but should not be considered to represent polydrug users.

The Client Oriented Data Acquisition Process (CODAP) provides current data on the combinations of drugs used by clients as they enter treatment. With any self-reporting system it is often difficult to distinguish between minor differences in the interpretation

of responses. The largest problem of concern here is the distinction between historical use and concurrent use of various drugs.

Clients upon admission to treatment have a tendency to overstate

their drug problem. In the revised CODAP system we have attempted

to be more specific in obtaining responses as to their current

drug use. This will be covered below.

Table 1 provides the primary drug of abuse on admission reported

under CODAP between April 1973 and December 1974. Most noteworthy

is the decline in the relative importance of heroin admissions and

the increasing importance of marihuana and hashish as the primary

drug problem of clients admitted. The drug categories of illegal

methadone, other opiates, barbiturates, and amphetamines have maintained the same relative importance. Clients admitted for alcohol

abuse have nearly doubled in relative importance but still account

for only 5.1 percent of the clients admitted to treatment under

CODAP. This provides a rough description of the trends identified

by CODAP since its inception in 1973.

TABLE 1

PERCENTAGE DISTRIBUTION OF REPORTED PRIMARY DRUG USE

APRIL 1973 THROUGH DECEMBER 1974

CODAP

Reporting

Quarter

Apr. - Jun. 1973 62.9 0.9 1.8 7.0 4.0 2.7 12.2

Jul. - Sep. 1973 62.1 1.4 2.0 6.1 5.2 2.6 11.5

Oct. - Dec. 1973 55.4 1.4 1.8 6.6 4.5 3.3 14.7

Jan. - Mar. 1974 55.5 1.3 1.7 5.9 4.5 4.7 15.3

Apr. - Jun. 1974 58.7 1.3 1.5 4.8 4.0 4.6 15.0

Jul. - Sep. 1974 56.7 1.2 1.6 4.8 4.0 5.1 15.2

Oct. - Dec. 1974 48.7 0.4 2.4 5.1 5.6 5.1 21.1

SOURCE: CODAP Quarterly Summary Reports

20
Opiate use of clients admitted to treatment has generally not been

in combination with non-opiate use. Tables 2 and 3 provide data

on the combinations of opiate use and non-opiate use for the quarters April through June 1974 and October through December 1974,

respectively. There is little difference in the relationships

shown for these two quarters. In each case, more than 95 percent

of the reported heroin use is as the primary drug problem.* The

use of illegal methadone and other opiates is either as a primary

drug or as a secondary or other drug to heroin. As shown by the

last column of Tables 2 and 3, opiates are not generally used as

a secondary or other drug to the non-opiate. Where these are reported as secondary to non-opiates, I must assume that they are

used less often than once per week to be consistent with the definition expressed above. This is an assumption and cannot be supported

by available data at this time.** However, this assumption may not

be unreasonable. Consistently, 20 percent of the reported heroin

users have reported use of this drug less often than once per week.

TABLE 2

COMBINATIONS OF OPIATE AND NON-OPIATE USE

(CODAP Admissions, April through June 1974)

Category

Heroin

Illegal

Methadone

Other

Opiates

Heroin 100

Illegal

Methadone

Other

Opiates

Total

Reported

Use

18,707

1,812

1,600

100 22.6 71.6 5.6

100 28.0 61.4 10.6

Used as

Primary

17,859

409

448

(PERCENT)

95.5

Used as

Secondary

or Other

Drug with

an Opiate

as Primary

223

1,302

983

1.2

Used as

Secondary

or Other

Drug with

Non-Opiate

as Primary

625

101

169

3.3

SOURCE: Calculated from the CODAP National Summary Report for

April through June 1974.

*This is subject to the limitations presented in another discussion in this volume entitled "Institutional Data -- CODAP"

(Section III).

**The revised CODAP system, however, does have the capability to

test this assumption.

21
TABLE 3

COMBINATIONS OF OPIATE AND NON-OPIATE USE

(CODAP Admissions, October through December 1974)

Used as

Secondary

or Other

Drug with

Non-Opiate

as Primary

164

Used as

Secondary

or Other

Drug with

an Opiate

as Primary

79

Total

Reported

Use

8,584

Used as

Primary

8,341

Category

Heroin

Illegal

Methadone 272 7 1 187 14

Other

Opiates 885 404 82

(PERCENT)

97.2

399

Heroin 100 0.9 1.9

Illegal

Methadone 100 26.1 68.8 5.1

Other

Opiates 100 45.6 45.1 9.3

SOURCE: Calculated from Table 8 included in this paper.

Tables 4 and 5 provide an estimate of polydrug abuse based in the

definition expressed earlier. Data are provided for the periods

April through June 1974 and October through December 1974 and are

also based on CODAP reports. Although there has been some shifting in the relative importance of some drug categories between

these periods, the estimate that 22 percent of CODAP admissions

fall into the category of polydrug users as defined for this paper

is consistent for the two quarters. In each case, 8.8 percent of

the defined polydrug users report marihuana or hashish as their

primary drug for which treatment was sought. Discounting the marihuana clients as probably not in need of drug abuse treatment --

which is also the current NIDA policy -- leaves approximately 14

percent of treatment admissions classified as polydrug users in

need of treatment. These are listed by reported primary drug type

by Tables 4 and 5. The specific combinations of non-opiate drugs

used will be discussed below at which time we can further define

the need for polydrug treatment.

22
TABLE 4

POLYDRUG ABUSE WITH NON-OPIATES AS THE PRIMARY DRUG

(CODAP Admissions, April through June 1974)

Alcohol

Barbiturates

Amphetamines

Cocaine

Marihuana

Hallucinogens

Psychotropics

Inhalants

Non-RX Over

the Counter

TOTAL

TOTAL LESS

MARIHUANA

Total

Clients with

Primary Drug

1,385

1,474

1,216

301

4,574

778

222

234

60 0.2 0.1 0.1

10,244 33.8 11.8 22.9

- - - - - -

Percent

o f

Total

Admission

4.6

4.8

4.0

1.0

15.1

2.6

0.7

0.8

Percent of

Admission

Reporting

Only

Primary

2.4

1.0

0.6

0.2

6.3

0.4

0.4

0.4

Percent of

Admission

Consistent

with

Definition

of Polydrug

Use

2.2

3.8

3.4

0.8

8.8

2.2

0.3

0.4

13.9

SOURCE: Calculated from the CODAP National Summary Report for

April through June 1974.

23
TABLE 5

POLYDRUG ABUSE WITH NON-OPIATES AS THE PRIMARY DRUG

(CODAP Admissions, October through December 1974)

Alcohol

Barbiturates and

Other Sedatives

Amphetamines

Cocaine

Mar ihuana

Hallucinogens and

Psychotropics

Inhalants

Non-RX Over the

Counter

TOTAL

Total

Clients with

Primary Drug

866

1,217

954

178

3,619

549 3.1 0.9 2.2

281 1.6 0.9 0.7

84

7,748

Percent of

Percent Admission

o f Reporting

Total Only

Admission Primary

4.9 2.8

6.9 1.9

5.4 2.2

1.0 0.4

20.4 11.6

0.5 0.3

43.7 21.0

Percent of

Admission

Consistent

with

Definition

of Polydrug

Use

2.1

5.0

3.2

0.6

8.8

0.2

22.7

SOURCE: Calculated from Table 8 included in this paper.

Although a clear understanding of the current drug use patterns is

important in order to establish the size and type of treatment resources needed, knowledge of trends or changes in trends is also

important. Prior to the implementation of CODAP the most complete

and respected drug abuse treatment data base was the Drug Abuse Reporting Program (DARP) operated by Dr. S.B. Sells. The research

results of this effort have recently been published in a two volume

series.* In an analysis of polydrug patterns, Sells and Simpson define multiple or polydrug users as:

Users who reported using at least three of six drug classes

(excluding heroin and other opiates). The polydrug users

who reported no use or less than weekly use of heroin were

placed in . . . (a "poly" classification), while those who

reported more frequent use of opiates were placed in . . .

(a pattern termed "poly plus opiates").**

* S.B. Sells, The Effectiveness of Drug Abuse Treatment, Volume I,

Evaluation of Treatments and Volume II, Research on Patients

Treatments and Outcomes. Ballinger Publishing Company: Cambridge,

Mass., 1974.

** S.B. Sells, Volume 2, pp. 180-181.

24
These definitions differ from the one used here, but, at admitted

risk, I will draw some comparisons. Table 6 sets forth these comparisons, some of which are more valid than others. The most valid

and the most frequent category in both reporting systems is the use

of heroin alone. The DARP system for the period June 1969 through

June 1971 records this category of use as representing 28.3 percent

of admissions, CODAP for the quarter October to December 1974 is

29.6 percent of admissions. No drug use reported under DARP was

6.9 percent of admissions whereas CODAP shows this at 2.9 percent

of admissions. The use of heroin and cocaine or marihuana does not

seem to have changed much over the last four years. It is difficult, with the currently available data summaries from the revised

CODAP system, to accurately calculate similar information from the

DARP summaries when three or more drugs used in combination are defined. Therefore, I have attempted to define rough ranges for

these two cases. In each of these cases shown on Table 6, the DARP

estimate falls within the range estimated from CODAP. The definition of polydrug used by DARP is too different from that used here

to draw any really valid comparison.

TABLE 6

COMPARISONS OF DRUG USE PATTERNS

(percent of admissions)

DRUG USE TYPE

DARP

6/69 - 6/71

CODAP

9/74 - 12/74

Heroin Only 28.3 29.6

Poly and Opiates 13.3 10.6 - 17.5*

Heroin and Cocaine 8.8 6.9

Heroin and Marihuana 7.8 10.5

Opiates plus Non-Opiates 7.8 <15**

Heroin, Cocaine, Marihuana 7.3 6.6 - 12.5***

No Use 6.9 2.9 

Polydrug 4.9 - -

*This range was estimated based on data from Table 8 included in

this report. The higher estimate is based on the number of

opiate users also reporting other drug use. The lower estimate

excludes opiates as secondary or other drug use.

**Only the upper limit of this category can be calculated with

current outputs from the revised CODAP system although the system is capable of providing this data.

***This range was calculated from the source document from which

Table 8 included in this report was calculated. The lower estimate assumes that, in CODAP terminology, cocaine was used as a

secondary drug and marihuana was used as the other drug. The

higher estimate relaxes this assumption by including heroin and

cocaine and heroin and marihuana.

25
Admittedly, these comparisons are not precise and with a few exceptions are subject to interpretation. However, I believe that

the data do show significant consistency in that it is unlikely

that there have been major changes in drug use patterns between

the periods covered by these two data systems.

I mentioned earlier that clients have a tendency to overstate drug

use at the time of admission to treatment. Tables 7 and 8 establish this trend. Table 7 provides reported drug use combinations

regardless of whether or not any frequency of use of the secondary

or other drugs at the time of admission is reported. Table 8 provides the same information, but requires that the secondary or

other drugs are used at least once per month at the time of admission. As can be seen from comparison of these two tables, the use

of only the primary drug and no others increases from 41 percent

(Table 7) to 55 percent (Table 8). More dramatically, the use of

heroin alone increases from 48 percent to 62 percent of all heroin

admissions or from 23.6 percent of total admissions to 30.6 percent

of total admissions. This relationship holds for most of the primary drug problems reported.

The picture of multiple drug use of non-opiates is primarily one

where marihuana or hashish is reported as one of the drugs being

used (Table 8). These combinations, in order of relative importance consist of:

Drug Combinations Number

Percent of

Total

Admissions

Marihuana and Alcohol 1,056 6.0

Amphetamines and Marihuana 716 4.1

Marihuana and Hallucinogens 666 3.8

Marihuana and Barbiturates 666 3.8

Barbiturates and Alcohol 253 1.4

Amphetamines and Alcohol 224 1.3

Based on the definition of polydrug abuse set forth above, polydrug

users in need of treatment currently account for 13.9 percent of

total admissions (Table 4). However, this 13.9 percent estimate

was based on the assumption that the primary drug problem was a nonopiate, excluding marihuana and that there was also an additional

drug problem. As can be seen from the drug combinations listed

above and from Tables 8A and 8B, marihuana is listed in highest frequency as the secondary or other drug to the non-opiate primary

drugs reported.

The current treatment population, on the basis of these data, may

therefore be characterized as:

consisting of 50 percent heroin users of which 62 percent use

no other drug at the time of admission.

26
TABLE 7A

COMBINATION OF DRUG USE REPORTED AT ADMISSION TO TREATMENT: TOTAL DRUG PROBLEMS REPORTED

(October - December 1974)

PRIMARY

SECONDARY AND OTHER DRUGS -- TOTAL REPORTED DRUG USE*

TOTAL OTHER OTHER

DRUGS PRIMARY NONE HEROIN METH. OPIATES ALCOHOL BARB, SED. AMPH. COCAINE MARIJ. HALLUC. INHAL. O-T-C OTHER

NONE 521

HEROIN 8,341

ILLEGAL METHADONE 71

OTHER OPIATES 404

ALCOHOL 866

BARBITURATES 878

OTHER SEDATIVES 339

AMPETAMINES 954

COCAINE 187

MARIJUANA 3,619

HALLUCINOGENS 549

INHALANTS 281

OVER-THE-COUNTER 30

OTHER 84

TOTAL 17,115 7,029 503 280 742 2,119 2,293 581 1.540 1.468 3,662 1,540 111 144

521 - - - - - - - - - -

4,033 - - 254 583 590 1,134

13 38 - - 11 2 16

132 91 7 - - 23 101

314 28 0 2 - - 113

151 80 7 31 203 - -

110 8 0 10 84 36

152 73 2 32 187 164

31 34 1 5 19 38

1,302 104 7 52 879 529

65 24 2 14 81 127

144 5 0 0 39 25

19 2 0 00 3 3

42 16 0 2 9 7

- - - - - -

182 518 1.183

5 2 3

32 46 18

45 69 11

95 190 38

- - 48 12

4 4 - - 59

4 28 - -

133 478 108

32 135 30

7 18 3

2 0 0

0 8 3

- - - -

1,795 362

7 6

6 8 3 4

330 6 0

349 133

109 2 4

497 234

7 5 3 3

- - 636

327 - -

8 9 1 3

3 0

1 3 5

- - - -

12 67

0 6

3 4

6 9

11 16

2 6

9 3

1 1

58 25

7 1

- - 5

1 - -

1 1

__

27

0

2

150

46

6

22

11

533

1

0

1

- -

799

* Drug use reported at admission may have been discontinued prior to admission.
TABLE 7B

COMBINATION OF DRUG USE REPORTED AT ADMISSION TO TREATMENT: TOTAL DRUG PROBLEMS REPORTED

(October - December 1974)

Percent

PERCENT OF SECONDARY AND OTHER DRUGS BY PRIMARY DRUG CATEGORY -- TOTAL REPORTED DRUG USE *

PRIMARY TOTAL OTHER OTHER

DRUGS PRIMARY NONE HEROIN METH. OPIATES ALCOHOL BARB. SED. AMPH. COCAINE MARIJ. HALLUC. INHAL. O-T-C OTHER

NONE 521 100 -- -- -- - - - - -- -- - - -- __

HEROIN 8,341 48.4 -- 3.0 7.0 7.1 13.6 2.2 6.2 14.1 21.5 4.3

ILLEGAL METHADONE 71 18.3 53.5 -- 15.5 2.8 22.5 7.0 2.8 4.2 9.9 8.4

OTHER OPIATES 404 32.7 22.5 1.7 -- 5.7 25.0 7.9 11.4 4.5 16.8 8.4

ALCOHOL 866 36.3 3.2 0.0 0.2 -- 13.0 5.2 8.0 1.3 38.1 6.9

BARBITURATES 878 17.2 9.1 0.8 3.5 23.1 - - 10.8 21.6 4.3 39.7 15.1

OTHER SEDATIVES 339 32.4 2.4 0.0 2.9 24.8 10.6 - - 14.2 3.5 32.2 7.1

AMPHETAMINES 954 15.9 7.7 0.2 3.6 19.6 17.2 4.6 -- 6.2 52.1 24.5

COCAINE 178 17.4 19.1 0.6 2.8 10.7 21.3 2.2 15.7 - - 42.1 18.5

MARIJUANA 3,619 36.0 2.9 0.2 1.4 24.3 14.6 3.7 13.2 3.0 - - 17.6

HALLUCINOGENS 549 11.8 4.4 0.4 2.6 14.8 23.1 5.0 24.6 5.5 59.6 --

INHALANTS 281 51.2 1.8 0.0 0.0 13.9 8.9 2.5 6.4 1.1 31.7 4.6

OVER-THE-COUNTER 30 66.3 6.6 0.0 0.0 10.0 10.0 6.6 0.0 0.0 10.0 0

OTHER 84 50.0 19.0 0.0 2.4 10.7 8.3 0 9.5 3.6 15.5 6.0

TOTAL 17,715 41.1 2.9 1.6 4.3 12.4 13.4 3.4 9.0 8.6 21.4 9.0 0.6 0.8 4.7

- - __ - -

0.1 0.8 0.3

0.0 5 0.0

0.7 1.0 0.5

0.7 1.0 17.3

1.3 1.8 5.2

0.6 1.8 1.8

0.9 0.3 2.3

0.6 0.6 6.2

1.6 0.7 14.7

1.3 0.2 0.2

__ 1.8 0

3.3 - - 3.3

1.2 0.0 __

* Drug use reported at admission may have been discontinued prior to admission.
TABLE 8A

COMBINATIONS OF REPORTED DRUGS USED AT ADMISSION TO TREATMENT:

SECONDARY AND OTHER DRUGS USED AT LEAST ONCE PER MONTH

(October - December 1974)

PRIMARY

DRUGS

SECONDARY AND OTHBR DRUGS -- FREQUENCY OF USE IS AT LEAST ONCE PER MONTH AT ADMISSION

TOTAL OTHER OTHER

PRIMARY NONE HEROIN METH. OPIATES ALCOHOL BARB. SED. AMPH. COCAINE MARIJ. HALLUC. INHAL. O-T-C OTHER

NONE 521 -- --

HEROIN 8.341 5,239 --

ILLECAL METHADONE 71 34 18

OTHER OPIATES 404 215 61

ALCOHOL 866 490 13

BARBITURATES 878 343 46

OTHER SEDATIVES 339 164 2

AMPHETAMINES 954 384 20

COCAINE 178 73 19

MARIJUANA 3,619 2,057 42

HALLUCINOGENS 549 165 11

INHALANTS 281 163 1

OVER-THE-COUNTER 30 22 1

OTHER 84 59 9

TOTAL 17.115 9.408 243

- -

184

- -

3

0

5

0

2

0

5

2

0

0

0

201

-- -- -- -- - -

395 492 745 140 274

4 2 14 5 1

-- 18 68 24 28

0

- - 79 36 4 5

18 174 - - 79 135

6 68 28 - - 29

12 149 118 29 - -

2 16 30 4 19

33 781 382 99 307

10 71 89 24 102

0 37 17 5 13

0 2 2 1 0

1 7 5 0 6

- - - - - - - - - - - -

823 1,391 224 7 4 5 9

3 5 4 0 3 0

10 55 22 2 3 2

6 275 32 3 9 1

27 284 88 9 12 2

8 93 1 1 1 4 3

36 409 136 4 1 4

- - 57 21 1 1 2

65 - - 391 46 19 10

19 275 - - 7 1 1

2 80 5 - 3 0

0 2 0 0 - 1

0 9 4 0 0 -

481 1.817 1,577 446 959 999 2,935 938 80 101 35
TABLE 8B

COMBINATIONS OF REPORTED DRUGS USED AT ADMISSION TO TREATMENT:

SECONDARY AND OTHER DRUGS USED AT LEAST ONCE PER MONTH

(October - December 1974)

Percent

PERCENT OF SECONDARY AND OTHER DRUGS USED BY PRIMARY DRUG CATEGORY --

FREQUENCY OF USE IS AT LEAST ONCE PER MONTH AT ADMISSION

PRIMARY

DRUGS

TOTAL OTHER OTHER

PRIMARY NONE HEROIN METH. OPIATES ALCOHOL BARB. SED. AMPH. COCAINE MARIJ. HALLUC. INHAL. O-T-C OTHER

NONE 521 100.0 -- - - - - -- --

HEROIN 8,341 62.8 -- 2.2 4.7 5.9 8.3

ILLEGAL METHADONE 71 47.8 25.4 - - 5.6 2.8 19.7

OTHER OPIATES 404 53.2 15.1 0.7 - - 4.5 16.8

ALCOHOL 866 56.6 1.5 0.0 0.0 -- 9.1

BARBITURATES 878 39.1 5.2 0.6 2.1 19.8 --

OTHER SEDATIVES 339 48.4 0.6 0.0 1.8 20.1 8.3

AMPHETAMINES 954 40.3 2.1 0.2 1.3 15.6 12.4

COCAINE 178 41.0 10.7 0.0 1.1 9.0 16.9

MARIJUANA 3,619 56.8 1.7 0.1 9.9 21.6 10.6

HALLUCINOGENS 549 30.1 2.0 0.4 1.8 12.9 16.2

INHAIANTS 281 58.0 0.4 0.0 0.0 13.2 6.0

OVER-THE-COUNTER 30 73.3 3.3 0.0 0.0 6.7 6.7

OTHER 84 70.2 10.7 0.0 1.2 8.3 6.0

TOTAL 17,715 55.0 1.4 1.2 2.8 10.6 9.2 2.6 5.6 5.8 17.1 5.5 0.5 0.6 0.2

- - - - - -

1.7 3.3 9.9

7.0 1.4 4.2

5.9 6.9 2.5

4.2 5.2 0.7

9.0 15.4 3.1

- - 8.6 2.4

3.0 -- 3.8

2.2 10.7 - -

2.7 8.5 '1.8

4.4 18.6 3.4

1.8 4.6 0.7

3.0 0.0 0.0

0.0 7.1 0.0

-- -- -- - - - -

16.7 2.7 0.1 0.5 0.1

7.0 5.6 0.0 4.2 0.0

13.6 5.4 0.5 0.7 0.5

31.8 3.7 0.3 1.0 0.1

32.3 10.0 1.0 1.4 0.2

27.4 3.2 0.3 1.2 0.9

42.9 14.3 0.4 0.1 0.4

32.0 11.8 0.6 0.6 1.1

- - 10.8 1.3 0.5 0.3

50.1 -- 1.3 0.2 0.2

28.5 1.8 -- 1.1 0.0

6.7 0.0 0.0 - - 3.3

10.7 4.8 0.0 0.0 - -
consisting of 21 percent that list marihuana as their primary

presenting problem. Of these marihuana users, 57 percent report using no other drug at the time of admission.

consisting of very few polydrug users in need of treatment as

this term is defined in this paper.

AUTHOR

C. James Sample is Senior Research Economist, System Sciences, Inc.,

Bethesda, Maryland.

31

II. PROBLEMS IN DATA ACQUISITION
Surveys of General Populations

Ira H. Cisin, Ph.D.

My subject is data acquisition in surveys of general populations

and my objective is to remind you of two important and unpleasant

facts:

First: if your objective is to estimate the prevalence of a phenomenon in a population, a samply survey is the only game in town;

there are no substitutes for a survey based on a rigorously designed

random (probability-based) sample; and

Second: the job of conducting a sample survey is full of problems;

and the problems seem to be getting worse as time goes by.

It should not be necessary in the year 1975 to issue pious pronouncements on the necessity for random sampling. The statistical theory

is clear: only a random sample can provide unbiased estimates for

the population; and only a random sample can provide the researcher

with the power to make probabilistic statements about the relationship between sample estimates and population values. We do not pretend that any one random sample will accurately reflect a population value; we do assert that only a random procedure can arm us

with knowledge of the probability of being wrong -- and by how much.

None of the shortcut inexpensive methods can give us that much

power.

Because of the expense of random sampling, the search for less expensive substitutes has been unremitting. We hear about quota samples, about "modified" probability samples (which are comparable to

34
a "modified" tomcat) , and about the ingenious application of multivariate techniques to aggregates of clinic patients or other volunteers in an attempt to use what is readily and cheaply available.

Without laboring the point, I think it is unnecessary to remind this

audience that all such procedures involve the bias of self-selection

or the analogous bias of selection by interviewer and thus provide

estimates that cannot legitimately be defended.

Some quite sophisticated researchers argue that the requirement for

random sampling is less important if we are studying relationships

than it is when our primary interest is in population estimates or

projections . This argument has a kind of specious appeal until we

remember that it is true only under certain restrictive assumptions

or conditions, which include perfect homogeneity within strata and

strict linearity in the relationships being studied. There may be

circumstances under which these assumptions are tenable, but I have

never encountered those circumstances.

So the escape routes are cut off and we are stuck with the requirement for honest-to-goodness random sampling in surveys. Let us

turn now to some of the problems we are encountering in trying to

carry out such surveys in the field of drug use.

The first of these problems is characteristic of all sample surveys

these days -- the lack of cooperation from respondents. In years

past, sample surveys were a novelty; people were flattered and

pleased to be asked about themselves; the interviewer was welcomed

into the household. Now we seem to be suffering from a new atmosphere of suspicion and distrust; doors are double-locked; the interviewer is an invader who, for nefarious reasons is abridging the

privacy of the selected respondent. You are welcome to speculate

on the reason for this change, but the fact is that the novelty has

worn off, the flattery doesn’t work and the interviewer needs some

salient justification beyond the researcher’s curiosity. More and

more we hear: "What’s in it for me?" from our respondents.

As recently as the early 1960’s, we were able, with diligent effort

and a lot of money, to produce a 90 percent response rate in a predesignated random sample of the general population (I am not talking about special populations,

brought).

where special pressures can be

Certainly we were worried about the biasing effect of the

missing ten percent, but we consoled ourselves with the fact that

they couldn’t change our estimates by much. At any rate, 90 percent

was about as high as our response rate ever went.

Now, with similar effort, we can produce a response rate of about 75

percent in the general population and considerably less in certain

definable segments of the population. When we remember that the ones

that get away -- the non-cooperators -- are quite likely to include

some of the most interesting cases, we may well worry about the quality of the population estimates that we make based on the cooperative respondents.

35
The rapid decline in the rate of cooperation in the general population is of great concern to all those who conduct surveys; the

market research people, the statistical association, the sociologists and the public opinion research association are all casting

about for solutions -- but so far all I have heard is a lot of

groaning and mutual sympathy. So much for the overwhelming problem of non-cooperation.

In the field of drug use, those who conduct surveys have a special

worry. We know how to do sample surveys of household populations.

If the people would cooperate, we know how to take a sample, we

know how to contact them, and so on. But it seems obvious that the

household population may be a relatively unimportant target population in the field of drug abuse relative to the floating population.

And we don't know how to do sample surveys in what may be the most

important population of drug abuse, the floating population.

The next problem to which I would like to draw your attention is the

problem of conceptualization in the planning of survey content.

One of the first discoveries I made in the field of drug abuse is

that there is a very large and varied list of behaviors that we are

concerned about. Merely inventing the term "drug abuse" does not

create a homogeneous concept. When we set out to study the incidence and prevalence of drug abuse we ask ourselves: what behavior

qualified as drug abuse and what behavior does not qualify as drug

abuse? By the time we finish our list of things that qualify --

the variety of human behavior that we are regarding as problematic,

that we are regarding as deviant -- we have a very long list. This

is a practical problem. We have such a long list of different

things that we are studying that we cannot study any part of the

list in any great depth. Doing a big national survey is expensive.

When you are dealing with face to face interviews in the household

population, you don't have three hours in which to collect data,

or your response rate is going to go down even lower. You have perhaps 40 minutes to an hour. If you have a very long list of things

you are trying to ask about, about all that you can do with respect

to each kind of behavior is ask primitive, simple questions; and

that is what we are doing. We can't have breadth of coverage of

long lists of varied behaviors and go into any one of them in any

depth.

I have one other conceptual problem here that may be of interest

to you: we face head-on into the question, what do you mean by current use? We can tackle the problem of annual prevalence and one

month prevalence and so on. What exactly is current use? If I say

I am not now smoking a cigarette, I intend to very shortly and I did

a little while ago -- what interval between past use and next use

is required for a definition of current use? I can only say that we

made a stab at this definition by defining current use in terms of

having used the substance within the month and not intending never

to use it again. Unless you have both these components and you

simply ask "Are you a user?" -- I think you have an ambiguity. Look

out for the problem of current use or so called regular use. I suspect that self reporting on these particular words is very unreliable.

36
Finally one of the problems that pervades the drug abuse field in

this kind of research -- interview research -- is the problem of

validity. We have made some attempts to assess the validity of

these behavior reports. It has been a very discouraging exercise

primarily because the psychometric concept of validity requires a

criterion, i.e., another measure which is assumed to be more valid

than the candidate measure we were using. If you detect a certain

circularity in the definition of validity, your quarrel is with the

psychometricians. In any case, we tried two kinds of validity

studies -- one a group validity study and the other an individual

validity study, and in both cases we are dependent on clinic records for our criteria. This was a revelation in terms of the operation of the clinics. We find ourselves sharing the feeling that

Binet had when he first invented the intelligence tests and validated them against teachers’ ratings. The relationship was not too

good, so he said, "That must mean that my test is very good because

the teachers’ ratings are very poor!" I have the same feelings

about our questionnaires -- they must be very good because they are

imperfectly correlated with the clinic records. Why is this? We

know the clinic records are rough. Clinic records contain fictitious names and non-existent addresses. Many of the clinics that

we have dealt with do not routinely take drug history, so if the patient comes in and is strung out on some particular substance, there

is nothing in his record to indicate any of the other substances he

has used. In our validity study which involved a double blind situation -- the interviewers didn’t know that they were interviewing

clinic patients and randomly selected matched cases -- we found that

our relationship with the clinic records showed approximately an

equal number of errors of the first kind and errors of the second

kind (as explained below). To be specific, in the case of marihuana

we found much more marihuana smoking than the clinics had a record

of. The clinics had apparently not asked for that. In the case of

heroin we found primarily errors of the first kind; that is, we

found that half of the people in our test group who had a clinic record of heroin usage admitted to heroin usage on the questionnaire;

a smaller number gave us heroin usage and had not given it to the

clinic. In the case of cocaine, on the other hand, (again apparently the clinics do not ask about it) we found a lot of cocaine use

that was not part of the clinic records. Now I don’t know how to

make an overall validity statement out of this. One gets the feeling

that if you are interested in prevalence the questionnaire studies

are going to give you approximately the same prevalence rate as the

clinic records; that is, for the same group of persons, clinic patients, you are going to get in questionnaires approximately the

same prevalence rate on the average across drugs as you would get

from the clinic records, but they won’t be exactly the same people.

NOW ponder that for a moment and ask what happens in terms of the

correlates of various kinds of drug use.

Having presented some of the problems in collecting data on state

and national surveys of the household population I conclude that it

is a very discouraging picture. But I say again that these frustrations must be viewed as challenges, since there is no alternative

to the sample survey. If you want data that you can comfortably

37
use, rather than bits and pieces which don’t fit together; if you

want the kind of projectable information that only a samply survey can give you, I recommend that you continue doing this kind of

sample survey but accept the fact that you must take the results

with more grains of salt perhaps than you are accustomed to using.

AUTHOR

Ira H. Cisin is Professor of Sociology, Social Research Group,

George Washington University, Washington, D.C.

38
Surveys of Target Populations

Lee N. Robins, Ph.D.

For those of you who don’t know, let me review what I’ve been involved in, and then I’ll try to give some general thoughts about

problems of surveying on drug issues and tell you very briefly about

some of our solutions, such as they were. I got into this business

a long time ago because I was interested in doing follow-up studies

on children, not really because I was interested in drugs. One of

the things we asked about in a follow-up study of black school boys

was how much drug use they had had by the time we interviewed them

at the age of approximately 32 years. That turned out to be the

first time, I believe, that anybody had asked a general population -- not in treatment, not known to the police -- about their

drug behavior. Although we really didn’t have a very big sample,

it was so unusual to have asked about this topic that this got me

into the drug business.

What I’ve done since then is a follow-up study of Vietnam veterans

in which we interviewed approximately 900 Army enlisted men who had

left Vietnam in September 1971, after they were back in the States

between 8 and 12 months.* We are now in the process of reinterviewing most of the same men again. We’re also interviewing a comparison group of non-veterans who are matched for age, education,

*Robins, Lee N.: The Vietnam Drug User Returns: Final Report.

Contract No. HSM-42-72-75, SAODAP. Government Printing Office,

Washington, D.C., September 1973.

39
region of the country, and, hopefully, eligibility for service. In

other words, we are trying to get people as much like the Vietnam

veterans as possible, except that they didn’t go into service.

We’re interested in finding out whether veterans’ drug use at the

present time is any different than it would have been if they had

never gone into the service at all.

Let me say very briefly some things I think about interviewing about

drugs and see if you agree with them. The first thing I’d like to

say, at the risk of making an extreme statement, is that just getting incidence and prevalence out of a survey of drug users is not

getting very much for your money. Not only is it very expensive to

go out and interview people, but I would also argue that you never

really want to know those figures. Things change very rapidly in

the drug field and these figures are true as of one moment in history; they don’t necessarily tell you how much treatment you should

plan for or even how much drug use there will be next year. What

is much more interesting are the relationships among variables

within your population. The only time it is worth simply counting

the numbers of people who use drugs is when you have some simple,

cheap technique for resurveying the same population over and over

again so that you can study trends. For the kinds of surveys most

of us do, just doing a one-time count of cases seems not terribly

rewarding. Patterns of drug use, not only in this country but

throughout the world, seem to be going through rapid changes in the

availability of drugs and in attitudes towards use. If you interview different age-cohorts, you get very different rates of exposure to drugs and different attitudes, and you also find that people living in one area have had quite different experiences and

opportunities to use drugs from those in another. Where there are

historical changes in progress, history moves at different paces in

different places. New York City in 1969 is quite different from

Great Falls, Montana, in 1969 but may be much like Great Falls in

1976. It is very hard to generalize from information about a particular time, cohort, and locality. One reason this is so is that

very different people use drugs when drug use is a rare phenomenon

than when it is a common phenomenon. To a certain extent that

statement is tautologous because if more people are involved, some

of them have to be different people. But there is more to it than

that. The meaning of using drugs changes when it becomes something

that a large portion of the population does instead of a rare and

unusual event. Different types of people are recruited to drug use

when it becomes commonplace.

The other thing that seems to be true of drug abuse in our experience is that the age of risk of beginning drug use is rather narrow.

Most studies find very few people beginning drug use after the age

of 30. Thus, if you want to estimate life-time prevalence and your

respondents are past 30, they are pretty well through the age of

risk. On the other hand, if your respondents are adolescents, you

don't know exactly where you are regarding the age of risk, because

the risk period keeps changing. It has been observed that the age

of beginning use seems to get lower every year. As a result, you

don’t know how to calculate how much of the age of risk an individual has been through if he is much under 30. It may well be that

40
if drug use becomes more acceptable, the risk period will also be

extended at the upper end. As some middle-aged Americans seem to

have discovered the sexual revolution, they may also be discovering

illicit drugs as time goes on. Then the age of risk will be changing at both its ends over time.

One problem in studying any form of deviance -- and drug use is no

exception -- is that the group that society has most concern about

is not the occasional deviant, but the regular and consistent deviant (in this case heavy users or drug dependents). This seriously deviant group is always a very small segment of the population.

This presents problems in choosing an unbiased sample and still

getting enough cases who have the behavior of interest to be able

to study its natural history in a natural setting.

The next problem is one mentioned earlier today, which is that there

are problems both of ethics and of scientific validity when you

collect information about illegal and disapproved behaviors. On

the one hand, you are very concerned about possibly harming the

individual from whom you are collecting the information, and on the

other hand, since he knows that you could damage him in some way,

you have reason to doubt that he is going to tell you the truth.

Another problem that was also mentioned earlier is that drug users

tend to develop special languages with which those doing the study

or at least those interviewing for the study may not be totally

familiar. This lack of shared language may impair the communication between the researcher and the subject. And, since there is a

great deal of negative public sentiment about drug use, interviewers may share these biases. The interviewers’ bias may make them

reluctant to ask respondents about behaviors that they (the interviewers) disapprove of. In most human interactions, and interviewing is no exception, people try to keep relationships friendly.

They like to ask about things that people are willing to tell them

so that they can maintain what social scientists like to call "rapport." (Other people call this "friendly feelings" toward anybody

you are interacting with.) If the interviewer is embarrassed or

reluctant to ask questions about drug use, or if he fails to understand the respondent’s references to drugs because he does not know

the language, the study will underestimate the prevalence of drug

use.

The final issue, which I think is a very important one, is that there

is a strong negative relationship between the seriousness of an individual’s deviance and the ease of reaching him as a respondent.

When the availability of respondents is related to the very issue

that you’re interested in investigating, you cannot assume that

failures to locate or refusals have not biased your results. Serious drug abusers tend not to be home in the evening when you knock

on the door -- they’re either dead, or in jail in a hospital or

out on the street hustling drugs. This makes it hard to reach them

through ordinary survey techniques.

41
I think it probably sounds now as if it is impossible to do surveys about drug abuse. Having been pessimistic, I now would like

to play Pollyanna and say that it is really not all that hard --

there are some solutions at least. Let’s talk first about the

problem of historical changes in availability and the narrow age

of risk. It seems to me that unless one has money to study enormous samples, one is better off working with somewhat homogeneous

samples with respect to their access to drugs and to the age and

background variables. It is hard to design a study that can apply

to all parts of the population at once, without being very superficial. Which questions about drug experience appropriate to

a 25-year drug pusher in New York would make sense to a 60-yearold farmer in Iowa? In studying Army enlisted men who were in

Vietnam, we had a sample that was extremely homogeneous. Its members shared nationality, sex, occupation, age, and location during

a specific moment of history. This solved many problems of questionnaire design. The difficulty is that once you choose a homogeneous sample you lose generality -- you don’t know to what extent you can extrapolate from your homogeneous subpopulation to the

population as a whole. What I feel at this moment is that you’re

better off first working with a carefully defined homogeneous sample and then trying to replicate your findings about factors influencing drug use in very differently defined but equally homogeneous

samples -- to see if your findings hold with different kinds of

populations in different places, at different times -- rather than

trying to solve everything in one study.

The next question is how to get enough really serious users in any

general population. One way is to see to it that the homogeneous

subpopulation from which you are sampling is a high risk population,

but in doing that you severely limit your ability to generalize to

the general population. A better solution is to over-sample, at a

known rate, the group within your population which you think is

going to be a high risk subsample and then weight it back in. This

is what we did in the Vietnam study when we took equal proportions

of a general sample and of a sample of people identified as drug

users at the time they left Vietnam. The second sample was simply

a blow-up of that 10 percent of the general sample we could expect

to have the highest rate of use after their return. Then, by knowing the proportion identified as drug users at departure in the

general sample, we could weight our large high-risk sample back into the general sample. Thus we simultaneously had an unbiased general sample and a large subsample of heavy users in whom to study

the progress of relapse and remission after return.

Solving the ethics problem requires some kind of super-inviolable

arrangement for confidentiality. It may well be that the most

serious users you are interviewing don’t care very much about confidentiality, because many of them will be known to the police and

have records here and there. We found that the people who cared the

most were the interviewers -- and me. Interviewers are typically

young, anti-establishment, dewy-eyed, and very sensitive about

ethics. That last characteristic applies to me as well. I felt in

undertaking this study that I had to be willing to go to jail rather

than compromise confidentiality, but I didn’t relish incarceration.

42
In fact, nobody so far has shown any interest in finding out anything about any individual we interviewed, but I felt we had to be

protected against every contingency. So we had a very elaborate

arrangement -- a double number system -- in which we sent interviews without any number on them except on the mailing envelope to

Canada, where they were given a new number, so that the link between the name and the number identifying the interview was broken.

Our Canadian contact didn’t have the name, only a list of two numbers: the original number associated with the name and the new number they chose. In the U.S. we had a list of names and the first

number, but we could not get from the first number to the second

number without going back through Canada. This system not only

guaranteed protection of confidentiality, it also meant I didn’t

have to worry about whether interviews were locked up, because

there was no way that anyone reading them could tell to whom they

belonged, even if they had my list of names and ID numbers. I

found that a very relaxed situation.

The problem of the relative difficulties in gaining access to drug

users for interview as compared to non-users is a serious one. The

methods used not only in this study but in our earlier studies in

which deviant outcomes were of interest are not very commonly used,

but I would like to recommend them. They are avoided because they

are considered to be very difficult. However, I didn’t find them

so. They involve using an earlier roster as a basis for sample

selection and then a reasonably relentless effort at follow-up.

In this study, the Army made a roster for us which contained every

enlisted man who had left Vietnam during a certain month. Because

appearance on that roster depended only on departure from Vietnam,

and not at all on behavior after return, the sample we chose from

that roster was not at all biased in terms of whether or not they

used drugs after they got back. We could have biased our sample of

respondents against men who used drugs after return by failing to

interview the hard-to-interview cases, but at least we would know

that we were missing them. That is the advantage you don’t have in

an area survey, where, since you don’t know what your base population is, you don’t know whom you have missed. When interviewing

civilians, you can get the same total count by using early school

or birth records. (If you use high school records, you will have

lost those too deviant to finish elementary school.) Whatever its

source, access to some sort of roster made up before the behavior

of interest has occurred guarantees that whether or not that behavior occurs later cannot influence whether or not the person is

in the sample. The other advantage in starting with a roster made

up before the behavior has occurred is that you can count deaths,

which you can’t do with area surveys.

Once you have a sample that is unbiased with respect to drug behavior, you still have to avoid bias due to the fact that it is

harder to contact the more deviant members of your sample. What

we did was, first, to pay the respondent for his time and second,

to set no limit on call-backs; each case had to be pursued until

located and a definite "yes" or "no" obtained. (Incidentally, once

43
located, deviant subjects don’t seem to be any more likely than

others to refuse an interview.) Locating virtually all subjects

sounds harder than it is. While the maximum number of call-backs

we had was eleven, most interviews were completed on the first

visit by setting up appointments ahead of time. ‘The fact is --

at least in the old days and I am beginning to think this is only

true of the past -- by the use of various and sundry records, it

was pretty easy to find out where somebody was. What we have found

in the last few months, however, is that many sources that were

public records and open to us as ways of locating people have now

been closed. One useful source we used routinely was drivers license registrations. These are now available only to police officers, after having traditionally been public records. There are

many other such examples. Even in recent studies, however, our

completion rates for follow-ups of cases selected from a roster

have been higher than rates in most area surveys. The reasons are

two: first, it is much easier to ask neighbors for information

when you can name your respondent and his close relatives than

when you want the "young man who lives in Apartment No. 3." People are used to answering questions about individuals identified

by name, not by dwelling unit, so long as you can convince them

that you’re not a bill collector -- and that is easy when you can

say you have money for the respondent. So communicating with

neighbors and neighborhood shops and using reverse telephone directories to call people who were former neighbors is considerably

easier when you are looking for somebody whose name and age you

know. Second, I believe both having a name and offering to pay

for the time to answer reduce refusals, because your prospective

respondent doesn’t think you might just as well talk to a neighbor

as to him.

We tried to solve the problems of the specialized language of drug

abusers and interviewer bias through extensive training and by

providing interviewers with a lexicon of technical and street

names for drugs. In the first Vietnam follow-up, most of our interviewers had never before seen anybody who had used heroin.

They were just plain scared. Their fear was further intensified

by one of the people we brought in to train them. He was a young

psychiatrist who had been treating addicts in the amnesty program

in Vietnam. He told the interviewers that the drug addicts they

would interview might well be sociopaths who would try to get

money out of them, and that they had to be extremely careful. His

viewpoint had been biased by his own experience, which was almost

entirely with men who had volunteered for treatment in order to

avoid standing trial for serious non-drug offenses. To overcome

the interviewers’ fears, we had them interview addicts during the

training period in a protected environment, rather than going out

to the addicts’ homes, as they would during the study proper.

They discovered that the veteran addicts who came from treatment

programs to be interviewed in the office were mostly nice kids,

for whom they felt enormous sympathy. This experience changed

their view of what a drug abuser was, and instead of being terrified, they felt warm and friendly toward their respondents. This

abandoning of fearfulness turned out to be justified. In com44
pleting 900 interviews, we had only one case in which an interviewer had reason to be afraid of a respondent.

While the training sessions enable the interviewers to see addicts

as people instead of monsters and to learn the drug vocabulary,

there was still a question as to whether they would get honest

answers from the users. We tried to test validity in every way we

could. We tested the validity of our estimate of point prevalence

of use by taking urines at the end of the interview, to provide an

independent measure of whether men were currently using drugs. We

got a test of the validity of our interview-based estimate of the

prevalence of heroin in use in Vietnam by reviewing Army records

to see whether the respondents had been known to the Army as drug

users while they were in Vietnam. We have been pleased with the

results of our tests of validity. It turns out that almost every

drug user is willing to tell you the truth so long as nothing is

riding on it. Addicts may be more honest with interviewers who

are going to go away and never come back again than they are with

the doctors they see in drug treatment programs. What the doctor

thinks is going to influence what happens to them, but it doesn't

matter to them what we think -- so they can afford to be candid.

AUTHOR

Lee N. Robins is Professor of Sociology in Psychiatry, Department

of Psychiatry, Washington University Medical School, St. Louis,

Missouri.

45
DISCUSSION

Dr. Gottschalk: Dr. Robbins, where did you get the names of the

drug users and how did you get them as of before leaving Vietnam?

I thought those data were confidential.

Dr. Robins: This was funded by the Department of Defense, so they

had an interest in the study and had access to the data.

Dr. Kramer: I would like to ask a few questions about the age of

risk. In some way this magic number of 30 years seems to have

gotten into these discussions. When interviewing people of 30

years to ask them retrospective questions, you may indeed have gotten all the information there is about their patterns of drug use.

But it depends on the kind of drug you are interested in. If you

are dealing with the way in which people might start using drugs

as a result of a chronic disease which took place after age 30 --

diabetes, cardiovascular diseases, cancers, and so on -- you run

into another problem. This population may have different patterns

of drug use, side reactions, or perhaps an abuse that resulted

from the prescribing habits of a physician. Therefore, it seems

to me this kind of clarification is needed in terms of the kind of

problem you are studying.

Dr. Robins: If John O’Donnell were here he would tell you about

his study of Lexington patients in the 1930’s, where he had a lot

of older people who were drug addicts; having been given morphine

by their doctors, they had become addicted. But that has pretty

much disappeared. It happens rarely now -- doctors have gotten

smarter; although there are a few people who get addicted this

way, they are few and far between.

Dr. Sample: I would like to ask Ira Cisin and Lee Robins a question. Dr. Cisin gave a somewhat pessimistic viewpoint in terms of

the 75 percent completion rates on interviews. Lee Robins, with

unlimited follow-up -- really unlimited cost considerations -- was

able to track, locate, and interview almost everyone. Johns Hopkins

in 1972 did a study of the NARA Program, Narcotic Addict Rehabilitation Act. This follow-up and evaluation study had very low

rates -- completing interviews of about 50 percent of persons

found not suitable for treatment at NARA and about 65 percent of

the people who had completed treatment at Lexington. I have not

read the reports, but, as I understand the results, they took a

46
sample of the not-founds in the first study, went after them,

found most of them this time, and found that the sample of the

not-founds did not differ significantly from the sample of the

founds. What I would like to ask Dr. Robins is, in the persons

that you did not find initially, where it took 8, 9, 10, 11 followups, did you analyze those cases particularly to see if they differed in fact from the ones who were found early?

Dr. Robins: Yes, we compared people who were interviewed the first

time around vs. people who needed four or more visits and there

are very striking differences, not only in terms of drug use but in

their total social adjustment.

Dr. Sample: Dr. Cisin, a question then. Have we ever considered

taking a sample of the not-founds and going after them in a more

intensive way to test that hypothesis?

Dr. Cisin: But then you need to sample the not-found of your sample of not-founds. There is an infinite regress model available

for more and more intensive effort on the "not-founds." You have

raised several questions though, and let me comment very briefly

on a couple of them. First, the decline that has been going on in

cooperativeness over the past 20 years is characteristic of the

general population. It is still possible with special populations

to produce rather high response rates and indeed we did in our

special population and I suspect Room and O'Donnell will in their

special population. In special populations the success rate is

better for a variety of reasons that we need to go into now. In

the general population, there has been a significant decline in

cooperativeness. To back up what Lee Robins said about the ones

who "got away," in the study that Cahalan and I did of American

drinking practices about 10 years ago, we did not subsample the

non-cooperators and go after them intensively. As I have said,

you do not find them all and, therefore, you do not really know

what you have when you subsample the non-cooperators. What we did

do was along the lines of what Lee Robins suggested; we compared

those who were easy to get to those that were hard to get. This

was a survey in which we went all out; as I said, it was 10 or

more years ago, and we indeed got over 90 percent of the predesignated respondents. We did an analysis of the drinking behavior based on how hard it was to get this interview -- the number

of calls, the amount of time, the amount of effort that went into

the interview, and indeed, we found the same sort of things that

Lee Robins found; not only did the "hard-to-get" differ from the

"easy-to-get" in background characteristics, but they indeed differed on the criterion variable considerably. There may be cold

comfort in an occasional study that finds no difference between

the "hard-to-get" and the "easy-to-get," but it is improbable.

Dr. Johnston: I think another point which is relevant here is

that the type of sampling that is used in the study may have something to do with the results. That is, there are different procedures for drawing a household sample. One is called quota sampling, which means you get someone off of a block or thereabouts,

47
and another is more specific because you are going after a particular individual in a particular household. If you are using quota

sampling, in essence, you are getting the people who are easy to

get, the ones who are there. Quota sampling is therefore, likely

to give you different estimates than other types of sampling.

is usually "finessed" in reports.

Dr. Cisin: This is not the year 1935. We are talking about probability based samples which produce unbiased estimates and that

sort of thing. If you duck into what some people call modified

probability samples (which, as I mentioned, is like talking about

a "modified" tomcat), you are dealing with a very different thing

that has nothing to do with the population in the study. I for

example, worked as an interviewer when quota sampling was all that

was being done in this field, and I can guarantee you that I never

interviewed anybody who owned a big dog!

48
Surveys of Special Populations

Eric Josephson, Ph.D.

Looking around, I can see I am one of about a dozen or more survivors of the conference in San Juan that Louise Richards mentioned. The proceedings of that conference have finally appeared

in book form, approximately 18 months after it took place. It is

an interesting question whether that makes it ancient history.*

For some time I have been associated with Jack Elinson and a national study of Drug Use in nearly two dozen high schools in the

United States. This study has had many ramifications. I do not

propose to talk in detail about it, but rather to attempt my hand

at discussing certain methodological and substantive issues which

have emerged from our own experiences and those of others. I

might also add, by way of background, that at Columbia University

a number of us, Kandel, Lukoff, Elinson, and I have recently established a new Center for Socio-Cultural Research on Drug Use,

with a grant from NIDA. Sometimes we have thought of calling it

the Center for Adolescent Drug Use, but that is not our only concern.

I am staggered by the topic next to my name because it says "Special Populations (Adolescents and Other)." It is difficult enough

to try to reach some consensus on the definition of adolescence --

*Josephson, Eric, and Eleanor Carroll, eds. Drug Use: Epidemiological and SociologicalApproaches. New York: Halsted Press,

1974.

49
just what "other" means I do not know. I have been trying to

think of some of the other populations we might also talk about --

infants, terminal cancer cases, people studying drug abuse, preadolescents, post-adolescents, etc. In listening to Jack Elinson

talk about the problems that his S.A.O.D.A.P. group is having in

defining terms in drug research, I feel we have equal problems in

trying to define "adolescence," although again, I know that is not

our purpose here. In many United States drug studies we arbitrarily define adolescence as the age group 12 through 17 years, i.e.,

the high school years. This is, I stress, arbitrary. One issue

that could be considered here, for example? has to do with evidence that physiological maturation is taking place earlier in the

life cycle; one of our colleagues in Puerto Rico may have some

data on the relationship between maturation and drug use. Then of

course, there is another way of looking at it. From a sociological point of view, it can be argued that adolescence has been prolonged as increasing numbers of people spend more and more years

in college and univeristy. I do not know if "adolescents" on this

agenda means college students as well. However, this is related

to a point that Lee Robins made just a moment ago --about getting

information on the starting point or initiation into the drug experience -- since it is in the college years that many begin such

experiences.

I do not know if it is possible in a few minutes to provide a

state-of-the-art report on the research that has been done in the

United States on adolescent drug use, however adolescence is defined. Glenn and Richards’ recent compendium has abstracted many

of the high school and college studies that have been done.* The

Shafer Commission did the same in its two reports. There have

been a great many such studies, perhaps too many. Maybe we should

declare a moratorium of a year or so on school studies. In fact,

looking at the compendium, it appears that there have been more

studies done in high schools than in colleges. Not only do they

vary enormously in quality, in the definitions they use, and the

methods they apply -- they also vary widely in their findings and

interpretations. It is worth noting too, that some of these

studies have been done by the kids themselves. I cannot think offhand of any other presumed health problems or health-related problems in which those experiencing them have actually conducted research about themselves, but I know of at least one high school

study which was planned, conducted and analyzed by high school

students. It is one of the better ones, as a matter of fact.

So in the last ten years there have been hundreds and hundreds of

such high school studies, most of them done in selected communities,

selected schools, or selected counties. There have been relatively

few national studies, however. I think ours is one of few, al-

*William A. Glenn and Louise G. Richards. Recent Surveys of Nonmedical Drug Use: A Compendium of Abstracts. Prepared for NIDA

by Research Triangle Institute, 1974.

50
though it is not a sample survey of high schools. One of the few

systematic sample surveys is the one Denise Kandel has been conducting in New York State, and she may wish to discuss that later.

It was difficult for the Shafer Connnission to try to draw inferences about national trends based on this bewildering variety and

diversity of many hundreds of high school studies conducted at

different times, in different ways, for different purposes.

As regards national data on trends in adolescent drug use there

have been few studies. Two were conducted by Response Analysis for

the Shafer Commission in 1971 and 1972.* In addition to our own

study of selected schools, we have so far commissioned three such

studies and are now starting a fourth small scale national sample

survey of adolescents in which questionnaires are administered to

youngsters in their homes. Looked at together, the surveys conducted by Response Analysis and our own, particularly in regard to

marihuana, show that in the period 1971 through 1973 there was no

significant increase in the proportions reporting "ever" having

used marihuana. The data we have and the data collected by Response Analysis show that in that period, 1971 through 1973, there

was apparently stabilization in the proportion of youngsters age

12 through 17 who said they had ever tried marihuana; the figure

was approximately 15 percent during that three year period.

I think it is worth pointing out that while the concern of this

meeting is so-called "drugs of abuse" and I also suppose specifically the illicit drugs, we have to be reminded that various studies show that if one is interested in the drugs of choice among

adolescents, they are alcohol first, tobacco second, and marihuana

third.

In the study of drug use many problems of data collection are not

special to adolescence or any age group, e.g., reliability, validity, maintaining confidentiality, protecting the anonymity of respondents. Some are however, and some I suspect may become more

serious.

One has to do with the issue of parental consent. From our experience in several states, we found that in many communities the

schools which were our sites for administering the study -- the

school principals acting in loco parentis -- made it possible for

us to reach all those in school on a particular day who were willing to cooperate with the study which we were doing. But in several communities where the law of the state required that informed

parental consent be provided before the study could be administered, this presented serious difficulties, not so much because parents were unwilling to provide that consent but rather because of

the breakdown in communication when youngsters were given slips to

take home to their parents. Youngsters sometimes forgot to give

their parents the slips, or the parents forgot to sign them, and

*Since this conference, two further national studies have been conducted, by NIDA, one in 1974 and one in 1975/76.

51
sometimes the youngsters forgot to bring the slips back so that in

at least several schools selected for our study the loss of potential respondents was considerable. In our experience this does

not seem to reflect any unwillingness on the part of parents to

have their children participate in such studies. However, the consequences of increasingly stringent requirements of informed parental consent for minors to participate in such studies remains to

be determined. It could present very serious difficulties for any

investigator who wishes to reach a fairly large population of adolescents.

Some of the other methodological problems presented in studies of

adolescent drug use are by no means unique. Perhaps most of the

high school studies that have been done in the United States have

been of the cross-sectional type, i.e., done only once. There

have, however, been a number of trend studies done in particular

communities, such as the annual study done for several years in

San Mateo County, California, as well as the panel studies in

which we and Denise Kandel are separately engaged.

On the substantive side there are a number of issues which I think

should be considered. One has to do with the age curve of drug

use. What I have in mind here is the notion that experimentation

with illicit drugs begins for some in adolescence (i.e., 12-17

years) but does not reach a peak until after the age of 17 or 18.

In limiting oneself to the study of this particular age group, one

is missing many who have yet to begin their experimentation with

drugs. The question as to whether the starting age is falling or

not remains to be determined, though in some parts of the country

the data show that it has indeed fallen. But this does not answer

the question as to what happens after the adolescent period. Thus,

an accurate picture of the age curve may require a wider range for

study.

This is a strong argument for going beyond trend and cross-sectional studies and following-up on adolescents as they reach adulthood. Relatively few such studies have been undertaken so far,

although some are planned. Again, since the use of drugs for some

begins in the adolescent period but not for all, one cannot by

some such age limited population study get the full picture of the

pattern of drug use over time which is involved with increasing

age.

Another issue has to do with the question of faddism. By reconstruction we can detect such fads -- for example, what appears to

have been the fad of interest in glue-sniffing a few years ago!

With regard to marihuana, it remains an issue of debate as to

whether this is a fad which will pass in time or whether it will

become a permanent part of the drug-using scene in the United

States. Will today’s adolescents continue to use marihuana as they

grow older?

I suggest too that most studies of drug use that have been conducted with adolescents are not really studies of drug abuse in

52
any sense of the term that I can think of. Most drug users in the

12-17 age group are experimenting, although, no doubt drug abusers

by some criteria can be found in this population. What has been

of concern, I suppose for political reasons, is public concern

about the drug problem which focuses not only on the fear of crime

but also has to do with parental concern about the presumed ill

effects of drug use on their children. Because of this concern,

many of us have been under considerable pressure to do what really

amounts to a nose-counting operation. I think what the public

wants is to know how many young people are using these "bad" drugs.

And next, of course, is how to stop them from doing so. Of course

that is not of primary interest to many researchers. Some investigators have gone considerably beyond those questions in trying

to understand the processes of drug experiences for young people

-- the factors that contribute to different kinds of use or nonuse, as the case may be.

There are just a few other points I would like to make. One has

to do with the need for comparative research, by which I mean

studies of ethnic groups which are likely to be missed even in

large-scale national surveys. However, I am also thinking of the

desirability of conducting studies in other countries. At

Columbia, we have recently collaborated with a team in Britain to

conduct a study of secondary school students' drug use and attitudes towards drugs in one town in England. Preliminary results

indicate that as regards illicit drug use, English adolescents are

far behind their American contemporaries -- at least in this particular community.

Looking at Louise Richards' list of eight topics, I feel that many

of them do not apply to adolescent drug users, especially as regards opiate addiction. Few adolescents are that heavily engaged

in drug use and fewer still have experienced adverse consequences,

let alone treatment.

Perhaps the most important issue with regard to the continuing

monitoring of adolescent drug use in which some of us are engaged

is Louise Richards' question as to our capability of predicting

new epidemics of drug use. I suspect that what is needed are surveys on a much larger scale than any undertaken so far since epidemics usually start with just one case. Most surveys that we do

are not likely to detect any such beginning or initiation of some

new pattern of drug use.

As to indicators which would be most useful in trying to predict

and to help us understand drug use -- the experience of a number

of us, particularly Denise Kandel's research, shows that if you

are looking for powerful predictors of drug use among adolescents,

knowing what their friends do perhaps predicts as well as anything

else, if not better. Of course, the interesting sociological and

philosophical question is whether it is the friends that choose

the drugs or the drugs that choose the friends.

53
AUTHOR

Eric Josephson is Associate Professor, School of Public Health,

Columbia University, New York, New York.

54
DISCUSSION

Dr. Eichberg: There is a problem that I am sensitive to regarding

faddists, and I think it is particularly important with adolescents. An example that I will use is the problem of developing a

questionnaire. Recently when I was at a school, I found that the

drug most commonly used was "flying saucers." Now, what do you

do? Do you list every individual drug that young people might be

using or do you group the drugs? If you group the drugs? you run

the risk of grouping it improperly, perhaps losing some information. If you don’t group the drugs, then "flying saucers" in a

different community may be a different drug. With regard to that

particular drug, I called several drug programs. Some of them had

never heard of it. One drug program had analyzed it as P.C.P.,

and another drug program had analyzed it as high doses of Valium.

So what do you do with a situation like that? With adolescents it

becomes more of a methodological problem than with adults, perhaps.

Dr. Elinson: This is not really a response to that, but I am reminded that in our study that I mentioned before we used a fictitious drug and we gave it the name of "El-Jo’s," an acronym for

the first two letters of the names of the principal investigators,

and, some of the kids in some of the schools weren’t fooled for

a moment. As a matter of fact, we could not, in going back to

these schools in the second wave, use the same fictitious drug because they had become intrigued by it. By which I mean that at

least in one school as I recall, banners appeared in public, advertising this fictitious drug. The next time we had to ask about

another fictitious drug although we could not be sure it was so

fictitious.

Dr. Eichberg: I am wondering what to do with that kind of situation because the incidence of the "flying saucers" at this school

is apparently higher than the incidence of the use of anything

else. And we don’t know what it is. They just said "flying saucers," and described the effects; some kids had overdosed on it.

I have a feeling there is no consistency in terms of what it is.

They don’t know where it is coming from.

Dr. Gottschalk: This is a question Dr. Josephson alluded to. In

most school systems that I know about where it is necessary to get

informed consent, we have written a letter to the parents, elimi55
nating the problem of whether or not the kids take the letter home.

But while you know that using the form letter approach would be

O.K. with the school system, you only get a certain percentage o f

responses. Is it easier to get a biased sample and how much can

you take?

Dr. Josephson: I mentioned our experience in which in several

schools in one state, we were required to get parental consent and

we did not do it by mail. (Perhaps we should have.) We did not

pursue further the methodological question to determine just what

bias may have been introduced into that particular population of

respondents. I am sure some was. In most cases in our experience,

since this is a selection of schools, the selection could very well

have been influenced this way. The principals themselves or the

school officials acted in loco parentis: they provided the consent.

Now the question I raised is how long can this go on? I don’t

know. In view of some of the develovments that have to do with

confidentiality and consent, it may be increasingly difficult and

precarious for school officials to undertake this responsibility.

Dr. Gottschalk: It doesn’t seem to be possible on the West Coast.

Dr. Lettieri: On the comment that Dr. Gottschalk made: At least

a beginning attempt has been made to grapple with the problem of

paper and pencil or self-administered questionnaire vs. interview

data in a grant awarded to John Griest. What he is doing is essentially a methodological study. He is tapping the same population

in a small town (actually Madison, Wisconsin), asking the people

to fill out a questionnaire, paper and pencil, self-administered.

He is also doing an interview and has a third variant, computer

generated questionnaires. He is setting up computers in various

locales including parking lots, for example, where anyone can come.

They literally see a question on a computer screen and punch in

the answers. He is testing human intervention and machine intervention; when the product is completed, we might discover that

there is not that much difference.

There is some overlap of the same people; and with the computer,

that poses a special problem because they don’t give their names.

There is, however, an observer around to see that someone is not

misusing it or continually sitting on it or playing with it. The

computer technique has been used as standard intake procedure at

the University Hospital. Any student who comes in with any kind

of problem at the hospital sits down not with an interviewer to

take the history, but with the computer. The computer instantly

codes out 12 copies in different formats to go to the nursing

staff, doctor staff, etc. They found that to be a neater way of

keeping records. They did VD questionnaires that way, checked it

against paper and pencil and discovered no difference in that kind

of response. So it is an attempt to find if it works with drugs.

Dr. Richman: In the surveys involving interviews, especially for

drug abuse, there seems to be an increasing tendency to match the

interviewer to the ethnicity or culture of the geographic area in

which the survey is occuring. I wonder if there have been any

56
methodologic approaches to assessing the expectations of the interviewer with regard to the responses that the interviewer gets from

the ethnically-matched respondents.

Dr. Elinson: There have been such studies -in fields other than

drug use. I am not familiar with any that have been done in the

area of drug behavior.

Dr. Josephson: We have, with matched groups of high school students, administered questionnaires in the classroom setting and in

a household setting. Both were really self-administered, although

in one, obviously, even though no names were asked, the respondent

knew that his identity was no secret because the interviewer had

gone to the house in order to leave the questionnaire.

In the classroom setting, we tend to try to match interviewers and

respondents both ethnically and culturally and in terms of dress

and costume as well. In other words, to get young people in high

schools to cooperate, we tended to recruit and train -- "coordinate" as we called it -- slightly older, usually college age individuals, presumably closer in life styles to high school students

than ordinary household interviewers. As a matter of fact, in one

high school we were almost thrown out because one of the coordinators came in such outlandish dress that the principal did not want

the student body to be corrupted by this individual!

Dr. Elinson: I think it is fair to say that there has not been any

systematic evaluation of interviewer effect in studies of this

kind.

Dr. Robins: We tended to use black interviewers with black respondents, but we used very few black interviewers with white respondents. We used lots of white interviewers with black respondents. They were sort of accidentally assigned. They happened

to be in the right part of the country at the right time. We used

both men and women and we looked for age differences, racial concordance, and sex concordances -- and none of them made marked difference in terms of the validity of the answers we got.

Dr. Chambers: We’ve done about 30,000 interviews. Where we have

tried to check interviewer effects, we found ethnicity to be an

important variable although probably not as important as sex was.

Female interviewers typically get considerably fewer refusals

than males do. When you start knocking on doors in the middle of

the afternoon, male interviewers could not get in to do the interviews and females could.

Dr. Robins: I think it depends on how you do it, too. All of our

respondents had received letters, so they were expecting somebody.

It wasn’t entirely the first effect, the first impression.

Dr. Chambers: I am still convinced that the strongest variable is

geography. Individuals who live in the region in which they are

doing the interviewing have always worked out better than people

57
who have come in from outside to do the interviewing.

Dr. Gottschalk: There have been pretty good experimental studies

with small groups that indicate that there are interviewer effects.

If it happens in these small experimental studies that are pretty

tight, you can fairly safely generalize that it probably happens

in these larger ones.

Dr. Elinson: No. I would not agree with that at all. Very special situations are not the same thing as what happens in the

field. A lot of other variables affect special situations which

influence what happens between the interviewer and the respondent.

Dr. Gottschalk: Let me rephrase my assertion. On the basis of

other studies, experimental studies, it would be wise in these

studies to try to standardize, to keep the same interviewer, so as

not to vary the race or ethnic background of the interviewer over

time in a longitudinal study, because one might generalize from

these other studies rather than be haphazard about this.

Dr. Lukoff: We did a screening interview to find parents who were

involved in deviance. We matched the interviewers with the ethnicity of the area to which we were sending them and all we discovered was that two of our interviewers, one white and one West

Indian black, were getting much more cooperation in screening interviews. So, we sent them to the other areas and we discovered

they got much better results than the original people. The interviewer effect was probably independent of ethnicity, age, etc.

They were better at gaining access and getting people to admit

certain kinds of things in a very short space of time. We did

not give them a long lead-time. There were also field surveys

in communities where we could not get most of our white interviewers to go where they were assigned. So, what you wanted to do did

not make any difference. You had to get the interviewer who was

willing to go into the neighborhood. You could not really randomize the effect scientifically.

Dr. Abelson: I would like to bring up a point which is of particular concern to us in a current drug study and others which has

not been mentioned yet today, and is at least as much an influence

as the interviewer on the possible outcome. Our concern is about

setting up a situation where the respondent is physically and manifestly guaranteed confidentiality. The elaborateness of the situation which involves the respondent having the return envelope into which he or she puts the materials, various assurances of confidentiality and disclosure throughout the interview trouble us

to the extent that we don’t know what kind of perspective it provides for a respondent who might not otherwise consider it.

I thought you might be interested in a couple of brief procedural

outcomes from the past two national drug studies. In both instances parents or eligible adults were interviewed first, and

then if the face-sheet data showed that there were one or more

eligible youngsters, age 12 through 17, in the house, one of them

58
was pre-selected for interview. We asked permission of the adult

who had been through the process to allow us to interview the

young person. Our overall completion experience in both of these

studies was over 80 percent with the 12-17 age group. I am sure

it was no less than 85 percent of the parents who said that it was

up to the young person as to whether or not they would be interviewed. Then also in the de-briefing of respondents on these

other studies, we asked some questions in the self-administered

mode that had to do with dissembling, exaggeration, or understatement of experience with drugs during the course of the interview.

Our findings were that six percent of the respondents reported

that, in fact, their drug experience was different from what they

had told the interviewer or indicated on the questionnaire.

The next question we tried to get at is the direction in which this

misrepresentation took place. It divides almost exactly down the

middle, with about one-half the people saying they exaggerated and

the other one-half saying they did not report the reality.

Dr. Josephson: May I just add that with regard to the question of

confidentiality, I agree that this raises serious questions when

you are looking for use of hard drugs. During pilot studies we

conducted, we were also testing a technique of self-generated code

numbers so that we could match a panel of students in the second

wave. In the earlier pilot study with matched groups, we asked

some of their names, asked the second group for self-generated

code numbers, and the third group for nothing at all. Our expectation was that the highest level of drug use, and I am not talking about the use of hard drugs, but of drugs such as marihuana,

would be reported by those who were asked for no information whatsoever, and the lowest level of use would be by those who were

asked for their name. We did not find this. In fact we found no

significant difference, and actually a somewhat higher level of

use reported by those who had actually been asked for their name.

59
Surveys—Logitudinal Studies

Lloyd D. Johnston, Ph.D.

I will address problems in data acquisition and interpretation in

longitudinal studies. This topic really cross cuts many of the

issues already discussed, so I will concentrate on those which are

unique to longitudinal work.

Let me mention what I think are the major values of the longitudinal approach. In terms of measuring incidence and prevalence

per se, the longitudinal design is not the best approach. Probably our best measures of incidence and prevalence come from crosssectional surveys. Obviously, each longitudinal study starts with

a cross-sectional survey, but after that first time point, panel

attrition introduces error of some magnitude into the estimates.

The unique power of the longitudinal design is its capacity to

make temporal connections between drug use (or drug-related attitudes) and other variables -- antecedent correlates (possible

causes), simultaneous correlates (possible symptoms), and subsequent correlates (possible effects).

The time intervals over which the follow-ups in the longitudinal

surveys occur have a lot to do with whether the relationship between variables looks like a simultaneous relationship or whether

it looks like a sequential relationship. The longer the interval,

the harder it is to get variables that relate one antecedent to

another . I will not go into the methodological problems of deciding what are antecedent conditions and what are simultaneous

ones. The fact is that a variable that has an antecedent relationship to another variable -- perhaps expressed in terms of a

60
cross-time correlation -- usually also has a simultaneous relationship (correlation) with that same variable. There is a whole

literature on trying to extricate the "truth" from these complex

sets of relationships.

ASSESSING MATURATIONAL CHANGES

Among the major uses and perhaps the most important use of longitudinal studies has been the assessment of the maturational process per se; that is, changes that occur with aging generally.

While this type of research undertaking may be less complicated

than the search for antecedent conditions, it is not without its

difficulties. The most serious one is that maturational changes

observed among people who grow up in a particular time period may

not be replicated among those growing up in a different period.

So far at this conference we have talked about the two stages of

development that have received the most attention in the drug literature, namely, the high school years and the college years.

Eric Josephson has already mentioned a number of studies which

have occurred looking at longitudinal changes during the high

school years -- his own work, Denise Kandel’s work in New York

State, and some work that I’ve been doing at the Institute for

Social Research at Ann Arbor. As far as I know, there has not been

that much longitudinal work on normal populations at the earlier

years of early adolescence or pre-adolescence, nor has there been

much serious longitudinal work on drug use in the adult years.

I might take a minute to tell you a little more about our own work

related to the high school and college period. It is called Youth

in Transition and involves a nationwide sample of some 2000 young

men whom we began studying when they were sophomores in high

school in 1966. In the intervening eight years that we have been

following them, they became the high school graduating class of

1969 and many comprised the college graduating class of 1973. The

assessment of drug behaviors and attitudes was a secondary purpose

added to the study in 1970. At that time and in 1974 we secured

information about drug use during the high school years and during

the five years subsequent to high school. (During the subsequent

years, these young men went into a number of different situations,

college being one, but also military service, work, unemployment,

and so forth.) The results of the 1970 survey are published

(Johnston, 1973) and we just now are beginning to analyze the

1974 data. I do have some early trend data on what happens to drug

use between the ages of 19 and 23 for this particular cohort, however.

period.

Generally drug use increases substantially through that age

Increase in marihuana use is the greatest, and regular

marihuana use increases quite substantially: about ten percent of

this nationwide segment of 23-year-old males said that they had

attained daily marihuana use sometime in the prior year. In the

cases of the more serious illicit drugs, it looks like there was

a peaking and drop-off in regular use during the five year interval after high school.

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DIFFERENTIATING MATURATIONAL, COHORT, AND SECULAR CHANGES

As I have already mentioned, age related changes such as those

found in the Youth in Transition study may not be replicted in

other age cohorts (i.e., in people born in other years). To differentiate enduring maturational patterns from cohort and secular

changes requires that a number of age cohorts be studied. Almost

no work of this type has occurred so far. Exceptions are work

done by Greene and DuPont (1974) and a study now being done by

O’Donnell and Cahalan on males aged 20 to 29. Both of these works,

however, are quasi-longitudinal since they use retrospective data.

There is a new repeated-cohort, longitudinal study now being

launched by myself and Jerald Bachman under SAO and NIDA sponsorship. It is entitled Monitoring the Future: a Continuing Study

of the Lifestyles and Values of Youth. Since we are still in the

process of getting ready for the first data collection in April,

1975, I don’t have any results to report. We expect to be picking up a new high school class of seniors each year, nationwide,

and then following them for a minimum of five years longitudinally.

We will be looking at a number of things -- incidence and prevalence of drug use among American high school seniors would obviously be one of the products we would try to report on a systematic

basis over time. But we also will be looking at maturational

changes in the college years and attempting to separate them from

cohort and secular changes.

ASSESSING THE EFFECTS OF SOCIAL ENVIRONMENTS

In addition to assessing maturational changes in drug use, longitudinal studies are often used to examine the impacts of various

social environments and life events on drug use. Lee Robins’

study of Vietnam veterans returning to civilian life (Robins. 1974)

is an example of this approach. The work that we are doing in

Youth in Transition and in Monitoring the Future also involves an

attempt to look at the effects of sosial environment, since some

of our young people go through college, others through military

service, some into the civilian work force, and so on, Some

other important life events that occur during this period are marriage and parenthood, and we expect to be examining their impact

on drug use, as well.

ASSESSING PLANNED INTERVENTIONS

Another possible use of longitudinal studies is to assess the effects of planned interventions. Drug education is one type of

planned intervention, and there have been studies in that area

with "before and after" longitudinal measures. There are also

some longitudinal studies attempting to assess the effects of treatment. I understand that David Nurco is doing a long-term 20 year

follow-up on heroin addicts who had been through treatment; Saul

62
Sells is also working on follow-ups of people out of treatment.

QUASI-LONGITUDINAL DESIGNS

I might mention a couple of quasi-longitudinal designs that are

sometimes used, and I think they have some pitfalls. One of them

is to attempt to look at maturational change not by following a

particular group over a period of time, but by contrasting two

groups that represent the beginning and the end of that period.

For instance, we could compare the drug use levels of freshmen and

seniors at a particular college and conclude that the differences

reflect changes that occur during college. This is a dangerous

assumption, however, partly because of the nature of cohort effects -- one class may simply not be like the other -- and partly

because of unknown losses in the population between those two periods (due to dropping out, for instance).

Retrospective reporting is another method to put together longitudinal data after the fact. It is certainly better than having

no data at all on earlier periods, but obviously, there are problems. Some variables are simply not amenable to measurement after

the fact, particularly psychological measures. Even for factual

events, it is known that respondent recall tends to be quite bad.

Therefore, retrospective data is certainly less desirable than true

longitudinal data. On the other hand, true longitudinal data requires a substantially greater investment of time and money.

SOME OTHER METHODOLOGICAL PROBLEMS

Some of the problems of data acquisition in this area have already

been touched upon. In order to do a longitudinal study you have

to have identifying information which allows you to get back to

your respondents. This makes the protection of respondent confidentiality a considerably more difficult problem in longitudinal

studies than it is in other types of studies; and when self-incriminating information is being secured, such protection is very important. I think it is easy to underestimate the difficulties of

creating a protection system that will really give respondents the

protection they are usually promised. Fortunately, it is now

possible for drug investigators to get rather sweeping protection

of their data by applying to the Drug Enforcement Administration

for a Grant of Confidentiality.

Another obvious problem in longitudinal studies is tracking down

respondents for follow-up interviews, and the difficulties increase

as the time interval gets longer. One thing that I learned early

in this game is that the post office does not keep forwarding addresses for more than a year; it is post office policy to destroy

them at that point. Some of the obvious means of tracking through

the mail, therefore, are simply not possible. But there are other

procedures -- contacting neighbors, using credit agencies, and securing in advance the names of parents or friends who would know

63
the respondent’s whereabouts. When youthful populations are being

followed, parents are probably the best intermediaries.

There can be a pretty high cost incurred in follow-ups. One faces

a trade-off between the monetary costs of increasing response rates

versus the accuracy costs of retaining smaller proportions of the

panel. Even when respondents are located and are willing to cooperate, it can be very expensive to get interviewers to those who have

moved some distance away in the intervening period. Mailed questionnaires and phone interviews, of course provide somewhat less

expensive alternatives for follow-ups than personal face-to-face

interviews. However, then there is a question of how comparable

the data may be to that gathered with face-to-face interviews.

Another concern, in those longitudinal studies in which the investigators return to respondents a number of times, is maintaining

respondent interest and cooperativeness. ln the Youth in Transition study already mentioned, we went back to the respondents five

times. They were paid money on each occasion except the first,

starting with $2.00 and ending with $10.00 on the most recent OCcasion. They were also sent newsletters periodically. We managed

to get a very high response rate throughout the study -- more

than 70 percent over an eight-year period. However, since there

was no experimental manipulation, it is not possible to determine

how much of the panel retention can be credited to having such

procedures.

It has already been mentioned that there is a selective loss of

people who are heavier users -- the people who are in some ways,

the most interesting in this type of research. We know from our

own data that the population which moves residencies more frequently also tends to have a higher incidence of drug use than average.

But in the case of the normal population in the Youth in Transition

panel we found that re-weighting the data to correct for differential loss rates really did not make that much difference in our

overall incidence and prevalence estimates. In any case, I reiterate that the incidence and prevalence data are the less important

of the longitudinal products and the relationships between variables over time are the more important; and I think it is still

possible to get quite valid estimates of relationships even with

some attrition in the sample.

One final note. There is an apparent dilemma presented by the fact

that the large samples are needed to accurately investigate rare

events in the population, such as the use of certain drugs, yet

the cost of intensively following up large numbers of people could

become prohibitively expensive. The optimal solution may be in

the use of a mixed strategy; that is, one in which one works with

large samples with limited follow-up efforts in order to secure

enough cases to explore relationships; but also has a smaller subsample which is followed up very intensively to elicit a high response rate, and against which the representativeness of the larger sample can be calibrated.

64
CONCLUSION

As I have tried to illustrate with this very brief overview, the

power of longitudinal research can be very great and much needed

in a field like drug research, with its constant search for

causes and consequences; but such research is also exceptional in

the number of methodological and practical problems it presents.

Let the buyer and seller both beware.

AUTHOR

Lloyd D. Johnston is Study Director, Institute for Social Research,

The University of Michigan, Ann Arbor, Michigan.

REFERENCES

Greene, Mark H. and Robert L. DuPont. The Epidemiology of Drug

Abuse. American Journal of Public Health, December 1974 Supplement.

Johnston, Lloyd D. Drugs and American Youth. Ann Arbor: Institute for Social Research, 1973.

Robins, Lee N. The Vietnam Drug User Returns. Special Action

Office Monograph, Series A, No. 2, May 1974.

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DISCUSSION

Dr. Rootman: Although I would not want to derogate the use of getting information on drug use, I think that much greater attention

should be paid to the question of getting information on drugrelated problems. I feel that surveys up to this point have been

focused on the former and not the latter and I feel that there

is some potential with using survey methodology to get relatively

useful information on drug-related problems as well.

Dr. Johnston: I think probably most of us would agree with your

general point which is that things other than incidence and prevalence are of importance -- perhaps of more importance. In the work

that I reported on "Youth in Transition," we did in fact look at

the history of both academic grades and junveile delinquency other

than drug use over time, as a function of drug use. Basically,

what we found was that an involvement short of addiction did not

seem to have any effect on academic performance nor any effect on

juvenile delinquency.

Dr. Robins: My study has involved asking interviewees about withdrawal symptoms, unemployment, treatment, whether they feel treatment has helped them or not and whether they feel drugs have made

a difference in their lives.

Dr. Gottschalk: We have been having a problem in longitudinal

studies with regard to the effects of different interviewers and

the slightly different interview biases. Secondly, in any kind of

interview you have the possibility of their positive or negative

biases with respect to the response of the interviewees. That is,

they want to make themselves look good or they may want to make

themselves look bad. Is there anything that your group attempts

to do in either of these cases?

Dr. Johnston: With regard to looking good or looking bad, Eric

Josephson mentioned putting a fictitious drug into the questionnaire; this has been done in other surveys as well. The responses

of those who want to look bad and say that they are using drugs

which they really are not using has been very low -- about one

percent say they have used whatever the drug is. Although we did

not test this item in this particular study, I have been convinced

by the other studies I have seen that we do not get much exaggeration in drug use.

66
I think whether or not you are dealing directly face to face with

an interviewer has relevance here. Although we had interviews in

this study, the drug data per se were gathered as self-administered

questionnaires which the interviewer never saw. The respondent

knew the interviewer would never see it because he sealed it up

himself. So I think there was a minimum of wanting to impress

someone involved in the situation.

67
Surveys—Relational Studies

Denise Kandel, Ph.D.

There are several issues I would like to address. First is the

problem of informed consent. I am afraid that this is going to

become an issue of increasing restrictions in our work. I know

that there are some regulations being contemplated by NIH recommending that any study on children seven years and up, the upper

boundary not being specified, would require informed and written

consent of both the child's parents. Obviously, this would completely prevent any kind of large-scale surveys. In my own case,

in 1971 when I started a longitudinal study of adolescent drug use

in the state of New York, I was faced with very stringent requirements. The requirements, interestingly enough, were not set up by

the schools which I contacted in the course of my work, but by my

own institution, the Psychiatric Institute, which is supported by

the New York State Department of Mental Hygiene and is affiliated

with Columbia University. The Clinical Review Committee which

reviewed my study specifically requested that I obtain written consent of the parents of the adolescents in the study, or approximately 10,000 parents. I pointed out that this would completely

destroy the study and I might as well return the money to NIH.

The compromise solution was for me to notify each parent of the

study via certified mail, return receipt requested, and to give

the parent an opportunity to refuse his child's participation in

this study. This was helpful since instead of requiring positive

consent, we relied on refusals. We also put a copy of the questionnaire on file in the principal's office of each of the sample

schools so that when the parent received the letter, he indeed had

the opportunity of informing himself by going to the school, look68
ing at the instrument and seeing whether or not he wanted his child

to participate. Out of interest, I tried to keep track of how

many parents actually took advantage of the opportunity of going to

the school to look at the questionnaire. I think that six out of

10,000 parents did so. Three percent of all parents sent back

slips requesting that their children not participate in the study.

However, in one New York City school the rate was much higher

(14%). The principal indicated that there was a very conservative

and closed group of Italian families who had all decided not to

participate. These refusals created a lot o-f complications when we

did the field work since we had to take these children out of the

classrooms. Some of the youths were embarrassed, they wanted to

participate but could not do so. It is very hard to know to what

extent parental refusals biased the sample. No information is

available on the youths excluded because of parental refusals.

The issue of the protection of human subjects also intrudes in our

work to a great extent. Because the behavior inquired into is

illegal, identification and linkage of records at one point in

time and over time has to be done without the use of names. In

my own case, I am not only involved in a longitudinal study, but

also in a relational study in which I am trying to put the behavior

of a particular respondent in his social context and want to study

closely his interpersonal relations. In this particular study, I

had to relate the answers of a particular adolescent to those of

his parent and his schoolfriend without the use of names. We

relied on self-generated identification numbers, a method increasingly used in longitudinal drug studies (Haberman et al., 1972;

Groves, 1974). In the particular procedure we used each adolescent

was asked to construct a number for himself based on the middle

letters of his first and last names, his date of birth and the

last two digits of his phone number, and, in five schools, a number also for his best friend in school, identical to the number

which the friend constructed for himself/herself. Most adolescents

(94%) were willing and able to construct a number for themselves.

Some of the numbers were incorrect or incomplete. However, individuals could often be matched on the basis of other information.

Having previously carried out a similar relational study on adolescents, parents and schoolfriends in which names were used (Kandel

and Lesser, 1972), I was able to evaluate the loss of cases involved when matching is done with codes rather than names. It is

substantial. For example, 92 percent of the adolescents could be

matched to a best friend in school in the earlier study as compared

to only 46 percent in the present one. Matching on the basis of

self-generated identification code numbers is a compromise procedure inferior to the use of names. Not only does it reduce the

overall rate of matching, but it potentially introduces a bias in

the resulting matched sample. Students who do not provide a correct code and cannot be matched are more likely to be drug users

than those matched. For example, 24 percent of the students who

could be matched to themselves at Time 2 reported marihuana use at

Time 1, compared with 41 percent of those not matched. This conf’irms the point made previously by Drs. Johnston and Josephson; the

people that are lost in surveys are the heavy drug users. Of

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course, the rationalization is that since we are interested in processes related to drug use, we assume that the heavy users that we

did include in the sample behave similarly to those we did not contact. I am not sure that this is a correct assumption. In any

event, the data are not available either to prove it or disprove

it.

‘The other point to which I would like to address myself, is one

that Lee Robins made in connection with heavy drug users. She

stressed the problems involved in locating those cases, and suggested on the basis of her experience that once you have located

them, you are able to get useful information.

Our experience has been different. In our school studies, we were

very much concerned about the drug use of students absent from

school on the days we conducted our surveys, and carried out two

studies to assess the levels of drug use among these youths. In

the first study, we obtained the names of absentees in three

schools and conducted household interviews. We stopped the study

after 60 such interviews -- only four adolescents reported having

ever used marihuana. We realized that these youths were not reporting any drug use. We analyzed the responses to see whether

the conditions surrounding the interview affected the responses.

None of the factors, whether the interview took place in the home,

with or without parents being present, or outside the home, seemed

to make any difference. We carried out a second study modelled

after a design developed by Drs. Elinson and Josephson. We contacted another group of absentees, asked them to come to a neutral

place and gave them anonymous questionnaires in a group situation.

Out of the 238 students we contacted, only 44 (or 18.4%) selfselected themselves to appear (Kandel, 1975). This is a tremendous loss of cases. But this time, we did get reports of drug use:

12 percent, for instance, reported to have used heroin. This is a

very high proportion: exactly twice as high as the rate of use reported by the students included in the regular survey in these

three schools. However, analyses of the data made it apparent that

the self-selected absentees underrepresents the heavy uses in this

group of youth. Whereas all high school studies report that drug

use increases with age, among the self-selected absentees participating in our study, the highest rates appeared among the freshmen.

It became very obvious that the juniors and seniors, especially

the boys and the black students, did not respond to our invitation

to participate. Therefore, I am pessimistic about the possibilities of getting useful data on heavy users using traditional epidemiological surveys. It may be better to use participant-observation in the streets, as has been done by Hughes and Crawford, or

other unobtrusive methods.

AUTHOR

Denise Kandel is Adjunct Associate Professor, School of Public

Health, Columbia University, New York, N.Y.

70
REFERENCES

Groves, W. "Patterns of college student drug use and lifestyles,"

Chapter 12 in Eric Josephson and Eleanor Carroll (eds.) The Epidemiology of Drug Abuse, Washington, D.C.: Winston and Co., 1974.

Haberman, P. et al. "High school drug behavior: A methodological

report on pilot studies," in Stanley Einstein (ed.) Student Drug

Surveys, Farmingdale, N.Y.: Baywood, 1972, pp. 103-121.

Hughes, P. and G. Crawford. "A contagious disease model for researching and intervening in heroin epidemics," Archives of General Psychiatry, (August) 27, 149-155, 1972.

Kandel, D. "Reaching the hard-to-reach: Illicit drug use among

high school absentees," Addictive Diseases, 1975 (in press).

Kandel, D. "Interpersonal influences on adolescent illegal drug

use," Chapter 11 in Eric Josephson and Eleanor Carroll (eds.) The

Epidemiology of Drug Abuse, Washington, D.C.: Winston and Co.,

1974.

Kandel, D. "Adolescent marihuana use: Role of parents and peers,"

Science, 181:1067-1070, 1973.

Kandel, D. "Inter- and intra-generational influences on adolescent marihuana use." To be published in V. Bengtson and R. Laufer

(eds.) Special issue on "Generations and Social Change," Journal

of Social Issues, 30:107-135, 1974.

Kandel, D. and G. Lesser, Youth in Two Worlds. San Francisco:

Jossey-Bass Inc., 1972.

Single, E., D. Kandel and R. Faust, "Patterns of multiple drug use

in high school," Journal of Health and Social Behavior, 15:334-357,

1974.

71
DISCUSSION

Dr. Lettieri: The phrase we are now using for that technique is

written "dissent" as opposed to "consent" and there are some draft

bills around that pertain to that.

Regarding the non-respondents, I would like to mention one of the

techniques used in the contract with Hempsted N.Y. Research and

Evaluation, Inc., by Richard Block. With a sample of 9,000 students in over 70 school districts in nine states, Block wanted some

record of non-respondents. He asked the teacher at the time that

the questionnaire was administered in the high school to fill out

a sheet of paper; there was a left column which listed all the

names of the students and there were several columns to the right

which listed the sex, the age, the grades, the race, and whatever

else the teacher happened to know. The teacher filled it out on

the whole class and then put a check mark whether or not the student was present that day and had handed in a questionnaire. The

teacher then tore off the list of names and gave the investigator

all the demographic information. He could then get a feel for any

kind of selective non-response rate if there was any, at least on

some demographic variables.

72
Non-Survey Observational Techniques

Gail A. Crawford, Ph.D.

I have been asked to introduce the topic of non-survey, observational techniques in drug abuse research and to discuss some of

the problems involved in carrying out epidemiological field studies. By observational techniques I am talking about a combination

of methods for collecting longitudinal or ongoing data on target

groups or individuals in the natural setting. Among the most

noteworthy of these techniques are direct observation of, and

informal conversations with people "on the street," as well as

more formal or structured interviews with members of the population of interest. A number of researchers also use indigenous

fieldworkers either as informants or as guides to facilitate their

own entry into the street drug using population.

There is considerable range in the types of observational studies,

from analytic, descriptive accounts of what the addict’s life on

the street is really like, to natural histories of drug using

groups over time, to studies that approach field experiments in

drug abuse control. Our own work has been primarily in the latter

category, and in this presentation I want to talk about some of

the problems and issues we have confronted in carrying out field

studies of Chicago heroin addicts.

We have developed an epidemiological field team structure that

combines exaddict fieldworkers with trained social scientists to

gather longitudinal data on heroin prevalence and incidence trends

at the neighborhood level. Our fieldworkers are generally patients

or counselors in the drug abuse treatment system. Most were high73
status dealers in the target areas and already have the trust and

respect of addicts on the street. Fieldworkers act as participant

observers to identify active drug users and record information on

the functioning and dynamics of local heroin distribution systems

or "copping communities." The social scientist’s role in this

team structure is to make periodic site visits to verify fieldworkers’ reports and to conduct structured, personal interviews

with members of the target population to gather additional epidemiological data.

The first kinds of problems I want to talk about are those that

involve locating active drug users in the community and, having

located them, collecting basic demographic and drug use information. Usually it is not difficult to locate drug using groups

in a particular area. By talking with knowledgeable people, such

as counselors in drug treatment programs, patients or police, one

can identify the sites where users buy and sell drugs and where

they "hang out" or congregate. However, having identified the major "copping areas" (or heroin distribution sites) and hangouts

within a neighborhood, how can the researcher gain access to the

active users who frequent those areas?

In our research we make use of indigenous ex-addict fieldworkers

who have established ties with addicts on the street; in effect,

they are abstinent members of the local heroin using subculture.

The legitimacy of the fieldworker’s researcher role stems largely

from his affiliation with the drug abuse treatment system. As he

begins to explain to addicts on the street the nature of his work,

he can point to the treatment program base to insure the confidentiality of all information collected and the nonpunitive, medical

orientation of the project. The only incentives offered to active

addicts for their participation in the research may be the possibility of later being given special access to a preferred treatment facility or an opportunity to participate in a paid interview.

When asked, ‘What’s in it for us?", the fieldworker must be honest;

he should make no promises regarding the provision of treatment

services or of interview money unless they are a virtual certainty.

However, he can point out that participation in the research is

neither time-consuming nor demanding on subjects; generally it involves nothing more than occasionally talking with the fieldworker

on the street. Therefore, participation does not constitute a significant intrusion or threat to the addict’s way of life.

I might point out that even our best fieldworkers have limited access to some kinds of drug users. Fieldworkers are likely to have

established relationships with people who were using drugs when

they themselves were on the street; it is more difficult for them

to identify and gain access to new, young heroin users who may not

"cop" every day and therefore are less visible. To partially resolve the problem of identifying new young addicts and experimenters, we make use of a "snowball" technique. In their everyday

conversations with addicts on the street, fieldworkers attempt to

gather information on new heroin users known to the respondents.

Similarly, in conducting formal interviews with active addicts, we

74
collect data on the process of heroin spread -- specifically,

who initiated the respondent to heroin and whom he in turn may

have initiated. The respondent’s help may then be enlisted in arranging interviews with addicts or experimenters not previously

known to the fieldworker.

I want to discuss briefly some of the problems involved in actual

data collection. Observational studies rely on repeated measurements or recordings over time. Their success, then, is contingent

upon the ability to maintain a good relationship with the target

population. For example, the researcher or the fieldworker who

makes too many promises to subjects in the beginning is likely to

be in an uncomfortable position later if he cannot deliver. Other

things that can jeopardize ongoing data collection are simply natural. or uncontrollable events in the community. Thus, police pressure on local copping areas or pressure from violent street gangs

can cause the addict population to temporarily leave a community

until it "cools off." Also, individual members may be removed from

the community as they enter treatment programs, are arrested or

die. Because our work relies on following a particular group of

addicts over time, perhaps a year or more, we try to insure that as

people are lost, as attrition occurs, we can obtain at least,

second-hand information on what happened to them.

Another factor that can be of great importance in observational

studies is simply the weather or the season of the year. In a city

like Chicago field studies are not much fun in the wintertime with

two feet of snow on the ground. When it is cold or rainy, people

disappear from the streets. Instead of hanging out at public

places to which fieldworkers have easy access, they stay home or

they cop their drugs and immediately "split." So there may be

problems in maintaining contact over time with the same group of

people. If the fieldworker has established good relationships

with individual subjects, however, he is more likely to be able to

follow them into a variety of places, including private places,

and to collect second-hand information from multiple sources on

subjects he does not see on every visit.

Next I want to talk about some of the problems arising from specific methods of data collection in observational studies. Our research methodology requires that the social scientist members of

the team regularly visit local heroin distribution sites in the

company of the fieldworker to make independent observations and

evaluations. There are, of course, some places to which we are

denied access and some kinds of activities that we are not allowed

to witness. We are then dependent upon the fieldworker’s description of these places and activities. Another question concerns

the reactive effects of our presence on the street. Do people for

the most part talk and act freely when we are around? Over time

these kinds of problems probably diminish. Gradually, we tend to

be accepted (or sometimes tolerated) by most addicts on the street

to the extent that we are often surprised by the kinds of information people freely volunteer. Nevertheless, there are some areas

where we simply cannot make lengthy field visits. For example,

75
we are currently involved in researching heroin spread in two

black inner-city areas. One of these areas is relatively safe; a

white researcher can go out with a black fieldworker, spend time

hanging out and talking to people. In the other area, even in

the company of the fieldworker who knows the local addicts and

can reassure them of our motives, we may run into problems. We

can spend a certain amount of time hanging out or conducting interviews, but beyond that people become suspicious or begin to worry

that our presence will "bring down the heat." We have learned to

take our cues from the fieldworker. When he says that people are

getting "uptight" and that we had better get out, we do. In these

communities we have to make frequent field visits for shorter

periods of time in order to minimize the disruptive effects of our

presence.

Our methodology relies on using fieldworkers not only as guides for

the researcher in the field but also as a primary source of data

collection. The advantages of having exaddict fieldworker-informants include their access to people and places to which we would

be denied entry and the minimal reactive effects of their presence.

On the other hand, there are some potential disadvantages to relying on fieldworkers as instruments of data collection. For example, our fieldworkers keep daily log books or field notes of local

events, such as changes in police pressure, heroin cost and availability, which might be expected to affect heroin prevalence and

incidence trends. It takes a good deal of time and effort on the

part of the researcher to teach fieldworkers what kinds of data,

what kinds of events are of interest and how they should be recorded. Problems can arise if the fieldworker relies on his own

preknowledge of what is occurring rather than actually going out to

talk to people and observe what is happening. To minimize these

problems we have developed a working partnership between the researcher and the exaddict fieldworker. We as researchers must also

make regular field visits to talk to active addicts so that we are

not too heavily dependent upon the fieldworker’s reports. The more

time we spend in the field, the more people we talk to, and the

more we find out about their daily routines, the more likely we are

to arrive at an accurate and well-rounded picture of the social organization and functioning of neighborhood heroin distribution systems.

I would like to say a few words about our efforts to conduct formal

interviews with addicts on the street. We found this to be necessary for at least two reasons. First, some of the things we arc

interested in, such as the process of heroin spread, are not observable. Because first use of heroin is not amenable to direct

observation, we have to use more formal interviewing techniques,

in other words, asking subjects to reconstruct the circumstances

of their initiation to heroin use. Structured interviews also enable us to check on some of the information reported by the fieldworker. By comparing what the fieldworker says about the subject

with what the subject says about himself and what other people say

about him, we can increase our confidence in the reliability of our

information.

76
Trying to conduct interviews with active heroin addicts is probably difficult in any situation, and the problems are compounded

when one tries to do paid interviews on the street. In any field

study the researcher or the fieldworker has to adjust his OWn

schedule to fit those of the subjects. He must make himself constantly available if he is to track down people for interviews.

We have found that fieldworkers often can prearrange interviews

with individual addicts for a certain day and a certain time, but

we must still maintain a good deal of flexibility. In some cases,

of course, addicts who have a good "hustle" are not interested in

making $10 for a one-hour interview so that we have to rely on the

street status and skills of the fieldworker to pull them in.

I want to end with a few remarks about problems with reliability

and validity of observational data. One criticism that is aimed

at many observational studies, and one that perhaps is often deserved, is that they fail to make a strong case for their conclusions or interpretations. The researcher may not define the population base or the period of observation; he may fail to specify

the number of people observed or interviewed, the number of times

a particular event was observed or the sources of his data. As a

result, the reader may be unable to judge for himself the extent

to which the sample is representative or the findings generalizable. Also I think there often exists a kind of distrust or socalled "soft" or descriptive data. The researcher presents his

interpretations of the addict’s life on the street or of the social organization of the addict subculture, but one wonders why

the researcher’s word for what is going on should be accepted.

There is no easy answer to this question, and whether the criticisms are warranted is, of course, dependent upon the particular

study. However, careful attention to methodological details and

the use of multiple observers and methods of data collection can

help to reduce problems of reliability and validity. In our work,

the exaddict fieldworkers and the addicts themselves are the

"participant" observers; the researchers are outsiders -- nonparticipant observers. By supplementing field observational data

with structured interview data, we are able to obtain a wider

range of information and to cross-check the accuracy of any one

source.

AUTHOR

Gail A. Crawford is Research Associate, University of Chicago

Drug Abuse Rehabilitation Program, Chicago, Illinois.

77
Non-Survey Techniques—

Sub-Cultural Groups

Joseph P. Fitzpatrick, S. J.

The study I am involved in and that I am going to use as the example to illustrate the larger discussion that I will suggest in a

few moments, is a study of Puerto Rican addicts and non-addicts in

the East Tremont section of the Bronx, New York.

We were not convinced that either the psychological, the medical

or the statistical reporting on the character of drug abuse or the

incidence or prevalence of drug abuse or the epidemiology of drug

abuse was really getting to what was actually happening. We chose

a neighborhood with which we are very familiar -- it is just south

of the University actually -- in that part of New York City which

is in advanced slum conditions and in an area which is rapidly

changing. It is predominantly Puerto Rican with a smaller percentage of blacks, and a tiny number of residual whites who are still

around. We sought an anthropological approach -- to look at that

neighborhood as a human dynamic experience and to look at what

really is going on, and what the life experience of these young

people is -- and to ask in that context, what the experience of

drug use or drug abuse really means. In that context can we say

anything about the epidemiology of drugs, can we say anything about

the treatment of drugs, can we say anything about the prevention

of the use of drugs?

We confined our study to the Puerto Rican population for two reasons. One, it simplified what we were doing because actually, although the blacks and the Puerto Ricans are living together on the

same blocks and the same houses, they are two very distinct popuIa78
tions. There is very little interaction between them. Walk along

East 180th Street and at one corner you have the blacks and two

corners up, you have the Puerto Ricans; they live in two quite different worlds. The character and quality of their cultural and

social lives are different. We selected the Puerto Ricans for a

second reason: for many years, I have been very much involved in

studies of the Puerto Rican experience and I had extensive contacts

with the Puerto Rican community which facilitated access to the

population we wanted to study. The problem that Gail Crawford mentioned regarding access to a population that you want to study is

extremely important.

We wanted to look at a youthful male Puerto Rican population -- we

eliminated the women also to simplify the study -- in a situation

where thev are in the process of adjustment to life in New York

City and in a slum situation, and to see if we could find out really what is going on. We chose a method of analysis, a method of

study that a colleague of mine, John Martin, and myself had developed in previous years in our studies of delinquency; it is what

we call structural analysis. It consists of a threefold interdisciplinary method. One method is very extensive area analysis. In

other words, we staked out an area of the city and we sought to

study it, to gather all the possible information about it. We

have been developing information on this area for years, so that

we know it very well and we have many contacts in the area. That

was the first dimension. What we were seeking really was an insight into the dynamic interaction that goes on among the Puerto

Ricans in that area and then examine the use of drugs in relationship to that. The area analysis was first. That is a continuing

process. It not only involves the accumulation of all the demographic data we could assemble from the census material, from the

city planning offices, from the schools, from the agencies in the

area; it also means continuing to update our immediate knowledge,

our observational knowledge of the area because of changes every

day. Every day we go down there another building has been burned

out. The place looks like Dresden the day after the bombing; there

are entire blocks where every apartment house is abandoned and

burned out. It is really a pitiful and sad looking situation but

it is there. Therefore, we must continually update the knowledge

of the area. Most important from the viewpoint of area analysis

is our information from the subjects. We learn from them what

they are doing, where they live, where they interact with others,

what is the pattern of their life as it unfolds in that area, and

we feed that back into a continually increasing knowledge of the

area. The knowledge of the area becomes an extremely important context for an understanding of drug use.

The second dimension of the method is what we call sociogenic case

history, which is simply a history of the young person with a focus not so much on the personality variables, on the character or

quality of his personality, but in terms of the total experience

that he has gone through in the social context in which he has

lived, the cultural background from which he comes, and the experiences that he lives through day after day.

79
This neighborhood, for example, is next to an Italian village.

There is a small, very stable, very well put together Italian section that borders immediately on the study site. The conflicts

between Puerto Rican and Italian communities have been severe in

both directions. As a result the social condition of hostility,

conflict, respecting various turfs and so on becomes very much a

part of the life experiences of these young men -- their experience with the police, for instance. The sociogenic case history

seeks to incorporate an understanding of the cultural background

from which the subjects come and of their attempts to adjust to

life in New York City.

Thirdly by situation analysis, we seek to get from our interviews

with them as clear a presentation as they can give as to how the

process of either using drugs or avoiding the use of drugs took

place. In the careful accumulation and analysis of the data from

this threefold method, we hope to achieve a very good perception

of the dynamics of life in that area. In this context, we hope

that we will be able to explain a little more clearly what the use

of drugs, the abuse of drugs, or the avoidance of the use of drugs

really means to that population.

The formalities of the study call for interviews with 50 addicts

and 50 non-addicts. The study is not a survey; we had to spend a

great deal of time, about six months, just getting a feel and a

sense for the neighborhood, seeing if we could locate where the

real sources of drug action in the area were. Critical to this was

our ability to establish contact with significant people in that

area, i.e., significant informants. Some of them were people that

I had already known. I am a clergyman and have been in close association with the parishes in that area. There are a number of

natural leaders in the parishes who have close contacts with many

of the young people. The value of this kind of contact is credibility. How can you convince these young people to talk to you?

What would motivate them to talk to you? Why would they be willing

to spend a couple of hours in an interview with one of your interviewer? What are they going to get out of it? Who are these people anyway? These neighborhood contacts were one basis of credibility.

Secondly, the University was another source of credibility. The

University is close to the area and the fact that this was a

Fordham University study brought with it a great deal of prestige

and interest in collaborating with a university project. We

still have not met anything like the "Town vs. Gown" conflicts that

some of the universities around the country have faced with their

neighboring minority groups, such as Columbia’s continuing problems with its neighbors. The Bronx has not had that kind of problem. An association with the University apparently means something to these young people and they are willing to collaborate.

Most important of all was one of our contacts, one key person who

plays a very critical role as an informal kind of leader and a center of information on activity in the area. I think he knows not

only every addict in the area or every person who is using drugs

80
but he must know everybody else too. It is incredible what influence this man has. He used it to assist our study.

Our street interviewers are three tough street-experienced Puerto

Ricans, completely bi-lingual and very carefully trained as interviewers. They are not uneducated street kids; all of them are

college graduates and one of them has an M.A. But they are still

close enough to the street to have the experience of the streets

and the ability to effectively contact people of their own kind.

They can very easily adopt the style which is common among the

young Puerto Rican men in the area. This question of effective

contact is crucial.

By the end of the study, we will have completed interviews with

50 addicts and 50 non-addicts. There is no attempt to reach a

representative sample; what we are looking for are the strategic

centers of activity. We have already begun to identify those,

trace them out and move towards them. We establish contact with

the addicts or the non-addicts who are related to those significant

centers and ask them to agree to an interview with one of our interviewers -- that is really the way that it has proceeded.

Technically, there are two stages in the accumulation of the data.

Once we have established effective contact with a person who is

willing to be interviewed and collaborate with the study, we administer a fairly long interview schedule, a carefully prepared schedule. The first thing that they do is fill that schedule out.

We had some interesting experiences with this during the pilot period of the project. We began by giving it to subjects and asking

them to take it home and fill it out if they wished. But we were

not getting them back. We then used a second strategy: when the

interviewer met a subject he would give the schedule to him and ask

him to take an hour to fill it out in the presence of the interviewer. That did not work very well. We are now following a third

strategy: the interviewer has a copy of the schedule and the subject has a copy of the schedule and they go through it together,

If the subject wants the interviewer to mark down his answers, the

interviewer will do it. If he prefers simply to answer the question and record it on tape, the interviewer fills out the spaces

later on. We are very flexible in this -- the object being to get

the interview schedule completed, every item filled in.

vides us with comparable data.

This proOn many of the questions, the inf‘ormation we accumulate is the standard information found on questionnaires or interview schedules employed in surveys. We developed

the interview schedule on the basis of an examination of a wide

range of schedules and interviews that have been used in previous

studies of addicts.

Much more important, however, after the schedule is completed, is

a lengthy informal interview with the subject. This provides a

great deal of elaboration which does not come through on the schedule as it is filled out. Every interview is taped. Four professors who are working on the study review the tapes. We review

81
the interview schedules and then we interview the interviewer.

This we find to be very important. The interviewers prepare a

report explaining how they contacted the subject, describing the

circumstances of the interview and adding observations of their

own. But we have found that the most valuable insights into the

area come not from the schedules, nor from the taped interviews,

but from our interview of the interviewer after we have gone over

the schedule and the tape. We spend considerable time with the

interviewers, and remarkable insights are gained in this process,

things which they saw or noticed or know, but which they did not

realize would be significant in this kind of a study.

These are the methods by which we are accumulating the data: the

schedule provides the systematic data that will be comparable for

all of the people we interview; the informal interview on the tape

and then our interview with the interviewer provide the more qualitat ive data. We will put this information together, analyze it

and, hopefully, by the time the study is finished we will have

some significant insights into the whole pattern of life that goes

on among these Puerto Rican youth in that area and be able to explain more clearly than it has been explained before what meaning

drugs have in this context. Is there any specific relationship between a background of Puerto Rican culture and the process of

either becoming addicted or avoiding addiction? These are the

kinds of questions we are really hoping we will be able to answer.

With that in hand what does this mean to the kinds of questions

that were raised for us concerning the utility of survey sample

data. In other words, what is the value of these data or any kind

of ethnographic study of the epidemiology of drug use or drug

abuse? Our data will be limited in area and limited to a particular population and a particular cultural group. There is no doubt

that what we learn from this population may have little meaning

for a population in Westchester or Nassau County. The youths we

are studying do not consider the use of marihuana as drug use.

They all use it. It is part of a pattern of polydrug use; they are

into all kinds of things, from alcohol down to all kinds of pills,

to methadone. The epicenter of the drug market is in a park across

from a methadone center. Some of them ask, "Why don’t they put a

pipline across the street, it would save us a lot of trouble," because so much methadone is leaking out of the center into the park

where they are marketing the goods. In terms of epidemiology I

think the value of our study is found in this: when we get the

kinds of scientific data that are made available through the processes that Dr. Elinson was discussing, these data must be supplemented by much more intimate knowledge of particular areas. I

think the value of what we are developing is the insight it will

give to a particular area. Secondly, the particular findings from

the Bronx will not explain what goes on in Bronxville or Scarsdale,

but a similar method used in Bronxville or Sarsdale will explain a

great deal more about Bronxville or Scarsdale than the statistical

reports on incidence or prevalence.

82
Thirdly, in terms of prevention and rehabilitation, I think that

we will be able to provide a number of insights into the way cultural backgrounds become related to drugs that will help us a

great deal in trying to clarify what kinds of programs may be effective in preventing drug abuse and what kinds of programs may be

more effective in the rehabilitation of people who become addicted.

Let me conclude with one brief comment. As we gather more and more

knowledge of this population of Puerto Rican youths which I am

studying, we continue to read of the preoccupation of the nation

with the problem of drug use and drug abuse. Once you begin to

deal with this population however, and gain an insight into their

lives, you begin to realize that in the context of the enormous

other problems that they are facing, the use or abuse of drugs is

a relatively minor issue. I think this may say something very

important to us as we try to deal with the different characteristics of drug use and drug abuse with different populations in the

nation.

AUTHOR

Joseph P. Fitzpatrick is Professor of Sociology and Anthropology,

Fordham University, Bronx, New York.

83
Institutional Sources—Arrests

Leonard Savitz, Ph.D.

This discussion addresses itself to problems of arrest data relating to the problem of drug abuse. There are obvious and considerable uses that can be made of criminal justice system records and

data with regard to the problems of drug addiction and drug abuse

-- such as, the association between criminality and addiction, the

relative criminality engaged in by drug users vs. that of nondrug users, comparative costs to society of the several criminal

populations. Under some conditions the data will be available to

the extent that one can use and perhaps develop temporal relationships, i.e., the sequential order of which came first, drug use or

criminality.

The first problem that seemingly has to be determined is at what

point in the criminal justice system do we intervene and gather

our data. It seems logical and perhaps useful to secure data at

three points in the processing system, each producing quite distinctive populations. We can select out, first of all, arrestees

when they first enter into official criminal justice processing,

that is when they first arrive at a police processing facility.

This would produce the largest numbers of "criminals" and have the

lowest case mortality. On the other hand, this group has the lowest probability of subsequently being convicted for the crimes

for which they were charged.

The second point of data collection is at that point at which arrestees (and convicts) are diverted from the criminal justice system into some treatment program and still remain under some degree

84
of law enforcement control. This can occur shortly after arrest,

or at a number of pre-trial and post-trial junctions of the criminal justice system. This population represents those arrestees and

convicts who enter into varying diversionary systems which operate

in various locales.

The third point of investigation could be at that point in the

criminal proceedings when individuals are found guilty of their

crimes and formally become criminals. The numbers here are the

smallest and differential administration of justice can produce

peculiar criminal populations, but they do represent the group

which is most surely criminal.

For the city of Philadelphia it was our considered judgment that

the best group to examine for the particular purpose we had in mind

would be arrested persons at the time of their entry into processing within the criminal justice system. Once the decision is made

a second problem arises: what is the full range of data which is

normally and naturally collected and therefore available at this

particular junction? There are, first of all, police records which

are normally and naturally generated for all arrestees. They are

also available with not much difficulty.

Typical police records, and there is some evidence that Philadelphia is not unique in this regard, are of three types. First there

is the brief police statement on the current direct charge: this

very simple document contains relatively little information beyond

a description of the crime and is used largely for record keeping

purposes. Secondly there is also a detailed police report on the

current charge completed by the arresting officer which gives a

great deal of information about the criminal event. It is extremely difficult to secure this particular document usually because it

is of enormous use to the Prosecutor in determining what type of

case he has and what witnesses he has and what evidence is available. The third body of data that the police have and which can

be made available is an Extract of (previous) Criminal Records,

containing, in considerable detail, all previous arrests, all previous charges, convictions, and imprisonments, both within and beyond the local jurisdiction.

Considering drug charges, certain specific problems do arise with

the use of police records. First of all, arrest records are filled

out by arresting officers who aren’t terribly concerned about certain types of details which do not have pragmatic implications.

Therefore the extract of criminal records, for example, will normally state that the individual has been arrested for private

possession or sales of drugs without specifying the type of drug.

The second problem with the use of the official records, particularly when drug charges are involved is that the police and the

district attorney often choose convenient charges rather than technically correct charges. The individual therefore may be charged

with possession of drugs or the sale of drugs or, in Pennsylvania,

possession with intent to traffic. This last offense is frequently used by the police and prosecutors rather than going through

the elaborate procedure of attempting to prove that a sale did in

85
fact take place or that there was an offer to sell; conviction for

the intent to traffic brings penalty almost equal to a sale conviction. Generally police-related data fail to give any detailed

demographic, social, economic or work-history data.

In many large metropolitan jurisdictions there exist some pre-trial

services branches within the criminal procedure. That is, there

are agencies involved with bail and court bail interviews typically

take place for virtually everybody who was arrested. The purpose

of the pre-trial interview is to secure data for determination of

whether or not the arrestee should be released on his own recognizance (R.O.R.). This type of interview given by the trained employee does gather an extensive body of data on family history and

relationships, educational history, occupation history, income and

wealth status, military history, residence, and migratory history.

Many of these bits of information are verified by direct contacts

with individuals who can substantiate what the arrestee has reported in the pre-trial interview. The court bail interview also

secures some details as to criminal history which cannot be found

in any other body of data; that is, information is secured not only

on previous adult arrests and convictions, but also on all juvenile

delinquencies and juvenile institutionalizations. One additional

feature of the Philadelphia court bail interview is a series of

items concerning current drug use. That is, the arrestee is asked

if in fact he is currently a drug addict. If he answers yes, then

a variety of other questions are asked of him concerning the types

and amount of drugs he uses, his treatment history -- current and

past treatment, and whether or not he desires drug treatment.

In June of 1973, the court bail interview was changed and a new

item was added in which the arrestee is asked if he is not currently an addict, whether he was ever once an addict. This is an extremely interesting piece of information. While there are obviously reasons for the arrestee to dissemble about current drug status

(it might be in his best interest to deny being an addict to avoid

being stigmatized, or to lie and state that currently he is an addict, which would then permit exit from the system by some currently operating diversionary mechanism), this seems to be no reasonable grounds for false reporting of exaddict data.

There is a third source of information frequently available at the

time of arrest and processing and that relates to the presence

of a mass urine screening program.

We are using these three different sources of arrest data to deal

with several problems, The major problem being dealt with is how

to operationalize the concept "drug users" in the criminal justice

system. One group which can be thought of as "drug addicts" are

people who take heroin, methadone, morphine or other narcotics and

are further defined on the basis of one or more identifying criteria.

and/or

They have either (1) self-confessed they are an addict,

(2) produced a positive urine and/or (3) their current arrest charge is possession or sale of narcotic drugs. We also use

one confirming criterion, which is the history of a previous arrest

86
for possession/sale of narcotics. (Note: if the individual has

had only a past charge of possession/sale of narcotics, that person is not classified as an addict.) It is therefore possible to

identify drug addicts by 1, 2, 3, or all 4 criteria; there are

14 combinations possible. Thus far, just by examining this population of drug addicts, we have found there are somewhat different

distinct populations. That is, those individuals who are identified as drug addicts on the basis of positive urine are somewhat

different from those drug addicts who are identified on the basis

of current drug charge.

Secondly, the number of people who are identified by all individual

criteria are themselves somewhat different. Positive urine alone

we have found, much to our surprise, identifies uniquely only 10

percent of individuals who may be identified as drug addicts in

the criminal justice system. That is if the mass urine screening

did not list, 10 percent of all identifiable addicts would be lost.

It is, in our judgment, a very cost-ineffective technique for identifying drug addicts. It is true that regardless of the cost,

urine identification is often an absolute imperative in some jurisdictions where the judiciary and sometimes the prosecutor believe

this is the only infallible identifier.

Another curious finding not easily explicated involves the varying

degrees of certainty we have about addicts. Drug addicts can be

identified by as little as a single identifier or by two, by three,

or by all four criteria. The higher the number of identifying criteria the more certain we are that the person is an addict. We

find that individuals who have been identified as drug addicts by

only one criterion had far fewer previous arrests than those identified by two criteria, and those with two had a less extensive history than those identified by three identifiers. Thus the greater

certainty that the arrested individual is a drug addict, the higher

his arrest rate will be.

On the average it was found that 17 percent of all persons arrested

were identifiable as current drug addicts. Current addicts had on

the average 7.2 previous arrests while non-addicts had a mean prior

arrest rate of 3.5. That is the total arrest population of 6,800

persons (in a 3 month period) had 54,638 prior arrests and 44 percent of these were that of current addicts.

‘The second group that can be identified from police records, in

addition to those who are addicted, are individuals engaged in the

use of non-narcotic drugs as identified by the urine screening or

by current arrest charge. These account for 6.5 percent of all

arrestees. There is a third population of exaddicts, individuals

who define themselves as having once been an addict but do not self

confess to current addiction or produce a positive urine or have a

current charge of possession or sale. This group is approximately

6 percent of the arrestee population. And finally, or course, a

fourth residual population of non-drug users exists.

We are interested, of course, in comparing the quality and seriousness of crimes committed by variously defined addicts, by abusers,

87
and by non-users. This can only be done, in our judgment, by the

development of some technique that can quantify and assign specific

values to the seriousness of previous and current criminal activities. We are, therefore, finishing a redevelopment of the SellinWolfgang Scale of Seriousness which assigns a standardized numerical value or score to each offense based upon physical injury or

property damage. This was originally undertaken in 1960. We are

updating it in 1974 in order to determine the stability of scores

after 14 years and to utilize statistical techniques such as A.I.D.,

and to ascertain scaled values for drug offenses.

AUTHOR

Leonard Savitz is Professor of Sociology, Temple University,

Philadelphia, Pennsylvania.

88
DISCUSSION

Dr. Robins: You said that 7 percent of the addicts would be missed

if they had not had a urine test. What percentage of them were

positive?

Dr. Savitz: If we tried to identify drug addicts and the criminal

justice system did not have a mass urine screening, it seems that

we would not pick up 7 percent; we would pick up the other 93 percent on the basis of self-admission or current charges.

Dr. Robins: Of all those who tell you that they are addicts how

many of them have positive urine?

Dr. Savitz: We are looking at that single criterion too. We are

looking at people who say they are addicts and produce positive

urines, and those who produce positive urines and deny that they

are an addict. We have 14 different groups of them right now, but

we have no results yet.

Mr. Romm: In the TASC study we did, we found that there was a 15

percent loss as difference between those that would be identified

as drug addicts or drug abusers by their own admission and those

who were then verified.

Dr. Robins: So 85 percent of those who admitted it would have had

a positive urine?

Mr. Romm: No, the other way around. We would have lost only 15

percent of the positive urines by self-admission. However, when

one challenges the value of the urine test itself, this 15 percent

variability gets lost in the "noise" level, I think, Dr. Berkowitz

will address this issue during his presentation.

Dr. Robins: How many of those arrested were addicts?

Dr. Savitz: Sixteen percent, or about one out of six. Add to that

an additional 6 percent who identify themselves as exaddicts and

you come up to 22 percent who are, or were addicts. I think the 6

percent is a staggering figure.

Dr. Sells: I have heard the tendency to arrest people for drug use

varies according to social and socio-economic levels. The appre89
hension of middle class drug users, for example, is a very dif

ferent kind of problem. How much of a bias does that create?

Dr. Savitz: It depends on the drug. In Philadelphia and, I think,

probably in other states, there are quarrels between the prosecuting attorney and the police on the bone fide nature of an arrest.

The police will arrest in any case where there is sufficient evidence to indicate that this person is involved in some illegal

drug use. The District Attorney operationalizes this, calling it

a minimal type of arrest. That is, if he had two or less joints,

the case is thrown out, it does not even enter the processing in

the earlier stages and no records are kept. This is in considerable conflict with the police, who say it was really a good arrest

and there was good evidence. The District Attorney says technically good, but it is too small to bother over. With middle class

kids it’s often the case of having just a few joints. Even the

use of demeaning behavior with the police will get different resuits.

Dr. Gottschalk: I would like to make one comment in connection

with Dr. Savitz’s conclusions about the finding of morphine or

heroin in urinalysis. I have often wondered about how carefully

those specimens were collected; if someone else’s urine were used,

it might get a false negative. Secondly, it has not been studied

as well as it should; for example, how long after taking the shot

will it appear in the urine? It is likely to be present in the

urine if the person recently took an injection, but if it has been

several days, as for some users who are "chippers" or who are doing

it with rather long intervals, you might not find it. I think

that percent should be taken with some caution before a conclusion

is drawn, because there have not been enough good studies. My presentation will deal with drug-related death and toxicological findings which indicate a rather disturbing amount of errors, either

false negatives or false positives, even when you provide what you

would think are the best toxicological survey groups in cities,

with known amounts of morphine or other substances.

90
Institutional Sources—Treatment

Saul B. Sells, Ph.D.

The topic assigned to me involves data acquisition for epidemiological research, from treatment sources. From the viewpoint of epidemiology, treatment data must be regarded as collected for other

purposes and, therefore, the use of treatment data for epidemiological research is a secondary use of such data. I wish to emphasize

this at the outset, and will try to develop some points related to

it as I proceed. It should be noted first that treatment samples

are not random samples of the user population. They are not only

biased, but they appear to be biased in systematic ways that need

to be understood. Unfortunately the relation of the portion of the

user population in treatment to the total user population is not

known, but systematic biases are suspected. Within the population

in treatment there is a dependence between treatments and the

characteristics of the individuals assigned to those treatments.

This could be a serious problem for anyone who attempts to use

treatment files without awareness of the systematic variations that

can occur.

Another problem that is characteristic of treatment agencies is

that their records are usually very limited and unsystematic. The

aversion of clinicians to keeping records is probably too well

known to deserve further mention here, but this does emphasize a

need for specially-designed reporting systems. The Institute of

Behavioral Research (IBR) at TCU has had the privilege for the past

six years of operating the DARP, the Drug Abuse Reporting Program,

started under NIMH. Right now we are engaged in a follow-up study

of samples of this population and we are finding that for a number

91
of the agencies that reported, the carbon copies of the reports

that were sent to us are their only systematic records of their

patients. There are other agencies, of course, that have maintained comprehensive patient records, but these are exceptions

and the importance of systematic records and reporting programs

cannot be overestimated.

Next there are problems of defining study samples; one of these involves the accuracy of entry and discharge records, and in particular the dates of these events. In our research involving treatment agencies, for example, we found initially an almost unlimited

number of local conventions for deciding who would be considered a

patient and who would not. There are some people who go through

the "revolving door" without leaving very much of a trace. Others

go through intake, but stay only a few days. And then there are

still others for whom we have records for a full five years, without interruption. When one looks at samples in terms of standard

definitions, the question of how to define a patient to be included in a sample is an important one. For some of our purposes,

such as calculating retention rates and evaluation of outcome, the

base on which these are calculated is naturally extremely important.

But in any case, the treatment sample is not given simply because

of files that may be available.

There are next a number of important legislative and ethical considerations concerning confidentiality and also issues concerning

the effects of further contacts on former patients that are typically encountered in follow-up studies; the latter reflect major

concerns of treatment staffs and should be treated seriously, particularly when the surveys are made by third parties rather than

by the treatment staff themselves. In our files, the records were

all recorded by agency code numbers which were meaningless without

the codes. We merely required that the same I.D. numbers be used

on every report. This was done to guarantee confidentiality, but

involves several limitations that are worthy of mention. One is

that when patients transferred from one treatment center to another,

they could not be tracked, because the only I.D. was this unique

number. The second is that now, when we are engaging in follow-up

studies , we have to go back to the agencies to obtain the identities of the patients that we are attempting to follow. And I

might mention that in the course of this, we have found that within the past year, a large number of different kinds of superordinate agencies have been created so that the agreement to disclose

the I.D. for the purpose of the research may be enmeshed in complex new state laws,

and county agencies,

in state regulatory agencies, and in municipal

so that the problem of negotiating to get this

information is becoming increasingly more burdensome.

I would like next to mention that the design of a reporting system

is in itself a problem; if it is designed for the purpose of evaluation of treatment, it may not satisfy the needs for administrative oversight or for epidemiological study. The concept of a

92
system to serve all purposes seems to me to be about as logical

as a speech for all occasions; neither of these has proven to be

effective.

Notwithstanding these problems and the difficulties, however, I

believe that there are values in the use of treatment sources for

epidemiological study. It is possible, for example, to fill in a

matrix of populations in treatment according to a set of classification variables so that trends in the composition of the samples

over time can be studied. In many cases it is possible also to

note the changes in relation to particular problems; for example,

in the case of our samples we have good reason to conclude that in

a number of cities the lowering of age over time probably reflected

the saturation of the available pool of people eligible for treatment that overstated the apparent change in the composition of the

population of drug users. The older addicts who had been using

for a long time were in many cases the first to enter treatment at

a number of agencies, and later on the population was more heterogeneous. This occurred notwithstanding the fact that over four

years of admissions we found a number of interesting changes -- a

lowering of the over-all age of the population, a shift from about

18 percent to 24 percent females in the cohort samples, a change

from about 55 percent black to about 45 percent, with a compensating increase in whites, a change from about 55 percent using heroin

daily either alone or in conjunction with other drugs to a much

lower percent, and a continuing increase in proportions of patients

defined as polydrug users. Whether or not these changes reflect

changes in the total drug using population, is a matter of speculation, but there are ways of examining support for such a hypothesis

particularly when you can replicate samples regionally over a large

number of cases.

Treatment data can also be used in designs using treatment and

other population samples as a basis for estimation of death rates

and related phenomena. In our studies we have published three reports in three succeeding years upon the differential death rates

of addict samples. The advantage of using populations in treatment is that time at risk can be accurately tied down and therefore when one takes into account demographic factors such as age,

sex, and race, drug use patterns, and other factors that might be

of interest, including type of treatment, one can obtain very accurate rate estimates. At the same time, it must be acknowledged

that people in treatment or under the surveillance of treatment

agencies are much less at risk than typical "street addicts" and

that as a result, the rates obtained for treatment samples are

undoubtedly underestimates. Nevertheless, this information is of

very great interest.

Finally, because of the extensive background data often obtained

from people entering treatment, such as we obtained in the DARP

program,

demiology in the same way that Gail Crawford and Father Fitzpatrick

it is possible to study problems that are related to epiindicated, namely by looking at correlates and different relationships among variables. We have reports on development of drug use

Patterns and on concomitance of drug use with alcohol; these data

93
indicate very clearly that the present widespread belief that alcohol use increases in methadone programs is unsupported and perhaps based upon biased samples in clinical settings.

I have also been intrigued by another result that has broad implications. As you know, in designing evaluation studies one can

approach the problem in several different ways. One approach that

we have followed has been to compare different samples, reflecting

patient types and treatment types on criterion measures reflecting

outcomes over time; this represents the conventional analysis of

variance and analysis of co-variance designs. Recently we approached the problem in a somewhat different way by comparing patients classified into different outcome groups. For example if

you take employment as a significant outcome you can classify patients in various treatments into a number of different groups

representing different patterns of employment outcome. In this

study of a methadone maintenance outpatient sample we used ten outcome groups defined as follows. The first were individuals who

were high in their pretreatment levels of employment and remained

high throughout treatment. Then there were four groups that were

at moderate levels of pre-treatment employment and who throughout

the course of treatment varied in one case by increasing their employment, in a second by decreasing, in a third fluctuated, and in

a fourth remained steady at a moderate level. There were four who

had low levels of pretreatment employment and were again classified as increasing, decreasing, fluctuating, or steady. And then

there was a group who was unemployed before entering treatment and

remained unemployed throughout treatment; that made ten. That,

incidentally, was the largest group. We classified samples in this

way on a number of different criteria. What we found that I say

intrigued me very greatly was that although when we look at outcomes for treatment groups without this kind of classification

there appears to be no correlation at all among outcomes in treatment -- that is, one may increase in alcohol use, decrease in alcohol use, decrease in drug use, and go any other way in unemployment, etc. -- we found that those groups that improved in employment during treatment improved on everything else. Now the signifi

cance of this to me is that employment may be a much more important

variable in organizing the life and the adjustment of patients in

treatment than is ordinarily considered. As we view the treatment

effort across the country the success of the entire overall treatment program in getting employment for patients has been very poor.

It is entirely possible that if a greater effort were made in this

direction, the overall payoff of the treatment program might be

much greater.

I will make two final comments. First, the results of our studies

have been available for the most part only in very limited editions

of technical reports and therefore have not been widely read and, I

noticed recently in a number of new books, have not been cited. I

feel that we have corrected this. Two volumes published by

Ballinger Publishing Company, a subsidiary of Lippincott, have ap94
peared within the past month.* These cover the results for the

first cohort of DARP patients for 1969 through 1971. There will

be a second set of volumes for the second cohort probably within

the next six months and our work is proceeding on the third cohort

at this time.** Second, the use of this file for further epidemiological studies will shortly be available to other investigators

in addition to those in the IBR by its incorporation in the Drug

Abuse Epidemiology Data Center which was set up last year, under

a SAODAP grant and continuing under NIDA, in which survey data covering a wide range of studies and institutional files are being

compiled and prepared for just this kind of research. This is described in the brochure on the data center located in the IBR at

Texas Christian University.***

*Sells, Saul B., ed. The Effectiveness of Drug Abuse Treatment,

Volumes I and II, Cambridge, Mass.: Ballinger Publishing Co.,

1974.

**Sells, Saul B. and D. Dwayne Simpson, eds. The Effectiveness

of Drug Abuse Treatment, Volumes III and IV, Cambridge, Mass.:

Ballinger Publishing Co., 1976.

***The Drug Abuse Epidemiology Data Center (DAEDAC), (Grant No.

DA4RGOO5), Texas Christian University, Institute of Behavioral

Research, October 1974.

AUTHOR

Saul B. Sells is Research Professor and Director, Institute of

Behavioral Research, Texas Christian University, Fort Worth, Texas.

95
DISCUSSION

Dr. Richards: I have a question that was not included on the

agenda: I am curious about experience with unobtrusive measures.

The only one I have every heard of is the use of cigarette papers

to estimate the use of marihuana. I thought maybe this group might

have had some thoughts or some experience with other kinds of measures which would add to those mentioned before.

Dr. Sells: In our studies the amount of poor reporting that we

received from different agencies correlates very highly with the

number of indices concerning the effectiveness of those agencies.

Dr. Lukoff: Poor reporting can be functional if it is deliberate

and not accidental.

Dr. Sells: Occasionally we had deliberate poor reporting, but then

we brought in Washington to deal with the problem and they did it

effectively; the cooperation throughout was magnificent. And yet

we could see where projects were poorly staffed with no back-up

people, no facility for training and so forth; poor reporting resuits.

Mr. Romm: And you dealt with some of the better programs that are

being supported by the federal government. In our experience with

CODAP we have found that those programs which were disciplined by

Saul Sells and his group are good reporters in CODAP.

Dr. Eichberg: Are you talking primarily about programs that are

dealing with opiate adddiction?

Dr. Sells: No, perhaps primarily but not by design. When this

started in 1969 the federal support was only for opiate addiction

and two years later new legislation broadened it. The data we have

reflect the shift; but even today heroin is by far the major drug

that constitutes the problem.

Q: Regarding comparability between institutional sources and other

-- to what extent can these findings be generalized?

Dr. Sells: This is one of the reasons why I have said that the

data system designed for one purpose does not always serve another

purpose as well. Ours was designed to study the effects of differ96
ent treatment, not even to evaluate particular programs, and therefore we have some sampling problems in respect to how well the samples we have represent the universe from which they are taken.

With regard to generalizing our data, I feel we could not generalize our data for almost any of the cities from which we have received reports. In San Antonio, there are two or three treatment

agencies now and we have one reporting unit. In St. Louis, I do

not know how many there are, but we only have one. In each case,

we are getting data from that city, but we are not sampling that

city.

Dr. Richam: Nor are you sampling the treatment modality.

Dr. Sells: No, but we are replicating our sub-samples of it so

that if we can get some degree of robustness in the estimate from

a chunk of three or four samples from a modality, then we will pay

more attention to it than if they are not consistent.

Unfortunately, the samples that we had to deal with were given to

us by fiat and we have no control over that.

Dr. Gottschalk: I understood Dr. Sells to say that his data indicated that increased occurrence of alcohol and methadone use was

not validated. How wide was your sample? Was it local in Texas

or across the United States?

Dr. Sells: This is a sample in the third year of our program

which totals 15,500, from 38 cities including Puerto Rico. Believe

it or not, there were not cities in Texas in the sample.

Dr. Greene: There is also some data out of treatment programs in

Washington, D.C., which suggest the same thing; increased rates of

alcohol use observed were compared with admission alcohol use rates

at some point later in treatment. It turned out that what was

missing was that pre-addiction rate of alcohol use. What they were

doing was returning to what constituted probable or normal use in

their own community.

97
Indicators of Drug Abuse—

Drug-Involved Death

Louis A. Gottschalk, M.D.

I am going to talk about studies that relate to drug-involved

death. Our research group in the Department of Psychiatry and

Human Behavior, University of California at Irvine, was involved

first in the development of a uniform reporting and recording form

for psychoactive drug-involved deaths. In the first year of our

study, we surveyed 20 cities in the United States for such deaths,

specifically through the Offices of the Medical Examiners and Coroners . We found out, as was suspected, that the recording and reporting system in the United States for drug-involved death was

rather haphazard and unsystematic. So we developed a recording and

reporting form of about 16 pages set up so that it could be filled

out by the medical examiners or coroners and the various other professionally trained people in those offices who are qualified to

fill out the various parts of this form. There was a trial run or

pre-testing of 300 of these forms to check on the understandability

of the items, the consensus with which agreement could be reached,

*This report represents the collaborative research of Louis A.

Gottschalk, M.D., Frederick L. McGuire, Ph.D., Eugene C. Dinovo,

Ph.D., Jon F. Heiser, M.D., and Herman Birch, Ph.D., from the Department of Psychiatry and Human Behavior, College of Medicine,

University of California at Irvine, Irvine, California 92664, and

the Orange County Medical Center Research and Education Foundation,

Orange, California 92668. This study was supported by a Research

Contract Grant (#HSM-42-72-139), 1972-1975, from the National

Institute on Drug Abuse.

98
and so on. The items in the form included the diagnostic system

used on the death certificate, that is, the International Classification of Diseases system for reporting the mode of death, which

falls into the classifications of direct and indirect and combined

causes of drug-related deaths that may not be directly due to the

drug itself. Items also dealt with noting those causes of death

in which predisposing, underlying physiological conditions were

already present, e.g., a heart disease which, with the addition of

a drug, may push the person to die or may lead the person to a fatal accident or to jump off a bridge. Other items addressed what

may have been seen by the medical examiners or coroners as related

to a drug-involved life style, that is, a bullet hole in the head

of the deceased due to involvement with people in the drug field.

For the purposes of this study, drug-involved death included any

type of psychoactive drugs -- analgesics (pain killers), narcotics,

barbiturates or other sedatives, psychomotor stimulants, and so on.

The next part of the study was involved with getting from nine

cities a total of 2,000 of these forms filled out; there was a certain quota from each city, based on the percentage of drug-involved

deaths out of the total number of deceased persons processed by

each office per year. The cities involved include New York,

Chicago, Philadelphia, Washington, D.C., Cleveland, Dallas, San

Francisco, Los Angeles and Miami; the quota related partly to the

population and the number of cases that are processed; for example,

the quota from New York City was 400, the quota from San Francisco

was 200. That does not reflect population entirely, but the number

of cases that go through their medical examiner’s or coroner’s system. Also, the quota was partly related to how many they could

process. You may not realize it, but, in general, a coroner’s case

or a medical examiner’s case is any deceased person who did not

have a physician in attendance at the time of the death or up to

four weeks before the death. But when it comes to how thoroughly

these cases are studied, there is quite a great deal of variance.

Most cases, however, that we reviewed were cases where there were

post-mortem and toxicological studies done. We are at the halfway

point, and some of the data that I am going to show you are going

to give you preliminary psychosocial and biomedical analyses of

about 1,000 drug-involved deaths.

Another part of our study of drug-involved deaths, we felt, should

be a proficiency testing of the toxicological laboratories of these

medical examiners and coroners, and we got them to agree to do

this. We have good rapport with this network of professionals because we have worked with them for some time. They agreed to accept five unknowns in blood plasma or urine for qualitative and

quantitative assay. Some of the unknowns had only one drug in

them, some of them had four or five. We knew exactly what was in

each, and, besides preparing these unknowns, we sent them to an

other reference laboratory to see what percent of these chemical

substances could be found by an independent biochemical laboratory.

Also involved, and this is a very important part of such a study,

is the determintion of the many ways to measure and analyze these

different psychoactive chemical substances: some of the factors

99
that can produce variance in the reported amount of drugs found in

the body and, hence, considered to account for the death might not

only be the method of extraction used to obtain the drug from the

biological fluid in which it is located but also the particular

assay method used. Some of the assay methods are not specific or

precise, whereas some of them are quite specific. In the process

of narrowing down the exact quantitative amount, the laboratory

has to go through a number of steps to finally get the specific

amount. Some of the assay methods used (for instance, the fluorometric method) measure not only the parent drug but many of the

metabolites of the parent. Other assay methods are more specific

and measure only one chemical substance (for example, gas chromatographic or radio-immunoassay methods). Hence, different assay

methods will give different quantitative results on attempting to

measure the same drug in a specimen.

What I am going to show you will give you some idea of the kinds

of data that can be generated from the drug-involved death reporting form my research team has developed. It is going to take us

quite a while to analyze all our data, You can imagine the many

questions we have. They cover not only data about findings at the

site of the death (on-site investigations) but any pre-treatment

procedures that the person was undergoing (whether medical or psychological), the so-called "psychological autopsy," post-mortem

findings, toxicological examinations (not only screening tests and

procedures used but the specific quantitative findings). The drugrelated deaths studied in our survey occurred in 1972 and 1973 and,

for some medical examiners, ran into the beginning of 1974. One

other thing that you should know about: these are all top-rated

medical examiners, but they are busy and they have a limited budget; so there is a problem to get them to fill out these forms on

their own bugets and to find the time in their own busy operations

to do the things they are supposed to do. So we have to pay them

a certain amount to fill out our forms and, in some instances (for

example, in New York), we eventually had to send a research assistant there to get all their raw data and assemble it and put it down.

100
FIGURE 1

Figure 1 is comprised of data from 920 cases. One way of looking

at this figure demographically is to observe that drug-involved

deaths (across all drugs) seem to be a condition that occurs maximally at ages 20-29 years and at a higher rate among males than

females. Over 50 years of age, females show a higher percentage

of occurrence than males.

This figure includes any cases that would come through the medical

examiner or coroner system, regardless of cause. These could be

suicides, homicides, medical therapeutic misadventures -- whatever

the medical examiners and coroners decided were drug-related are

all lumped together here.

101
FIGURE 2

Figure 2 will show that, for narcotics deaths, there are many more

mules than females; with barbiturates, there is not such a sex difference. By the way, on ethanol-related deaths, we do not collect

cases where alcohol alone was the cause of death. The death had

to be due to alcohol with some other psychoactive pharmacological

agent.

102
FIGURE 3

Figure 3 shows an interesting relationship between employment status and drug-involved deaths. For some reason or other, a relatively high percentage of the decedents were employed; a surprisingly

small percentage were unemployed.

103
FIGURE 4

Here is another incidence graph. Again, the modal age range for

a fatal consequence due to an overdose of a barbiturute is 20-29

years, but after the age of 50, barbiturates become an increased

factor associated with death, obviously from suicide.

104
FIGURE 5

Here are the deaths involved with ethanol. The coroners had to

rank what they thought the death was due to. Polydrug use, with

or Without the use of alcohol, is fairly common. So if the coroners found a number of drugs in the biological fluids of the body,

they had to draw an educated conclusion about which drug was the

major factor.

105
FIGURE 6

Here is indicated something about racial differences by drug class.

Among deaths due to narcotics, blacks are relatively high. Among

deaths ascribed to barbiturates, the whites are very high.

106
FIGURE 7

Figure 7 shows suicide by drug class. As you would expect, barbiturates are relatively highly associated with drug-related deaths,

very highly, as a matter of fact. We have a breakdown of the likelihood of suicide in terms of definite, probable, and possible, and

we have also incorporated some of Shneidman's distinctions in these

respects -- that as, whether the suicide was "intentional" or "subintentional," but these distinctions are not diagrammed on these

figures.

107
FIGURE 8

Figure 8 shows a breakdown of drug-involved deaths in terms of

sex differences for different cities. The patterns for each of

the seven cities represented are somewhat different. You will

notice the N's are different this time because we have not yet

collected all our data. Also, we have not included data from

New York or Miami. You will notice that, for 1973, in Cleveland

the female deaths are a little higher than the male deaths, but

this difference may not hold up after we have finished collecting

the full quota of drug-involved deaths from Cleveland in 1973.

108
FIGURE 9

Figure 9 shows unother breakdown of drug-involved deaths in the

racial differences for each city. The profiles would certainly

illustrate what somebody has already said here, that all greater

American cities have somewhat different drug abuse patterns. Maybe we do not yet have enough data to draw any conclusions, but

some of the differences are marked and look as if they will hold

up, for instance, the different racial patterns of drug deaths in

Philadelphia and San Francisco.

109
FIGURE 10

Here in Figure 10 we see the distribution of various psychoactive

drugs by class, as they were perceived to be the major cause of

death by the medical examiners. For San Francisco, barbiturates

were relatively high, whereas for Philadelphia, narcotics were

high.

110
FIGURE 11

Of the 1,562 specific drugs mentioned in these 924 deaths, the frequency by

rank is as follows:

Heroin 22%

Alcohol 19%

Secobarbital 6%

Pentobarbital 6%

Quinine 6%

Phenobarbital 6%

Methadone 5%

Amobarbital 3%

Propoxyphene 3%

Valium 3%

Tuinal 2%

Figure 11 is a quick run-down of all the drugs mentioned in the

reporting forms us being involved in the death in these 924 ease

reports. In many cases, several drugs were mentioned. We found

that heroin was the most frequent psychoactive chemical substance

mentioned, with alcohol the next most frequent, even though eases

involving the use of alcohol could be included only if it was involved with another psychoactive drug. Secobarbital and other

barbiturates were rather highly involved. We also see that a

drug like propoxyphene (® Darvon), mentioned in 3% of eases, and

this drug is claimed to have an increasing association with druginvolved deaths.

111
Figures 12-19 are presentations of a different kind of data.

They are more biomedical, but they will be of interest because I

do not think there is anything quite like these data reported

anywhere, and we cannot aspire to an accurate epidemiological understanding of drug abuse patterns until we begin to acquire valid

criteria for the human toxicological effects of these drugs and

the body concentrations of the drugs that are absolutely necessary

to produce a fatal outcome. The assumption is unwarrented that we

know, with certainty, what drug levels are fatal or, in combination with other drugs or preexisting medical conditions, can lead

to death. The wide ranges of drug concentrations recorded here

and the frequency distribution of these drug levels serve as a

descriptive base line for comparison with other studies and for

further validation.

The figures show the range of morphine or other pharmacological

substances found in the blood, urine, or stomach contents and the

breakdown of the percentage of distribution of these drug concentrations.

FIGURE 12

112
FIGURE 13

FIGURE 14

113
FIGURE 15

FIGURE 16

114
FIGURE 17

FIGURE 18

115
FIGURE 19

The next is a series of tables which will show you some of the

results of our quality control and proficiency testing studies as

reported by the toxicological laboratories of the medical examiners or coroners in the cooperating nine cities. Table 1, headed

"Serum I Sample," was sent to the nine laboratories as a general

unknown. It contained, as is indicated in the top row, 6.5 micrograms per milliliter μg/ml) of secobarbital 6 μg/ml of pentobarbital and 400 μg/ml of salicylic acid. These were the amount that

our own departmental Biochemistry Laboratory put into the serum samples sent to each toxicology laboratory. The bottom row on Table 1,

labeled "Reference Assays," gives the amounts of these various

drugs that an independent reference laboratory obtained from this

serum sample. You will note that the amounts obtained by the reference laboratory (not one of the participating laboratories associated with the medical examiners or coroners) are not precisely

the same as the amounts of drug we put into the samples. The differences between the reference assays and what we actually put into these unknowns indicates the amount of error variance that would

be acceptable in such assays. What should be noted in the results

reported by the nine participating laboratories is that some of the

amounts found by them were close to what should have been found,

but that, in several instances, the drugs were found but not quantitated and, in one instance (salicylic acid), no drug was found.

116
TABLE 1

SERUM I SAMPLE

Preliminary Compilation of Results - 9 Cities Reporting

DRUGS PRESENT - CONCENTRATION (in μgm/ml)

Secobarbital Pentobarbital Salicylic Acid

6.5 6 400

RESULTS (in μgm/ml) REPORTED BY PARTICIPATING LABORATORIES

REFERENCE ASSAYS

6.2 4.9 410

This sample was sent as a general unknown.

* Secobarbital and pentobarbital were reported together by this

laboratory.

(+) Drugs were found but not quantitated.

(-) Drugs were not found.

Table 2, headed "Urine IV Sample," shows on the top row the six substances which were in the unknown, namely, secobarbital, 6.5 μg/ml;

methadone, 2.5 μg/ml; morphine, 3.5 μg/ml; methaqualone, 20 μg/ml;

flurazepam, 30 μg/ml; and ethanol, 0.15%. In assaying the amounts

of these drugs in this urine sample, the participating laboratories

did not do SO well. In many instances, the drug was detected but

not quantified. In many other instances, the drug was not even detected. And, in many instances, though the drug was detected and

quantitated, there was a sizable deviation from what was actually

in the urine sample. On the other hand, at least two laboratories

(see row 1 and row 5 under "Results Reported by Participating Laboratories") did quite well for the most part. These variations obtained from presumably good toxicological laboratories may be due to

the different methods of extraction, or the different assay methods used by these laboratories, or to different instrumentation

and human error, From the findings, you can see that social scien117
tists cannot safely assume that all biochemical measurements are

automatically reliable and accurate.

The last point to notice in Table 2 is that one false positive was

reported, namely, salicylic acid, in a sample in which it was,

deed, not present.

inTABLE 2

URINE IV SAMPLE

Preliminary Compilation of Results - 9 Cities Reporting

DRUGS PRESENT - CONCENTRATION (in μgm/ml)

Seco- Methaqua- False

barbital Methadone Morphine lone Flurazepam Ethanol Positives

6.5 2.5 3.5 20 3 0 0.15%

RESULTS (in μgm/ml) REPORTED BY PARTICIPATING LABORATORIES

7.0 2.8 4.1 27.4 36 0.12

4 1 0 3 - - 0.12

3.8 -

- 1.8 - -

7.0 - + + + 0.12

6 3 3 28, 25 42, 38 0.10

5.2 - + 5.1 - -

+ + + +

Salycylic

- -

acid

5 - - - - 0.12

+ + + + - -

REFERENCE ASSAYS

3.5, 5.6 2.1, 2.2 3.4, 2.7, 4.6 15, 6.7 +

This sample was sent as a general unknown.

(+) Drug was found but not quantitated.

(-) Drug was not found.

118
Proceeding to Table 3, we see the results obtained by these laboratories (only seven cities reporting) on "Serum III Sample."

Again, we see that a number of laboratories detected the drug but

did not quantitate it, and in a number of instances the drugs were

not even detected. Moreover, two laboratories located drugs which

did not really exist in this serum sample. Such a range of errors

might well increase a social scientist’s skepticism about the accuracy of the medical diagnoses related to cause of death. On the

other hand, some of these toxicological laboratories were consistently more accurate than others. This might mean that their epidemiological findings were more to be trusted than those reported

by other medical examiners’ and coroners’ offices.

SERUM III SAMPLE

Preliminary Compilation of Results - 7 Cities Reporting

TABLE 3

Drugs in this sample were identified as neutrals and volatiles.

(+) Drugs were found but not quantitated.

(-) Drugs were not found.

119
Proceeding to Table 4, headed "Urine II Sample," we again see

one false positive and sane instances in which the drugs were detected but not quantitated or instances where the drugs were not

found when they should have been. On the other hand, as we continued sending these unknowns to the participating laboratories and

giving feedback of their results in a confidential and coded fashion so that the nine laboratories could not identify which laboratories were very accurate and which ones were not, the overall accuracy of all the laboratories gradually began to improve.

TABLE 4

URINE II SAMPLE

Preliminary Compilation of Results - 9 Cities Reporting

This sample was sent as a general unknown.

(+) Drugs were found but not quantitated.

(-) Drugs were not found.

120
Proceeding to Table 5, headed "Urine V Sample," we again see two

false positives in an unknown in which the generic name of the

drug was identified (at the time of pre-testing, the laboratories

were told that a barbiturate was present, but not which one). Note

that one laboratory reported 384 μg/ml. This was possibly an error

in placing a decimal point, but, even so, an error that cannot be

ignored.

TABLE 5

URINE V SAMPLE

Preliminary Compliation of Results - 8 Cities Reporting

DRUG PRESENT - Secobarbital

FALSE POSITIVES

CONCENTRATION 6.5 μgm/ml

RESULTS (in μgm/ml) REPORTED BY

PARTICIPATING LABORATORIES

9.5

4

6

4.4 Phenobarbital, 4.4

8.5, 6.4

5.8

5 Doriden, 3.6

384

REFERENCE ASSAY

5.4

(Drug class was identified for this sample.)

The last, Table 6, headed "Time Study of Secobarbital Measurements

by City," is also interesting from the viewpoint of quality control.

Every one of the five unknowns, listed under the heading "Sample"

in column 1, contained 6.5 μg/ml of secobarbital. We can see that

some laboratories obtained results fairly close to the amount of

secobarbital actually in each sample, and some laboratories showed

considerable deviation.

121
TABLE 6

TIME STUDY OF SECOBARBITAL MEASUREMENTS, BY CITY

(Concentration - 6.5 μgm/ml)

I think by viewing this series of slides from our quality control

and proficiency studies of the toxicological laboratories associated with the determination of evidence for a drug-involved death,

you should be reassured that some laboratories, on the one hand,

get fairly respectable results. On the other hand, some laboratories show a consistently high error variance which might influence the accuracy with which they determine the final cause of

death.

We are coming to a conclusion that the epidemiological data, using

the expert opinion of forensic pathologists and medical diagnoses

of the cause of death, are not equally accurate, at least from the

point of view of one of the important sources of data on which

medical and legal opinions are based, namely, the toxicological

findings.

122
Indicators of Drug Abuse—Hepatitis

Michael Alexander, M.D.

I will briefly discuss the use of hepatitis as an indicator of incidence and prevalence of intravenous drug abuse. The way I would

like to approach the discussion is to go into some of the limitations of this technique and, thereby, give you some idea why one

has to be critical when looking at these kinds of data.

The first major problem in using hepatitis as an indicator is the

difficulty in diagnosing a given case of hepatitis as being the

kind of hepatitis associated with drug abuse. Hepatitis is a

broad term, meaning inflammation of the liver. It is believed

that most cases of hepatitis are caused by two viruses, hepatitis

A and hepatitis B. However, hepatitis can also be caused by other

viruses and by drugs and perhaps other sorts of infectious agents.

Hepatitis A is infectious hepatitis; hepatitis B is serum hepatitis. It is hepatitis B that classically has been associated with

drug abuse . Usually, a given case of hepatitis can he diagnosed

as being either hepatitis A or hepatitis B by combining epidemiologic, clinical, and laboratory information. However, even when

one is able to pinpoint the case as being typical of hepatitis B,

the problem remains that hepatitis B can be contracted by routes

other than intravenous drug abuse; for example, transfusions, personal contact, or perhaps as recent evidence would suggest, by

sexual contact. Furthermore, even when a case seems typical of

hepatitis A, the problem remains that hepatitis A, in addition to

usually being contracted by non-intravenous routes, can also be

spread by intravenous drug abuse. As you can see, separation of

the two types of viral hepatitis becomes difficult and their mean123
ing becomes very confusing. In addition, while hepatitis B is

the kind of hepatitis we are most interested in looking at as a

measure of drug abuse, the vast majority of cases that are seen

are probably hepatitis A. And as a result, there is a large background "noise" which may obscure changes in what we are trying to

assess. As a result, interpretation of cases reported is further

complicated.

Another problem area is the hepatitis reporting system. There are

,a number of nationwide hepatitis reporting systems which are channeled through public health agencies. Theoretically, all physicians in the United States are to report cases diagnosed as hepatitis to the local public health authorities. These in turn are

reported by the local authorities to the state public health authorities and on a weekly basis, these reports are forwarded to

the Center for Disease Control in Atlanta. The mechanisms within

each state for doing this reporting are variable, so to understand

what is going on in any given state, one has to examine that system individually. In the national weekly reporting system, cases

are reported as being hepatitis A, or B, or unspecified, but the

information on which that diagnosis is based is not given. As a

result, one can never he certain of most diagnoses.

Most cases of hepatitis that are diagnosed are not reported. In

fact, the Public Health Service has investigated major epidemics

because they were interesting or important in terms of understanding the disease, yet, those same epidemics were never reported

through the routine reporting system. A fraction of the cases

that occur get reported and it is certainly possible that this nonreporting is not a random phenomenon. For example, in a ghetto

area where the major source of medical care is a county hospital

which is likely to have a university affiliation with faculty interested in public health or infectious diseases? the reporting

system might be very good. In a suburban community, where reporting a person as having hepatitis B might imply drug abuse or similar social stigmata, there might be a bias against reporting

cases. Analysis of the data does not show that this is occurring,

hut potential bias like this must be considered.

Another major problem area of hepatitis reporting is that there

should be a lag period between an increased incidence of drug abuse and when we would see rising hepatitis case reports. This

lag would be the result of a number of factors. First of all,

the addict would have to go through a stage of "chipping" and

would have to achieve a certain level of drug abuse before his exposure level got to a point where he would get hepatitis. Secondly, hepatitis B has an incubation period of two to six months.

‘This means a delay of two to six months between the time that one

becomes infected with the virus and when one has clinical evidence

of hepatitis. In addition, there is the lag between getting the

reports from the private physicians to the local level, to the

state level, and to the federal level. I think all of these would

combine to present difficulties in terms of using the hepatitis reporting system as an early indicator of changing incidence of drug

124
abuse. This is especially relevant if one is thinking of using

indicators of increases in drug abuse as a clue to when to intervene.

Retrospectively, we can certainly show that at times when other

epidemiologic data have suggested "epidemics" of drug abuse, the

hepatitis data are in agreement. Whether or not they would have

been very sensitive at the onset in terms of suggesting when and

where to try to combat the epidemic is not clear.

What I planned to do next was to briefly describe some of the data

which has accumulated at the federal level on this Hepatitis Surveillance Program and how that reflectcd on the epidemiology of

drug abuse over the last 10 years. However, I think that Lee

Minichiello has done an extensive evaluation of our data, much

more extensive than we ever did. I think that I will defer to him

in discussion and ask if he would like to raise some of those

points.

AUTHOR

Michael Alexander is Fellow in Medical Oncology, Stanford University Medical Center, Stanford, California.

125
DISCUSSION

Mr. Minichiello: I wouid like to comment on our study of the use

of hepatitis as an indicator. As has been mentioned, our work has

not always gotten outside the Government.

In 1972, we were asked by the Office of Science and Technology,

which was then a part of the Government since abolished, to do a

study on heroin data. In that study we conceptualized the measures that we liked and did some prototype analyses which over the

last three years now have been completed and in one form or another have been recommended to the Government for implementation; to

some extent they are being implemented. There are four such indicators: the treatment data base; federal purchases and seizures;

hepatitis; and the DAWN system. Using the treatment data in 1972,

we looked at what was happening in the heroin epidemic at that time

based on age of incidence from admission data. We were able to

shop some peaking at that time; however, there was some discussion

about whether it was zero or going up or down. In that study we

also said the treatment data had some problems and one was the

time lag between the start of using heroin and going into treatment and the other was the bias that Dr. Sells mentioned -- the

data we looked at were mainly ghetto users in Eastern cities.

Therefore, we said we would like to sample nationally and look at

both the suburban and white young person. In addition, we said

that we were interested in more than just incidence and prevalence

-- we were interested in availability. I was very interested in

Dr. Newmeyer's comments, for two reasons. One, availability actually influences incidence and prevalence -- for example, the

East Coast heroin shortage. Then secondly, availability drives a

lot of these indicators perhaps more than the absolute number of

users. Drug deaths and overdoses is one example, urinalysis may

be another, and there are probably others. That study was publisted in December 1971 and has not yet been distributed outside

the Government.

The nest study we did was to look at the DEA laboratory tapes,

which are a record of all federal drug seizures. They are unique

in that their strong point is that they are a good, definite, precise, chemical identification of the drug that was used. I have

great confidence in that chemical data. From that, we developed

all indicator of availability, using the price of heroin, the puri126
ty of it, and certain chemical characteristics. From this we

have examined over the last three years the availability, the

changes in the distribution system both at the retail and wholesale level, and the changes in the source -- the fraction of the

country’s heroin coming from different sources. Initial results

were clear about six months ago. They are very similar for the

nation to what Dr. Newmeyer said was happening in San Francisco.

We saw a shortage develop from the East Coast of the United States

which went all the way back to France and a decline in that source.

We saw a corresponding increase in heroin coming across the Mexican border which had certain chemical characteristics that arc

unique to a process different from either the French or Southeast

Asian; this began to represent a large supply of heroin that was

more potent than the declining French. That has also been published and not disseminated, perhaps for good reason because, in

terms of enforcement action, one does not want to get too open

about the source signatures.

Then we extended the laboratory analyses to look at the other

drugs. Here we have the concept of relative availability -- what

happens to drug use when one drug becomes less available and

another drug becomes more available? That appears to be very important if one wants to discuss polydrug use. This work is just

being published and in it we have compared those data with the

DAWN system using a grouping of the drugs that are compatible.*

That, I think, may receive wider distribution than the earlier

studies. In that study which covered the last three years --

1971 through 1973, we saw an increase in narihuana that was quite

pronounced. We saw a decline in heroin. We saw a relatively constant use of the other drugs, perhaps with some interesting changes

within drug groups. For instance, you would see a decline in LSD

but a corresponding increase in PCP, a decline in barbs, hut an

increase in non-barb sedatives.

Then I have done a study that is about to be published on trends

in intravenous drug use, looking a hepatitis and DAWN.** I tried

to tackle all the problems that Michael Alexander has mentioned

in terms of using that system. Yet in spite of all those problems, hepatitis is perhaps the best indicator, so you can understand the problems of the others! I looked at it over eight years

and we saw a great increase that is different in different parts

of the country and different geographic and different demographic

areas; you really have to do all these things -- geography and

demography -- to compare these data bases. We saw an 8-fold increase from 1966 to 1972. And then in 1973, we saw a decline that

was very preferential in time and geography to the area where the

East Coast heroin shortage occurred and that was in New York City,

*L. Minichiello, et al. "Supply, Distribution, and Usage Patterns

of Drugs of Abuse." (DEA-STS-TR-13; IDA Paper P-1066), October,

1974.

**L. Minichiello. "Indicators of Intravenous Drug Use in the

United States." (DEA-STS-TR-14; IDA Paper P-1068)) March, 1975.

127
mid-Atlantic States to a lesser extent, and out of Chicago and

down to the South Atlantic Census Division. We saw an increase

in the number of whites in the last few years -- white cases grew

and female cases grew. Then I compared the demographic and geographic distributions of those hepatitis reports with the DAWN

mentions and found general gross agreement at the current time.

The most recent thing that we are doing with DAWN now that it has

a year and a half of reporting history, is to look at time trends.

In the last six months, we see a turn upward in heroin mentions

of about 30 percent, almost uniformly across the country in emergency rooms. We are trying to understand if this is related to

some peculiarity within the DAWN system that is entirely unreal,

to an increase in potency, or to a change in heroin usage.

Dr. Sells: In our data, as I reported earlier, between 1969 and

1972, we had an eight percent shift from the number of males to

females and also an increase in the number of whites. Now, is it

possible that what you are finding is merely reflection of the

change in the population of users rather than a change in whatever

is producing these cases?

Mr. Minichiello: I think the changes that I have observed are probably underlying patterns of drug abuse showing a real increase in

the number of white male and female users in the United States

since 1970.

Dr. Sells: I agree with that.

Mr. Minichiello: I base that on two independent systems. In other words internally I looked at the non-drug related hepatitis

to see if it was distributed right -- geography, race, and sex --

and it was , so it was hard to demonstrate obvious biases of the

system. All this is very preliminary and we hope to get it out

and let people tackle it and learn more as we go on. The Stride

system is being implemented within the DEA and we are hoping that

this kind of data will be routinely available to them. Stride is

the data system in which the laboratory analysis of the federal

seizures arc reported.

Dr. Chambers: I have a comment concerning the use of hepatitis as

an indicator. It is my experience that most drug use in this

country is not intravenous. And if hepatitis is presented as one

of the best measures of drug abuse, and plans are written and problem groups arc defined, and strategies are made on the basis of

hepatitis, I think it is misleading. I am not sure what I want to

use as an indicator, but I do not want to use that one.

Mr. Minichiello: How about heroin? Most heroin use is intravenous.

Dr. Chambers: I am not sure that is true either.

Mr. Minichiello: We chose I.V . specifically with the rationale

that it represented a form of serious use that people might con128
sider abuse and that it was one way of getting a look at a population which you could demonstrate was in some sense serious.

We do not want to say any more than that. We do not say you

should not look at non-I.V. use. I am just saying that I cannot

do everything at once and here is one mode of insight into one

form of the user population which we think captures many, if not

most of the heroin users, and to a lesser extent the other drug

users. We have documented the percent of I.V. use for each drug

type within the DAWN system by each facility type to get an idea

of the variance that you might see from those different things,

like crisis centers vs. emergency rooms. What we arc seeing is

about 10 percent of the mentions being I.V. in DAWN and about 90

percent of the heroin mentions reported as T.V.

Dr. Chambers: What has been the correlation between the DAWN data

obtained at crisis centers vs. the DAWN data obtained in emergency

rooms?

Mr. Minichiello: They give essentially the same answers. There

is not a good variance in these data with respect to T.V. use by

facility type in DAWN. These give you the same answers.

Dr. Sells: What is the basis for your questioning the extent of

J.V. use of heroin?

Dr. Chambers: We do not have any.

been demonstrated.

Our contention is it has not

What we have is I.V. use as a predominant vehicle in the known or treated population.

Dr. Sells: In our data I would say we have maybe 30,000 cases involving heroin use of which 98 percent is I.V.

Dr. Chambers: I am not going to question that. Rut among the

hidden users, and the recent users who are totally functional,

the social or recreational users, I am not sure that 98 percent

of them are I.V. users. That is all I am saying.

129
Indicators of Drug Abuse—Buys

John Newmeyer, Ph.D.

In regard to buys, we at the Haight-Ashbury Free Medical Clinic

have been concerncd mainly with heroin. Through a network we purchased samples of heroin from time to time on the street and submitted them to pharmacological labs for analysis.* These data are

of spccial interest lately because of the detective work we are

doing in regard to the second "wave" or "peak" of the incidence of

heroin addict ion in San Francisco. ‘The latest estimates I have

made show that the big peak of new addicts in the Bay Area in

1969-1970 was followed by a decline by about two- thirds in the incidence of new addicts as of 1972. Then in 1973 and 1974, there

seems to have been a resurgence of new addiction to heroin, to a

second peak. We sought to find out what was the character of this

new wave of addicts. We got some demographic data from our own

clientele and from the death-by-overdose roster, and it appears

that this new wave of addicts was primarily of lower-class backgrounds. These individuals are not from the suburbs, nor from

middle-class backgrounds, but more traditional addict-types, of

black, Latino, and white working-class origins. Also, this time

around, there is a higher proportion of females, more like 40 percent as opposed to the 15-20 percent of ten years ago. Also,

there is a return to a lower proportion of whites. ‘The age at

which the typical San Franciscan now becomes involved with heroin

is not significantly different from five years ago; if anything,

it is very slightly higher than before.

*See Attachment.

130
My hunch in regard to the second "wave" is that it was due to the

higher quality of heroin coming into the Bay Area and "taking

hold" more easily than did the poorer-quality heroin that was

available there during 1971-1972. I believe we were getting a

higher quality of heroin at a lower price, due to San Francisco

becoming a depot or entry-point for Southeast Asian or Mexican

heroin. In other words, I perceive the new peak as resulting from

more immediate, close access to the ultimate source of heroin,

which now seems to be coming principally from Southeast Asia rather than from Turkey as it was five years ago. Hence, instead of

having to come from the East Coast and all the way out to the West

Coast through many layers of middlemen, our heroin market now has

few layers of middlemen and hence fewer layers of price raising

before it gets to the ultimate consumer. In summary, it appears

as if -- in contrast to the first-wave epidemic of 1969-1970 which

appeared to result from the germination and rapid spread of heroin

use in the middle-class white youth subcultures which had already

gone through several stages of abuse of other drugs (primarily amphetamines) -- the second-wave heroin epidemic was due to the introduction of good-quality heroin into traditional black and

Latino communities of poverty.

We looked at the samples that we had picked up in various parts of

the Bay Area. The way we did this was to pick our clients at random, asking them if they would bring in samples for analysis, for

which we would pay them for any expense they had gone to. It is

very hard to get any kind of random sampling of the heroin available on the streets. You can not use the Crawford-Hughes method of

going out to a particular copping area, because that copping area

is likely to be dominated by only one or two sources of heroin.

About the best that you can do is to go to all the treatment centers in the city and ask a random sample of clients to go out to

their connection and get you a sample of the heroin that is available.

I did summaries of these analyses, in which I developed one important statistic, the "price per pure gram of heroin" -- that is,

how much does each buyer at a particular level of the distribution

hierarchy have to pay for his heroin. The most current figure is

a median of $835 for a pure gram of heroin at the lowest retail

level, which is equivalent to $.83 per milligram of pure heroin.

Traditionally, one thinks of a bag of heroin as containing 10 milligrams of pure heroin or $8 or $9 worth of heroin at the current

retail price. (This study also necessitated discovering the weight

of a Bay Area "bag" of heroin. To do this we asked several clients

to tell us how much "Pream" equalled one bag, and this worked out

to about .33 grams of powder. We assumed this was representative

of the Bay Area; thus, with .33 grams, you only have to have three

percent purity to get your traditional 10 milligrams of pure heroin.)

The interesting thing is that in the Bay Area, we have seen a resurgence from 1972 levels of roughly two or three percent purity

of heroin to 1974 levels of five, six or seven percent pure heroin

in the typical bag at the lowest retail level. This suggests to

131
us that we are indeed seeing fewer levels of middlemen and fewer

steppings-on of the high-purity heroin which is imported into the

country. The other interesting thing about the recent samples is

that there is a much higher incidence of the use of procaine as an

adulterant. Of course, almost all samples have milk sugar, or lactose, or quinine as traditional diluents; but the procaine which

we have seen in ever-increasing frequency suggests that perhaps

there is use of procaine and other active drugs -- codeine, caffeine, amphetamines -- to deceive consumers who are much less sophisticated in the use of opiates than those of five or ten years

ago. In other words, we believe that with the current wave of addicts, you can give them poor quality heroin and they will inject

it and believe that they are getting high quality junk, because

these active adulterants mimic the action of heroin, particularly

the initial "rush" We are now examining some of the pharmacological aspects of the procaine rush as compared to the heroin rush.

It does seem that there are now many people who can ingest substances which actually contain no heroin at all -- but which do

contain a certain combination of procaine or codeine or other substances -- and remain convinced that they are using heroin. This

pseudo-junkie phenomenon, this minority of people who believe

themselves to be addicts but who in fact are not addicted to heroin,

is something which we had not seen until three or four years ago,

but which seems to be becoming ever more significant,

The wholesale samples -- the ounces and grams samples -- are fairly similar in median cost per pure gram and in the actual weight

of the samples. The difference is that one is called an "ounce"

and the other is called a "piece," and "pieces" tend to cost more

and to contain a lower quantity of heroin.

The other interesting thing about this new second wave epidemic in

the Bay Area is in regard to the expected correlates of heroin epidemic. Now, the overdose deaths that we would expect to result

from the new wave of heroin addiction have indeed paralleled that

pattern in 1974 -- i.e., deaths showed a sharp rise in 1974 over a

low point in 1973. The property-crime figures, however, which were

expected to parallel not so much the incidence of new addicts, but

the prevalence of addicts who have to support their habits illegally, have shown a decline from those for 1971. We saw in 1970 and

1971 a peak incidence of property crimes in San Francisco, especially robberies and burglaries, and a decline since then. The

year 1972 was a particularly low year, then there was a resurgence

in 1973, and a further decline in 1974. Right now, in San Francisco, property crime is running about 30 percent below the 1970-

71 peaks. It is almost as if both the incidence of new addicts

and the incidence of property crimes are caused by a third factor,

perhaps a kind of social anomie or some other kind of social phenomenon which is subject to periodic improvement and decline, such

that we had a peak of poor conditions in the early 1970’s which

gave rise both to a high crime rate and a high incidence of new

addiction; then there was a drop in both phenomena in 1972, followed by a resurgence in 1973, and now in 1974, the incidence of

property crimes and perhaps also the incidence of new addiction

132
seems to be dropping off again. Clearer answers are yet to come;

examining the quality of drugs on the street is certainly one

path to those answers.

The cause of the current epidemic of heroin in San Francisco is

still not clear to me. It does seem from our data that Mexican

and Southeast Asian heroin are playing an increasing role in the

heroin picture of San Francisco.

SUMMARY OF ANALYSES OF HEROIN SAMPLES – 1974 UPDATE

During the period from January to August, 1974, some forty-one

samples of substances alleged to be heroin were analyzed by PharmChem Laboratories in Palo Alto. A few of these samples were forwarded from the Haight-Ashbury Free Medical Clinic, which had obtained them from clients or friends, but other samples came from

places as far distant as Vietnam. Twenty-nine of the samples were

provided from the greater Bay Area, three samples came from other

places in California, six were from other states in the U.S., and

three came from abroad.

As with our earlier (1973) sample series, the "burn rate" was quite

low. Only two samples (5%) contained no opiate at all, while a

third had no heroin but did contain 13 percent methadone. The

remaining samples all contained at least some heroin, but in varying level of dilution. The most frequent diluent was, of course,

lactose, but procaine was seen in fully two out of every three

samples, even among the "ounce-sized" samples. Evidently dealers

are adulterating their heroin with an active substance which mimics

some of the qualities of heroin and hence has the capacity to deceive some consumers -- and this adulteration is taking place at

a fairly "high" stage in the local distribution hierarchy. Other

adulterants included caffeine, glucose, quinine, mannitol, and

phenobarbitol.

The "price per pure gram of heroin" is an important statistic,

which was available for thirty-two of the samples. These samples

came from both the wholesale and retail markets, as follows:

OUNCES: Eight samples

Range of stated prices: $750-$2800

Range of tested purity: 0%-74%

Range of cost per pure gram of heroin: $132-$930

(excludes one "burn")

Median: $353

GRAMS: Fifteen samples (including three "spoons" of approximately 1.33 grams)

Range of stated prices: $45-$200

Range of tested purity: 5.4%-84%

Range of cost per pure gram of heroin: $98-$910

Median: $335

133
BAGS: Nine samples

Range of stated prices: $5-$50

Range of tested purity: 2.6%-67%

Range of cost per pure gram of heroin: $135-$1560

(excludes one methadone "burn")

Median: $835

As compared to the 1973 samples, the wholesale (ounce, gram) buyer

seems to be getting much less for his money, while the retail (bag)

buyer seems to be getting rather more. The quality of some of the

1974 bags was extraordinarily high, compared to the 1973 bags;

this may account for the high number of opiate overdose deaths

noted in 1974.

AUTHOR

John Newmeyer is Epidemiologist, Haight-Ashbury Free Medical

Clinics, San Francisco, California.

134
Indicators of Drug Abuse—DAWN

Philip H. Person, Ph.D.

I am to speak about DAWN which has already come up in discussion

today. DAWN is the acronym for the Drug Abuse Warning Network.

It is a cooperative project between the Drug Enforcement Administration and the National Institute on Drug Abuse. The participants

in the DAWN System consist of emergency rooms of general hospitals,

medical examiners in-patient hospital units, and crisis centers

located in 23 cities. In three cities very large samples are

drawn and in the remainder, an attempt is made to include all of

the emergency rooms; the medical examiners are included in their

entirety from all 23. There are six additional cities which are

included on a partially sampled basis.

Someone this morning asked if it is true that anyone can get into

te DAWN System by virtue of having been admitted to an emergency

room with a drug emergency. The answer to that question is "Yes."

You do not have to be a heroin addict or an addicted or dependent

person before you can get reported into the system. The definition, as a matter of fact, of who to report goes as follows. Drug

abuse admissions to emergency rooms include "the non-medical use

of a substance for any of the following reasons: psychic effects,

dependence, and self-destruction. Non-medical in this context

means: a) the use of prescription drugs inconsistent with accepted medical practice; b) the use of over-the-counter drugs contrary

to their instructions on the label; and c) the use of any other

substances, for example, heroin, marihuana, peyote, glue, aerosols,

etc." I am quoting here from the instructions that are given in

the booklet to the reporting facilities.

135
The idea in obtaining reports of these various episodes is to

identify drugs that bring people to the attention of emergency

facilities, to identify the patterns of drug use and trends in

these patterns with the idea of doing something about it if the

problems become big enough, and to schedule drugs into one of the

various DEA schedules.

The medical examiners report a different kind of episode from the

emergency rooms. Drug-related death is defined to be "any death

involving a drug overdose, where a toxic level is found or suspected. A drug-contributory death is one where a drug was only

contributory and not said to be the cause of the death."

There are 836 emergency rooms, 613 of which are located in the 29

cities and 223 of which are located outside of these 29 cities.

These other cities were sampled in such a way that when combined

with the data from the 29 cities a national projection can be constructed which is valid for the entire United States. A similar

kind of arrangement has been made for the medical examiner data

such that they too can be projected to the entire United States.

‘There is a total of 336 medical examiners reporting. The number

of in-patient units is much smaller with 61; crisis centers data

are reported from 71 places. To give you an idea about the volume

of the system, in the nine months between July 1973 and March 1974,

there were 70,000 episodes reported into the emergency room part

of the system. Since each episode can report as much as six drugs,

obviously, there are more drug mentions than there were episodes.

In fact, there were a little more than 100,000 drug mentions. For

the medical examiners, there were about 1,800 episodes reported

within this nine-month period with 2,700 mentions. In the output

from the system, the drugs are reported as to whether they were

mentioned alone or in combination with something else. Somebody

commented this morning about the difficulty in not being able to

deal with episodes and drug patterns. Hopefully, we may be able

to change some of the output and get into this type of analysis.

There was another remark this morning about comparing DAWN and one

of the other reporting systems. Since DAWN is an indicator or is

used as an indicator, and since other data reporting systems are

also used as indicators, I think it behooves all of us to be careful as we compare the results of one indicator with the results of

another. They are not necessarily comparable, and so to say that

DAW reports "x" number as mentions of a particular drug in a particular place and compare that with CODAP, which I think was the

data system being used, one has to remember that the populations

being described are quite different. CODAP is a description of patients coming into treatment and DAWN is a description of people

experiencing emergencies with drugs, whether they are in treatment

or not.

136
There is a report that has just been finished, called DAWN 2

Analysis, which is available on request.* I have another minute

according to my watch; maybe Joe Murphy would like to comment. Joe

is the DEA project officer and I am the project officer for NIDA

--so we are basically a dual team here.

Mr. Murphy: One other way that we use the particular system, of

course, is we are attempting to use it as a measure of some activity within the DEA. There is a great concern now of measuring the

effect of scheduling a particular drug, looking for indicators to

give some indication of the effectiveness of the schedule. DAWN

is one of the indicators. We at DEA use DAWN considerably, but we

don't use it independently by itself. We are very conscious of

its limitations and we are equally conscious of utilizing DAWN with

other bits of intelligence information before any definitive action

is made regarding a particular dangerous new substance.

*Drug Abuse Warning Network (DAWN) Phase II Report, July 1973-

March 1974. BNDD Contract No. 72-47. Drug Information Section.

Special Programs Division. Drug Enforcement Administration, U.S.

Department of Justice, Washington, D.C. 20537

AUTHOR

Philip H. Person is Chief, Forecasting Branch, National Institute

on Drug Abuse, Rockville, Maryland.

137
Indicators of Drug Abuse—

Urinalysis Screening*

Alan Berkowitz, M.D.

Urine testing for drugs of abuse is another one of those indicators that mystifies and makes problematic the findings of epidemiological research more than it illuminates the area. The results

of urine testing in our commercial laboratories are so inaccurate

as to all but preclude any attempt to determine if the tests are

really useful to clients, therapists, administrators, funding

agencies or researchers.

An example of these findings is the experience of the Army with

almost one million urine tests done in their screening and identification program in 1971. Figure I represents a blind proficiency

test of these contract laboratories. Accuracy rates range from

50 percent to 65 percent. This level of accuracy seems to be typical of the state of the art today when blind proficiency testing is

done; that is, when the laboratory is unaware that it is being monitored and treats the urine sample as it routinely processes any

sample it receives.

*SOURCE: System Sciences, Inc., Cost Effectiveness of Urine Testing; prepared for the National Institute on Drug Abuse, Department of Health, Education and Welfare, November 1974.

138
FIGURE 1

URINALYSIS ACCURACY RATES OF COMMERCIAL

LABORATORIES PERFORMING UNDER ARMY CONTRACTS

MONITORING PERIOD: NOV. 22, 1971-JAN. 3, 1972

Another example is the blind proficiency reported for Ultrachem

Corporation which does more than 100,000 urine samples per year for

the State of California Department of Corrections.* A 60 percent

error rate was reported.

The results were no better in New York, which has had a proficiency

testing program since 1970. Figure II** summarizes the results of

three proficiency tests involving between 42 and 53 laboratories.

Excluding reference laboratories, 68.5 percent of these laboratories did not receive passing grades.

*Los Angeles Times, June 25, 1974.

**Sohn, David. "Analysis for Drugs of Abuse. The Validity of

Reported Results in Relation to Performance Testing." Int. J.

Addict., 8(1),(1973):65-74.

139
FIGURE 2

Distribution of Overall Grades in

Drug Screening Performance Tests

Test

Percent of labs with:

1 2

Total

3 (all 3 tests)

Passing grades

(all laboratories)

Passing grades

(reference laboratories excluded)

31.0% 43.2% 41.6% 39.0%

23.9% 37.3% 32.3% 31.5%

Conditional grades 14.3% 9.9% 22.6% 15.8%

Failing grades 54.7% 46.9% 35.8% 45.2;

Participants 42 51 53

Reference Laboratories 3 3 5

Range of Scores -45 to -188 to -140 to

100 100 100

Outright failing scores (less than 75 percent) were achieved by

45.2 percent of all laboratories across the 3 tests. A total of

7 samples containing no drug at all were submitted to these laboratories; 49 or 14.2 percent of the 345 tests done on these samples

resulted in the report of the presence of a drug of abuse -- in

other words, false positives. The implications of this level of

performance for epidemiology should be obvious? but what makes

things worse is that there is a huge differential error rate. For

example, of the 267 total false positives, 55 were methadone false

positive reports, 24 phcnothyazine, 42 barbiturates, 23 morphine,

and so on.

The final example of a "blind" proficiency test is taken from a

study of 24 laboratories made by the Center for Disease Control in

Atlanta. Figure III* compares 24 laboratories that were given

both open and blind proficiency tests. Only two of the 24 laboratories scored 80 percent or better on the blind proficiency test,

whereas all but one passed the open proficiency test, the usual

testing procedure at the Center for Disease Control.

*Supplied by Dr. Louis LaMotle, Director, Licensure and Proficiency

Testing Division, Center for Disease Control, Atlanta, Georgia.

140
FIGURE 3

OPEN VS. BLIND PROFICIENCY TESTING

Lab Number

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

Grade

Open PT

100

90

71

100

100

100

100

100

90

100

100

81

90

100

100

100

100

100

100

100

100

100

Grade

Blind PT

38

100

6

57

57

71

62

48

46

43

42

52

90

43

33

0

0

71

57

62

57

Discarded Samples

29

71

SOURCE: CDC

04/16/74

Dr. Sells: I am curious about one thing. I spoke with Allen

Green when he was in SAODAP about 5 years ago and he had figures

very similar to yours at that time. What I am curious about is,

why have these tests continued?

Dr. Berkowitz: That is a question I think we had best discuss

later. I agree with you. They should not have continued in the

form that they have.

The open proficiency test is the major test that CDC does and is

supposed to represent the laboratory's best effort. The blind

test, of course, represents their everyday performance. The

specific kinds of false negative errors that these 24 laboratories

made are instructive.

only 24 for methadone. Again, we see a differential error rate

There were 46 misses for amphetamines, but

for false positives and false negatives.

141
Coming to the first graded survey that the CDC conducted in February 1973, we find that of 209 participating laboratories, 41 percent failed.

In Figure IV, Sample CT3-05 is instructive. It contained no drugs

yet 60 laboratories (28.6%) reported false positives, mainly amphetamines (25 laboratories). Two samples contained only morphine

(CT3-01 and CT3-10), both at a level of 1 mg/ml; 12 laboratories

(6%) failed to identify the morphine in CT3-01 and 16 (8%) obtained false negative results on CT3-10. An additional 33 (15.9%)

laboratories reported false positive results for CT3-01 and 31

laboratories (14.7%) had false positive results on CT3-10.

Dr. Sells: How does this compare with other kinds of tests that

these laboratories do, for example, testing for sugar?

Dr. Berkowitz: When I was at the Center for Disease Control I

saw the proficiency test results for blood sugar and most other

laboratory tests. The results were comparable to those for urine

testing for drugs of abuse.

These data are based on spiked urine samples. They are not metabolic urines. Recently CDC has submitted an addict urine as an

open test containing only morphine at a concentration of 1.7 micrograms per ml, which is roughly three times the concentration they

should be able to identify. Using thin layer chromatography, only

50 percent of the laboratories were able to identify the morphine,

43 percent could not use the EMIT system, and 6 percent did not

identify the morphine. For the EMIT technique, by the way, there

was an overall 12 percent false positive rate. EMIT is supposed

to be one of the more accurate methods and is certainly one of the

most widely used in jail screening and in epidemiological work.

In this last survey, reported in July 1974, 295 laboratories participated; 61 percent passed. The addict urine sample is shown in

Figure V.

A total of 36 percent of the laboratories reporting did not find

morphine to be present, 5.8 percent obtained false positive results. In that same test, there was a very interesting problem --

a sample with only Darvon in it presented the problem of cross

reactivity. In the sample that had only Darvon and nothing else,

142 laboratories (48 percent of the total) had false positives;

61 laboratories identified the Darvon as cocaine, 53 as methadone,

14 as amphetamine, and so on.

The analysis of results by drug and methods shown in Figure V also

shows some interesting results as well as those discussed for the

addict urine. For amphetamines on gas chromatography, the 295

laboratories had a cumulative false positive rate of 8 percent.

For barbiturates, using EMIT, only 59 percent of 295 laboratories

had a correct response, 41 percent reported false negative results.

142
FIGURE 4

DRUG ABUSE PROFICIENCY TESTING 1973

DISTRIBUTION OF RESPONSES BY 209* LABORATORIES

143
FIGURE 4 (continued)

DRUG ABUSE PROFICIENCY TESTING 1973

DISTRIBUTION OF RESPONSES BY 209* LABORATORIES

*Some of the respondents do not offer services for all of these drugs.

144
FIGURE 5

ANALYSIS OF RESULTS BY DRUG, METHOD AND CONCENTRATION

MORPHINE
Dr. McGlothlin: Do you have any data on the radio immunoassay

technique?

Dr. Berkowitz: Yes I do. For morphine there was an 8 percent

overall false positive rate for 295 laboratories.

Dr. MeGlothlin: It is not supposed to give any false negatives

essentially.

Dr. Berkowitz: For .5 micrograms, they had an 8 percent false

negative rate, but for higher concentrations the false negative

rate approached zero. That addict urine, which was a metabolic

urine, was an exception with a 17 percent false negative rate.

Dr. Sells: How do the tests work under standard laboratory conditions compared to commercial laboratory conditions? What I am

thinking about is very often, something works well in the laboratory where it is developed and tested under controlled expert

conditions and then when it goes out in the hand of the practitioner , somehow or other, it deteriorates.

Dr. Berkowitz: There are some very fine laboratories, laboratories

that consistently score 100 percent on both blind and on open

proficiency tests. As a matter of fact, the Army’s own laboratories did extremely well. In the same blind proficiency test in

which Ultrachem Corporation had a 60 percent error rate? Brooks

Army Hospital had only a 5 percent combined false positive/false

negative error rate. It is not a function of the technique. There

are plenty of problems with the technique, but major problems still

lie elsewhere.

Dr. Kramer: What are these problems? What differentiates the

laboratories that get the high positive and false negative rates

from those that do not?

Dr. Berkowitz: I think you have to distinguish among methods.

Thin layer chromatography, despite what many people think about it,

is an extremely difficult procedure and correct interpretation of

chromatographic spots takes quite a bit of experience. One of

the problems with the Darvon false positives that I mentioned is

that nicotine and caffeine spots look like Darvon. They can also

look like other drugs. Without running proper standards and proper controls, thin layer chromatography degenerates into a guessing game. The major problem, however, seems to occur when, in

order to be able to submit low contract bids, laboratories sacrifice excellence for cost.

Dr. Francke: What were you using for passing? What did you mean

when you said a passing grade? Was that your own interpretation

or CDC’s?

Dr. Berkowitz: That was CDC’s score of 80, which is not a percentage but is based on a point system. Errors are penalized, but

they are penalized in a differential manner. False positives are

146
penalized more than false negatives. Errors on some drugs are

penalized more than errors on others. It is a complicated scoring system.

Dr. Francke: I have been looking at CDC laboratory reports over

a period of time and I have seen CDC reports come back zero to 100.

So I how there is great variations there, but this sounds serious.

Dr. Berkowitz: CDC reports are very difficult to interpret because of the contradictions in the scoring system. For example,

a laboratory that fails may make only three errors, while another

that passes may make nine errors. It is not a clearcut thing.

AUTHOR

Alan Berkowitz is Research Psychiatrist, System Sciences, Inc.,

Bethesda, Maryland.

147
DlSCUSSION

Dr. Gottschalk: I would like to endorse what Alan Berkowitz said

in connection with the proficiency of laboratory analysis. We

found that there are some medical examiners or coroners that have

amazingly high levels of proficiency and some that have surprisingly low, as you might expect. Our thought was that you could grade

the proficiency of different reporting bases and in that way temper the demographic and psychosocial findings from those areas.

That is, you work in a correction factor regarding how seriously

you take the conclusions.

Dr. Berkowitz: I do not know how you can do that. One thing comes

to mind from your field: in 1970, Baden* found negative urine

tests in one-third of the heroin overdose deaths and those were

tested shortly after the deaths.

Dr. Cottschalk: That is not the kind of question and statement I

made. I said if you take those nine cities, we can tell you which

ones have consistently high or accurate reports on unknowns and

those that had consistently low ones.

Dr. Berkowitz: But the type of error and the extent of error depends on what is in the sample.

Dr. Sottschalk: This is what I am saying is not true; we have

found something over and above that. We have a variety of things

in the unknowns. Varieties of substances are consistently correctly identified whether you have phenothiazincs, barbiturates, narcotics or a mixture, by those toxicology labs that are amazingly

good across all these drugs. It is true, there is a difference

within drugs. For instance, in phenothiazincs, there is no radio

inmmoassay method as yet developed, whereas, with narcotics, there

is a method. But that is what I meant when I said you are involved

with the state of the science and the art in assaying some of these

drugs accurately and quantitatively. However, over and above that,

some labs are just amazingly good considering the state of the

science and art. I do not know whether they have a large budget

or people who spend a lot more time at it or what.

*Medical Examiner’s Office, New York City.

148
Dr. Berkowitz: I do not think there is much wrong with the technology.

Dr. Gottschalk: It is the technology in the sense that some medical examiners have a routine. If they find something present on

the screen, they do or do not do other tests. They are living

within a budget. They may have proficient people, but they have

a routine where they figure they can just spend so much money on

following this down to exactly what it is. That is something beyond the people.

Mr. Romm: Dr. Berkowitz was referring to data where there were

verified positives by a second test.

Dr. Sells: I have recently seen a couple surveys about the accuracy of companies that score psychological tests by optical

scanning and some other methods. The results come out very similar to those that you have seen. I daresay that if we take statistics turned out by different service bureaus, we might also

find some glaring errors that would horrify editors that accept

papers for publication. I wonder if what we are talking about,

now that you have reassured us on the technology, is not simply

the standards of workmanship that are accepted in our society.

Dr. Berkowitz: I would agree with that, and add the lack of control or power in CDC or other agencies of the federal government

to regulate these things.

149
General Discussion

Dr. Gottschalk: I would like to propose that it is too narrow and

parochial just to focus on narcotic use if you take the title of

this conference seriously, "Epidemiology of Drug Abuse." I would

like to propose that there should be surveys and ongoing studies

not only of treatment areas that are labelled as treatment centers for drug abuse, but all general public and private medical

clinics and psychiatric clinics where I know there are many instances of drug abuse covered up or not made available. They

might well give somewhat different patterns, certainly of the nonnarcotics. It is our impression from preliminary surveys we have

done that 75 percent of the people coming into general medical

clinics for the first time are already taking some drugs, not narcotics, but analgesics, combinations of drugs, drugs which do not

have prescriptions, over-the-counter substances, or drugs which

have been given to then by members of the family or just taken.

By any conservative measures of drug abuse, they are abusing these

drugs. I have not heard anything here about that broad area of

everyday drug abuse. We are narrowing down, it seems to me, too

much, although there certainly are interesting problems to be discussed regarding the narcotic drugs or other illegal drugs.

I would like to broaden the scope of this discussion to include all

those and if we are not doing any surveys or any kind of "nose

counting" in those area, we certainly should.

150
Dr. Robins: I would like to raise one issue that I think is terribly important. Most of the treatment data that we have heard this

afternoon is not related to any kind of population data. Once you

are given the fact that they have to be in treatment, if you have

fewer male heroin addicts than earlier, then there have to be more

women. It does not necessarily mean there are more women abusing

drugs than there were before, or more polydrug users than before,

but just that you have exhausted the group of heroin users. You

are not working on a total population base but only on the base of

people in treatment, so the less there are of men, the more there

have to be of women. I think we get the peculiar idea that just

because there are more women, there are more women drug abusers.

It does not mean that, unless the number of the whole treatment

group has gone up at the same time.

Dr. Sells: It would be nice to know what the prevalence rate is

in the total population and then we could answer that question.

Dr. Robins: Exactly. When you do not have a population base, you

cannot interpret that as meaning there are more polydrug users, or

more women.

Dr. Sample: In the last year, June 1973 to June 1974, the trends

we are talking about have not been reflected in the federal treatment structure, where the males have increased from 71.8 to 72.6

percent. The same applies for the blacks.

Dr. Sells: That could not be explained by error, you do not

think?

Dr. Sample: It could be, but I do not think the error would be

sufficient enough to reverse that trend. I doubt if the error is

such that it would make it statistically significant in the other

direction.

Dr. Kramer: There is a whole area of services that I have not

heard mentioned here, namely, that if you look at a universe of

psychiatric services defined by the state mental health hospitals,

out-patient psychiatric services, and community health services,

you get into another whole area of people who are coming in for

treatment with (at least) a diagnosis of drug abuse, alcoholism,

etc. I do not know how these fit into what you are talking about,

but they account for some striking changes in the rates at which

patients have been coming into state hospitals with the diagnosis

of drug abuse. It seems to me that one ought to look at the other

parts of the whole medical care system that may get involved with

the persons who are given the label of drug abusers. When it

comes to local planning and local use of information at the catchment area level, one has to look at these particular kinds of services. This brings up another point that I would like to emphasize and that is the need to put together the data that we have

from these diverse kinds of treatment services into a unified pitture.

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Dr. Sells : Some of these clinics we are talking about are parts

of community mental health centers. Are your data based only on

hospitals?

Dr. Kramer: I have other data for hospitals, for community mental

health centers, and psychiatric services in general hospitals, and

other groups. I do not have trend data on that. The best trend

data we have are for the state mental hospitals. There has been a

tremendous change in the patterns of admissions into state mental

hospitals where about 33 percent of the current admissions of males

into state mental hospitals are for alcohol disorders and six percent are for drug abuse disorders; for females, it is now about

four percent for alcohol disorders, and 2.5 percent for drug abuse

disorders.

Dr. Sells: If you go back 15 years, most of the proliferation of

clinics that treat drug abusers in the community did not exist

and the only place that a person could go was to a state hospital.

Dr. Kramer: I know that. All I am trying to say is that, in looking at this overall problem, one has to in some way pull together

these data in a meaningful way so that one can get measures of who

is coming into a treatment service, by some definition of treatment

service.

152
III. PROBLEMS RELATED TO

APPLYING AND EXTRAPOLATING

DATA
Problems Related to Survey Sampling

William Glenn, Ph.D.

My concern is with the quality of the kinds of estimates of the

extent of drug abuse that you can get with a sample survey. I

want to say, first of all, that in order to use the sample survey

properly, you must have a probability sample. This is a sample in

which every member of the population has a known non-zero probability of being selected. Quota sampling, frequently used in

statewide drug-abuse surveys, is not probability sampling and

therefore cannot yield estimates which are "good" from a statistical point of view. Reference to this point has been made by Dr.

Cisin, and I am sure it is recognized by many others.

The quality of an attribute estimate (such as the percentage of

heroin users in a stated population) may be measured by a statistic called the coefficient of variation (CV). CV may be estimated

as

where p is the estimated proportion of the population having the

attribute and n is the sample size. CV is simply the standard error of the estimate expressed as a fraction of the estimate itself.

The criterion for a good estimate, according to my colleagues who

do a lot of sample survey work, is

CV 0.30. (2)

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This criterion is saying that for an estimate of reasonable statistical quality, the standard error should not exceed 30 percent

of the estimate. The particular choice of 30 percent is arbitrary,

of course, but it is a value commonly cited by statisticians specializing in sample surveys.

We may use the criterion cited above to estimate the sample size

needed as a function of the proportion p. Combining (1) and (2)

and solving for n, we have

n 2 1-p/.09p. (3)

Suppose, for example, that p is on the order of 0.01 (about 1 percent of the population has the attribute of interest). The relationship (3) tells us that for a "good" estimate of p, our sample

size should be at least 1100.

We have seen reports on statewide surveys which give the percentage of regular users of heroin as something less than one tenth of

1 percent. The report on a recent survey in North Carolina cites

an estimated 2,760 regular users of heroin in a population of

3,731,520. This yields p = 0.00074 (i.e., we are being told that

about 7 persons in every 10,000 in North Carolina are regular users

of heroin). This small proportion could be encouraging to those

who are concerned about heroin use in North Carolina, if they

choose to believe it. But should anyone believe it? How good is

the estimate? It was based on a sample of size 2,007, so, according to (1), it has CV = 82 percent, which far exceends the maximum

criterion value. It is, therefore, a very poor estimate. Add to

this the fact that it was obtained with a quota sample, and you

must conclude that you have nothing with which statistical credibility can be associated.

The estimate of 2,760 regular users of heroin in North Carolina

proves, upon close examination, to be totally incredible from any

point of view. (See Attachment.)

Suppose we had wished to estimate the percentage of regular users

of heroin in North Carolina by means of a sample survey. Suppose

further that the true percentage in the population is about one

tenth of 1 percent. Our criterion tells us that we would need a

sample size of at least 11,000. Such a survey based on a probability sample at today's prices could cost half a million dollars.

Any reasonable person must conclude that spending that amount of

money for that purpose makes no sense. There are, of course, those

who would argue that if we can't afford a sample of 11,000, let's

do the best we can with 2,000. This is fallacious reasoning because the low-quality estimate (based on 2,000 observations in

this case) can give totally misleading information. The analogy

that "we can't afford a Cadillac so we'll settle for a Chevrolet"

can be pushed too far. The estimate with CV = 30 percent is a

Chevrolet-class estimate. If I order something at a lower price,

I may receive a beaten-up Volkswagen painted to look like a

Chevrolet, and not know the difference until I look under the hood.

155
If I am the type who just rides off down the road before looking

under the hood, I will never know the difference. That is how the

analogy can be pushed too far; believe me, this is not an unfair

description of what is happening.

In conclusion, I would like to emphasize the following points:

(1) Sample surveys aimed at estimating rare attributes can be

very expensive if conducted properly. They can be so expensive that their cost/benefit ratio is too high for serious consideration.

(2) Sample surveys not conducted properly can be even more expensive to society through the imputed cost of wrong (and therefore

misleading) information and the misuse of available resources.

(3) The presentation of any estimate based on a sample survey

should give the reader/user a frank statement about the validity/

reliability of the estimate.

(4) We may not know a priori the ballpark in which an estimate

may fall. If we elect to do the best we can with the resources

available, our report should include a fair statement of what the

data tell us. If that turns out to be less than our client wants,

we must live with the facts. To do otherwise with drug-abuse data

is to do a potential disservice to society.

ABSTRACT:

Regular Users of Heroin Within the General Population of North

Carolina

A report prepared for the North Carolina Drug Authority in February 1974 cites an estimate of 2,760 regular users of heroin within

the general population of North Carolina (Table 100, p. 211). The

report also provides the following information on the 2,760 regular users (Tables 101-105, pp. 212-216):

All 2,760 are in the age group 18-24,

1,320 are male

1,440 are female

1,320 are black

1,440 arc white

All are in "Middle" socioeconomic status

1,320 are in "Lower Middle" social position

1,440 are in "Upper/Upper Middle" social position

1,320 arc employed in the category "Skilled/Semi.-Skilled"

1,440 are employed in the category "White Collar/Other

Clerical"

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1,320 use heroin "at home"

1,440 use heroin "at a social gathering"

1,320 also use non-controlled narcotics/prescription nonnarcotic analgesics

1,440 also use barbiturates, non-barbiturate sedativehypnotics, controlled narcotics (non-heroin), LSD,

and cocaine.

All 2,760 also use marihuana/hashish, psychotogens other

than LSD, and methedrine/methamphetamine.

1,320 are moderate drinkers of alcohol.

1,440 are heavy drinkers of alcohol

All 2,760 are "moderate or light" smokers of tobacco

All 2,760 are regular users of prescription drugs.

The report also breaks this information down by geographic regions

within the state, as follows:

Region 1: Western (32 counties)

Regular users of heroin: none (Table 198, p. 353)

Region 2: North Central (16 counties, including Durham and

0range)

Regular users of heroin: 1,440 (Table 268, p. 424)

411 1,440 are white, female, and in the age group

18-24 (Table 269, p. 425)

All 1,440 use heroin "at a social gathering" (Table 270,

p. 426)

Region 3: South Central (20 counties, including Wake)

Regular users of heroin: 1,320 (Table 339, p. 495)

All 1,320 are black, male, and in the age group

18-24 (Table 339, p. 496)

All 1,320 use heroin "at home" (Table 340, p. 497)

Region 4: Eastern (32 counties)

Regular users of heroin: none (Table 406, p. 564)

Thus the estimated 2,760 regular users of heroin within the general

population of North Carolina consist of the 1,440 white females

in the north central region who use heroin at social gatherings

and the 1,320 black males in the south central region who use

heroin at home.

In a report dated March 1974, were present "implications and recommendations" pertaining to the findings in the February 1974 report.

157
Those implications which pertain to the regular users of heroin in

the general population are the following:

100.0% are in the age group 18-24 (Table 19, p. 95)

47.8% are males; 52.2% are females (Table 29, p. 105)

100.0% of those in Region 2 are females (Table 33, p. 109)

100.0% of those in Region 3 are males (Table 35, p. 111)

47.8% are black; 52.2% are white (Table 39, p. 115)

100.0% of those in Region 2 are white (Table 43, p. 119)

100.0% of those in Region 3 are black (Table 45, p. 121)

100.0% are employed persons (Table 49, p. 125)

47.8% are employed males; 52.2% are employed females (Table 51,

p. 127)

100.0% are non-students (Table 53, p. 129)

These implications follow, of course, from the data cited in the

February 1974 report. If we are to accept them as credible, we

must agree, among other things, that:

1. Regular users of heroin in the general population of North

Carolina are found only in the two central regions of the

state (in 36 of the 100 counties).

2. In one of those regions all of the regular users are white

and female; in the other, all of them are black and male.

3. There are no white males or black females who are regular

users of heroin in the general population of North Carolina.

4. No students in the general population of North Carolina are

regular users of heroin.

5. No persons over age 24 in the general population of North

Carolina are regular users of heroin.

It is unlikely that anyone familiar with the current "drug scene"

will accept all of these statements as credible.

It is clear from a few quick calculations that all of the "conclusions" cited above are based on two observations. One was the

white female in Region 2, the other the black male in Region 3,

both of whom admitted to being regular users of heroin. These

were "projected" into 1,440 and 1,320 respectively, and the rest

was simple arithmetic. However, arithmetic cannot erase the very

tenuous nature of the conclusions. The only valid conclusion is

that in the general population of North Carolina, two people were

willing to admit to the regular use of heroin. One was a white

female in Region 2; the other was a black male in Region 3. What

does this tell us about regular users of heroin in the state? Very

little, except that out of 2,007 people interviewed, two were willing to admit being regular users. Apparently one person in 1,000

interviewed is willing to admit to regular use of heroin. The number who actually are regular users and their sociodemographic

characteristics remain as unknown as they were before the survey.

158
AUTHOR

William Glenn is Senior Statistician, Research Triangle Institute,

Research Triangle Park, North Carolina.

159
DISCUSSION

Dr. Robins: One difficult problem is that you do not know the "P"

more or less until after you have done the study.

Dr. Glenn: Correct, we do not know the "P" until after we have

done the study. Then let us tell the people what the C.V. is; we

know that after we have done the study. If the estimate is poor,

let us say so; admit it. I am not suggesting that you must know

the "P" before. If you did, there would be no point in doing the

survey. I am saying that when the "P" comes out to be 130 percent

instead of 30 percent, that we should tell our readers that.

Dr. Sells: I think there is a methodological point to be considered. There is a great deal of pressure to edit the kind of information that the surveys are addressing. There is a real conflict that one encounters between attempting to do something that

might be productive without violating the rules of inference too

greatly. I wonder whether a possibility here is that of attempting to survey the high risk segment of the population where the

"P" would be higher but the cost of the survey in relation to a

usual estimate would be more reasonable. In other words, use that

as an outside or upper limit figure for the purpose of estimation.

Dr. Glenn: I believe that Lee Robins mentioned something very

much like this yesterday -- working with homogeneous sub-populations. Yes, that would certainly be a suitable solution.

Dr. Sells: The reason I wanted to mention it is I think that sometimes in this kind of discussion, sentiment swings one way or another. Of course, this is a very sophisticated group, but I do

not want this to turn into a general condemnation of the survey

method.

Dr. Glenn: I hope you do not think I am condemning the survey

method. I am merely saying let us try it properly.

Dr. Cisin: I do not think anyone is condemning the survey method.

I do not think we can do without the survey method and no one

dares condemn it without something better to suggest for the kinds

of purposes that we are dealing with. I have not heard a better

suggestion. As surveyors, we are groping with some extremely difficult problems that we have to solve and, as usual in science, we

160
are trying hard, but the message that is coming through does not

deal with survey method as method. What I hear Bill Glenn saying

is: these darn point estimates, that lead us to the 9 million

alcoholics or the 2700 heroin users, or whatever they are. These

point estimates should be recognized as the terribly fallible

pieces of data that they are. We all grew up on interval estimates and this coefficient of variation that Dr. Glenn suggests is

a short cut to reminding us that we are dealing with an interval

estimate.

Our interval estimates can be pretty good but our point estimates

are rotten. We are embarrassed, in some cases, by the fact that

the interval estimate is very broad. All we really know in some

cases is that the proportion we are estimating -- the attribute we

are estimating -- is either characterized with some reasonable

confidence, somewhere between zero or delta, and 5 percent. For

certain political purposes that may not be enough, but for scientific purposes, that is about all we have.

161
DEA Register

Joseph A. Greenwood, Ph.D.

I will describe the DEA Register very briefly. The register contains narcotics abusers, cocaine and marihuana abusers. Police

everyhere are supposed to send in DEA form #34 which has on it

about a dozen elements of data, e.g., sex, date of birth, residence, how long addicted, the drug used, source of supply, and so

on. Sometimes they do not do that. They may send in their own

rap sheet which has at least that much information on it. At any

rate, it eventually gets into our files.

I am supposed to say something about the problem of the register.

The problems pertain only to what we are going to do with it, of

course. This is a voluntary reporting system, and consequently,

it has elements of being sporadic. There are efforts to improve

this. ‘The best of these would appear to be to take advantage of

the FBI arrestee reporting system wherein identification is unequivocal through the fingerprint system. That would eliminate

the present problems of sporadic reporting to DEA, and identifying

numbers of unique persons being reported, and how many times each

was reported. Another possibility would be to have someone make

copies of the rap sheets in most of the largest cities and send to

DEA to process.

The arresting policeman decides whether or not to label an arrestee as an addict. We think that he does a pretty good job at

making the correct decision. The police are concerned about the

drug problem and do see many abusers in the course of duty and

162
have several symptoms they look for besides questioning the

arrestee. Of course no one can get around the ambiguity of definition of an addict, but basically they are turning in to DEA what

we now call abusers. These include addicts, of course.

Now to discuss some of the uses of the DEA register data, actual

and potential. When an investigator has access to certain kinds

of data, he usually must devise or find procedures and analyses

specific to these data if he hopes to get his questions answered.

The DEA data sampled the entire U.S., which gave it a drug coverage

of narcotic abusers greater than any other extant system. However, being of a voluntary nature, it was subject to sporadicity

of reporting, the effect of which we cannot be sure of. In spite

of this defect of the data, my adaptation* of a method in order to

estimate prevalence of U.S. narcotics abuse seems to be rather robust for large coverages, and I believe has an averaging effect

which accounts for its robustness.

It appears quite possible to do other things with the DEA register.

For one thing I envisage the following reasonable attempts to estimate the fraction of the DEA-obtained narcotics abusers who are

addicts in the sense that a treatment facility (TF) patient may be

termed an addict. Obtain random samples of TF patients and of DEA

arrestees. For each sample make a histogram or graph of frequency

versus average daily dose. Superpose the graphs so the abscissae

coincide and shrink (uniform reduction factor for all ordinates)

the TF curve until it is essentially all just under the DEA sample

curve . Then the ratio of area under TF curve to area under DEA

curve is an estimate of the desired fraction.

Another possibility is obtaining U.S. relative incidence of narcotics abuse using a procedure** developed for and successfully applied

to treatment facility data. The appropriate data are already being collected in the DEA system.

As a final use I have in mind for the DEA register, I need it as a

testing ground for another method of estimating prevalence. This

is based on the Poisson distribution which, in an initial try, gave

a prevalence agreeing with 5 percent of the corresponding value obtained by the present capture-recapture method. If it should work

out reasonably well in another try on the DEA data, I would feel

inclined to apply the method to estimate prevalence of dangerous

drug abusers in a large city. The basic data would be abusers entering emergency rooms.

*Joseph Albert Greenwood. "Estimating Number of Narcotic Addiets." SCID-TR-3, Oct. 1971, Bureau of Narcotics and Dangerous

Drugs, Justice Department, Washington, D.C.

**Joseph Albert Greenwood. "Estimating Relative Incidence of Narcotic Addiction Using Treatment Facility Admissions." RTP-TR-11,

June 1974, Bureau of Narcotics and Dangerous Drugs, Justice Department, Washington, D. C.

163
AUTHOR

Joseph A. Greenwood is Chief Mathematician and Statistical Advisor,

Drug Enforcement Administration, Washington, D.C.

164
DISCUSSION

Dr. Rootman: I would like to say a few words about the Bureau of

Dangerous Drugs, Narcotics Registry in Ottawa, Canada because compared with what Dr. Greenwood has said, the Registry in Ottawa is

somewhat different . I think it is a reasonably good source of information in that it draws not only from police reports, but also

from pharmacy reports and from treatment centers. We have been doing a number of studies based on this narcotics registry, and I

would like just to mention a few of the studies that we are involved in. One of the studies is a look at some of the trends in

incidence and prevalence over the past 10 or 15 years; we have

almost completed that and hope to send it in for publication shortly. We are also doing a study based on 1973 cases that have come

to the attention of the Register. In other words, we are going to

look in great detail at the incidence for 1973. We plan to do this

on an on-going basis every year. This will allow us to get tabulations by particular locations in the country, which has never been

done before. Another study that we are thinking of doing involves

taking a close look at cases dropped from the Registry. In contrast to the DEA Register, cases are maintained for 10 years, rather than 5 years, so that it gives us a little different perspective.

WC are also planning to look at the spread of reported heroin use

in Canada using the Registry as a basis. As I mentioned earlier,

we found that in the interior of British Columbia, there was a

relatively high incidence of narcotics cases reported in 1973. We

are going to follow-up these cases with other sources of information to find out whether or not they originated from the area or

came in from other areas. We are also planning to do a number of

validity studies of the Register comparing the Register with other

sources of data, such as death data. That describes some of the

things we are hoping to do with the Bureau of Dangerous Drugs

Registry. The point that I would like to make is that, at least

in Canada and I assume in the States as well, it is a very good

source of information on reported incidence and prevalence. It

certainly has a lot of problems with it, but it is satisfactory for

some purposes.

165
Research Uses of the NYC Register Data

Irving Lukoff, Ph.D.

I have been asked to talk to you about the research potential of

the Narcotics Register in New York City. I may not be the happiest

choice, at least from the perspective of the staff of the Narcotics

Register, since my two efforts to obtain cooperation from the staff

of the organization ultimately drew blanks each time. One of these

efforts, which is discussed in one of the reports prepared by the

Register, was an expensive and time-consuming experience. I will

briefly discuss them because they bear upon important public issues. I will also attempt briefly to reconstruct the way in which

they assemble their data and report on some of the uses to which

information on the files of the Register have been used.

The concept of a Register for a particular disease or disability

or social category is not a recent invention. A Narcotics Register

has to cope with problems that arise in most such registers where

there are almost insuperable difficulties in assuring an accurate

flow of information from a multitude of sources and where the very

status of the individuals may be dynamic, undergoing significant

alterations through time. The oldest and most successful activity

concerns the accumulation of information on death, although the

identification of the "causes" of death is still troublesome. At

least the requirement that individuals be buried has ensured reasonable compliance with the demand for death certificates so that

a cumulation of reasonably accurate data is ensured. Births, it

should be noted, until a few decades ago were only collected in a

limited area even in an advanced country like the United States

because of the unreliability of reporting sources. The compila166
tion of morbidity statistics raises all the issues that arise in a

Narcotics Register and there is an accumulation of experience in

working with such data sets that could be helpful in improving

the uses to which such information can be applied, although this

has not been done.

In an earlier research reincarnation I had to work with a register

for the blind where all the issues of identification of who might

be legally blind, the problem of cooperation of multitudes of referral sources, the alterations in the status of blind people, and

the culling out of deceased or recovered blind persons raised the

same issues as arise in the documents preparcd by the Narcotics

Register. And though our heightened sensitivity to confidential

ity, as well as the perhaps more profound stigma, at least the

legal aspects, associated with addiction certainly add additional

complications to a Narcotics Register, these are only ones of degree and not qualitatively dissimilar.

But this accumulated experience seems to never havc been brought

to bear on the Narcotics Registcr. As one reads their own materials one has the feeling that the wheel is being rediscovered once

again. Yet it would be conceivable that various administrative

devices, as well as special investigations, could provide reason

ably accurate estimates of many of the errors, some unavoidable,

in order to facilitate adjustment of the data, At the least it

would be possible to modulate one’s interpretations of the findings with some clear information on the direction that errors might

take.

The basic sources of information for the Narcotics Register arc the

police and treatment programs. The latter have increased in prominence as the treatment system rapidly expanded after 1969. In

the beginning, police reports predominated, coming to a peak in

1972. In the latter half of that year and subsequently, treatment

programs have become the major source of information. This, of

course, reflects the emergence of a large number of programs although the decline in police reports is subject to many interpretations. There have been policy changes throuqhout this period

that shifted police emphasis from street-level addicts to persons

involved in the sale and distribution of narcotics so that the

decline in the absolute number of arrested addicts is at least

partly the result of policy changes by the police department.

It is noted in a recent report by NR (September 1973) that the police are more likely to report cases previously unknown to the

register. We also know that the treatment population is likely

to be from 7 to 10 years older than recently recruited addicts.

All of this raises serious questions on the credibility of the reports that "incidence" is declining since the interpretation of

successive cohorts of new cases are, in a very real sense, noncomparable. Police activity, as is well known, is a variable and

cannot he presumed to be constant over time. This is particularly

the case in a volatile area like the arrests of addicts.

167
These estirmates are further confounded since the Board of Education does not act as 3 referral source and juvenile arrest data

is severely limited in New York City. Consequently, the limited

sources of referral for a crucial age-range for estimating incidence and the decline of police activity create almost insurmountablr problems. Although there could conceivably be efforts at

estimation of these various sources of error, they have not been

carried out.

There arc clear legal rulings that support the requirement that

programs and physicians report to the Register. Despite this

clear legal back-up many private physicians, as well as treatment

programs, do not systematically report to the Register. Nor does

any concertcd effort seem to be operative to encourage compliance.

Further , although only minimal information is requested, the forms

often arrive without significant identifying data, some of this

reported in earlier reports put out by the Register. Identification of addicts is troublesome under most circumstances and where

reliance is often on judgments of police and court staffs, this

adds even further ambiguity to the compilation of the data. A n

index of the magnitude of some of these issues may be gauged by

a follow-up study I carried out on patients who dropped out of one

program. The Register as a matter of police will not assist programs in tracking down patients or in learning whether they may he

simultaneously enrolled in other programs. This is a troublesome

problem for methadone programs that want to avoid multiple registrations. However, at the Rockefeller Institute they do keep records on all programs related to the Beth Israel group of programs

and on any other programs willing to cooperate. This file is also

one of the major sources of information for the Narcotics Register.

Yet, fully half of the individuals I was seeking could not he located on that file. This proportion may only reflect the administrativc vagaries of one particular treatment program; however,

it also provides some indication of the way in which even addicts

in publicly funded treatment programs may also escape the referral net of the NR.

Although at one time the Register culled out individuals who were

not reported to the Register for five years, this policy has been

rescinded so that even the prevalence figures raise further questions. Not only are non-narcotic users commingled with those

who use opiates, hut many persons not addicted at all are presently retained on the files for estimating prevalence.

Other registers, notably DEA, cull people out on whom reports do

not appear for five years. In Toronto a ten-year span is used.

This at least contributes to the (1) elimination of many possibly

erroneous reports; and (2) allows for individuals who make the

transition to a more conventional life-style to be removed. Obviously, some addicts will also he eliminated but this at least

serves as a counterbalance to the inevitable "false positives" to

some unknown extent. The prevalence estimates prepared by NR do

not make any effort to account for mortality, long-term jail sentences, migration or successful treatment. Instead, in a recent

168
document the assertion is mde that "It is also imperative that individuals never be dropped from an addict registry," although no

rationale is even suggested.

Where precise estimates are made NR does adjust for the likely rate

of recovery (and mortality), but on a foundation that is clearly

inadequate. It is a method that is extraordinarily sensitive to

the problems we previously described so that it exaggerates the

typcs of errors that influence the referral patterns over time.

These include the growth of the treatment system, on the one hand,

and the shifts in the operations of the police department.

Many of these problems are a result of the particular structure of

programs and legal restrictions concerning juveniles in New York

city and arc probably not altogether surmountable. Although improvements could he made in working with various referral sources

and in ensuring more complete information, this also has its limits. The only solution would be one that is directed toward providing more realistic estimates of various sources of error so

that meaningful adjustments could be made. Early efforts were

made to identify some of these sources of error; however, this

activity is no longer carried out.

Confidentiality is an essential feature for a narcotics register

if cooperation is to be achieved from physicians and treatment

programs. Dr. Newman has been fervid and couragcous, even having

gone to court for his refusal to cooperate with the district attorney to provide information on an addict. In a recent monograph

he states categorically, "Demands for identifying information must

be refused with firm consistency whether made by the FBI, the police department or homocidc squad, the United States Secret Service, Federal Narcotics Agency, researchers, employees, friends,

relatives, or even the reported individual himself...". Two issues deserve comment. First, what appears to be a civil-libertarian stand has in fact engendered conflict with one or the main

thrusts of civil liberties groups; namely, an individual’s right to

access to information that might be harmful to him. There arc

serious questions concerning the quality or the reporting sources

that may result in stored information that is not only harmful to

the individual but may be erroneous. Civil liberties is a twoedged sword and here ‘it appears to have been invoked somewhat haphazrdly.

Researchers also have an obligation to protect their sources of

information and there is abundant activity presently to elaborate

the procedures to ensure protection of human subjects. Serious

questions arise, however, when a tax-funded organization not only

compiles data with only vcry limited utility, but also refuses,

a matter of policy, to provide access for legitimate research and

as

program use. There are many devices to ensure anonymity that

would protect the individuals on the register from harmful consequences. It is legitimate to attempt to prevent multiple registration of methadone patients. The refusal to provide this service -- one that might have as a trade-off improved cooperation --

169
forces the programs to establish a costly independent register.

Thus, individuals in programs have multiple files and the assumption that an individual’s records are unassailable is simply not

the case for most methadone patients.

There have been cooperative research efforts, the major activity

associated with the early research conducted by Dr. Francis

Gearing at MMTP. Other studies were carried on by staff members

and outside researchers, but this activity seems to have been curtailed. A recent report refers to a study initiated with the predecessors of the present administration but which was aborted unilaterally after a large investment of money and time. There is what

is stated about this research activity in its entirety:

"Other requests (for cooperation) are superficially more

reasonable and seemingly offer no threat whatever to those

whose records are sought. Researchers, for instance, have

asked for the identity of a random sample of persons known

to the Register who could serve as a matched control group

against which to measure the outcome of a particular treatment approach."

There was indeed no possibility to identify any individuals in the

design of this study. It would have provided) however, one of the

rare opportunities to gain insight on (1) selective factors within a community on who seek treatment; and (2) provide a matched

untreated group of addicts in order to contrast with patients ill

treatment. Neither of these activities has ever been carried out

in the assessment of drug programs and the arbitrary discontinuance

of this activity, which was nearing completion, prevented a rare

research option in evaluation from being completed.

The emphasis on protecting confidentiality prevents activities that

could improve the quality of the data, provide important services

to treatment programs, or assist legitimate research activities.

While rigorous strictures are indeed necessary, it appears that

these terminate in a no-win policy: poor data difficult to assess,

and little or no contribution to the ongoing treatment and research scene.

It should also be noted that at present there are no experienced

epidemiologists or bio-statisticians, or rersons with related experience on the staff. It would appear that the Register, if‘ it is

to serve its purposes, must. he separated administratively from its

present location within a city bureaucracy which perforce has its

own commitmcnts, and these arc often at loggerheads with the total

treatment and research scene.

AUTHOR

Irving Lukoff is Co-Director, Center for Socio-cultural Research

on Drug Use, Columbia University, New York, N.Y.

170
REFERENCES

Amsel, Z., Fishman, J., Revkind, L., Kavaler, F., Hrug, D., Cline,

M. , Brophy, F. and Conwell, D. The Use of the Narcotics Register

for Follow-up of a Cohort of Adolescent Addicts. The International

JournaI of the Addictions, 1971, 6(2),225-239.

Fishman, J., Conwell, D., Amsel, Z. New York City Narcotics Register: A Brief History. The International Journal of the Addictions,

1971, 6(3), 561-569.

Newman, R., Cates, M., Tytun, A., and Werbell, B. Narcotic Addiction in New York City: Trends from 1968 to mid-1973. American

Journal of Drug and Alcohol Abuse, 1974, 1(1), 53-66.

Newman, R. and Cates, M. The New York City Narcotics Register: A

Case Study. New York: The City of New York, Department of Health,

1974 (mimeo).

Newman, R. and Cates, M. The Dilemma of Addict Registries, New

York City Department of Health, undated (mimeo).

Richman, A., Fishman, J., Bergner, L. and Patrick, S. A Narcotics

Case Register -- Some Perspective on Multiple Reports. Social

Psychiatry, 1971, 6(4), 179-184.

The City of New York, Department of Health. Narcotics Register

Statistical Report: 1964-1970. May, 1972 (mimeo).

The City of New York, Department of Health. New York City Narcotics Register -- Analysis of Narcotic Addiction Trends Through

June 1973. September, 1973 (mimeo).

The City of New York, Department of Health, New York City Narcotics Register: 1973 Report. 1974 (mimeo).

The City of New York, Law Department. Opinion #107408. March,

1971.

171
DISCUSSION

Q: Who is it funded by?

Dr. Lukoff: Originally by NIMH, now by DAAC.

Dr. Rochman: The case Register has been involved in collaborative

studies with researchers in the past, one of whom is myself. We

had a very satisfactory relationship in which the researcher input was provided to the data and worked out to three studies. Currently we have an understanding with Dr. Newman that he will collaborate in providing tabulations on the basis of not violating

confidentiality. This is somewhat of a different perspective than

what Irving has talked about. I want the numbers and not the

names.

Dr. Lukoff: The protocol we worked out with the predecessor of

Dr. Newman is one in which we would have access to no names. We

trained their people to get the data from the Register and to get

the police records and to perform cecrtain tabulations for us. We

would never see the police records and never see the names. Their

staff was trained to code the material. We would get aggregate

outputs from them. There was no possibility of violation of confidentiality in my case.

172
Ecological Studies of Narcotic Addiction

Alex Richman, M.D., MPH

This research is concerned with the ecology of narcotic addiction

within selected areas of New York City. The objective of this research is to increase knowledge of the social factors associated

with the onset and prevalence, distribution and spread of heroin

addiction in the community, and is intended to:

improve our epidemiologic knowledge of the natural history

of heroin addiction (causes and course)

assess social factors associated with the extent and distribution of heroin addicts in New York City, and their entry

into treatment

provide better data for use with statistical models of

the distribution of spread or diffusion of heroin addiction.

The approach is ecological and is therefore related in concept and

method to medical geography,

analysis. Ecological studies of mental disorders suffer from many

statistical geography and social area

difficulties. Difficulties in ecological research include scanty

data; lack of age-sex standardization; transiency of the denominator and relative mobility of the numerator; the "ecological fallacy" of applying areal correlations to individuals. In addition

there are problems in assessing to what extent ascertainment is

affected by social area differentials in "visibility"; or whether

differential treatment results in area differences in morbidity.

Research is also hampered by unsatisfactory clinical methods for

173
characterizing and classifying the type, severity, or prognosis

of the disorders being studied; and problems in defining the onset of the disorder and determining the time relations of exposure

to the social factors being considered (Ross; Dunham).

‘These specific problems are illustrated in Figure I which shows

the geographic distribution of "narcotics" arrests in Fresno,

California during 1970, 1971 and 1972. In addition to the number

of arrests increasing from 415 to 1,186 to 1,320, there is a progressive extension of the areas in which the arrests occurred;

areas in which arrests for prostitution and assault also increased.

Although the concentration and spread of arrests are striking, it

is not possible to assess to what extent the changes represent extension of the disorder or changes in police activity; or whether

the increasing number of events (arrests) represent Increasing

number of individuals. The clinical characteristics of the arrestees arc unknown; a population base is not presented from which

to determine rates; year of first arrest or onset of "addiction"

is unknown; the apparent correlation with arrests for other social

problems such as prostitution and violence is not straightforward.

(See Figurc I -- a, b, c.)

The epidemiologic perspective of the research to be outlined in

this paper is concerned with the relation between social factors

and the distribution of heroin addiction; is clinically substantiable and current; is population based (permitting comparison

with the general population); considers demographic and geographic

characteristics and relations between person, place and time; is

standardized for sex, age and ethnic factors; and distinguishes

events and individuals as well as prevalence, incidence and admission rates.

BACKGROUND

Faris and Dunham (1939) reported the ecological distribution of

772 drug addicts without psychoses admitted to institutions for

the insane in Chicago during 1922-1933. Since 50 percent of the

cases were in hobo or rooming house areas at the center of the

city, the authors concluded that drug addicts came mainly from the

zone of transition where"...it is, of course, easier to obtain

an in-group solidarity and maintain contacts with other addicts

and dope peddlers," and that "... drug addicts tend to select the

more mobile areas of the city where their habits and activities

arc less likely to be scrutinized."

Bingham Dai (1937) widened Faris and Dunham’s study by collating

data from law enforcement sources, as well as, from Cook County

Psychopathic Hospital for 2,619 individuals seen during 1928-1933.

Dai concluded that the areas with the highest rates of addiction

were characterized by "...indications of a considerable degree of

physical deterioration,

the neighborhood spirit,

as well as, the lack of what may be called

and that most of the occupants of the

areas were unattached men who were constantly moving from one

174
FIGURE 1A

NARCOTICS ARRESTS, 1970

FRESNO, CALIFORNIA

175
FIGURE 1B

NARCOTICS ARRESTS - 1971

FRESNO, CALIFORNIA

176
FIGURE 1C

NARCOTICS ARRESTS - 1972

FRESNO, CALIFORNIA

177
place to the other; and that the environment of the area was most

conducive to personal disorganization."

Chein et al. (1964) studied the distribution of 3,357 boys aged

16-20 reported from courts and hospitals as having been involved

with narcotics in New York City between 1949 and 1955. They

found that the three variables that stood out most in all three

boroughs in accounting for the variance in drug rates were percentage of Negroes, percentage of low-income units, and percentage

of males in "lower" occupations. Tn the case of some of the variables) the correlations with drug rates were quite different, even

in ordinal terms, in the three boroughs. They concluded that

there was an association in "some fashion" between adolescent addiction and living in areas of economic squalor. "As far as the

social environment is concerned, the vulnerability of teen-aged

males in New York City to the lure of narcotics is in the main

associated in some fashion with living in areas of economic squalor, but other unwholesome aspects of the social environment also

contribute in substantial measure. That is, conditions of economic squalor dominate the picture but virtually the entire complex of unwholesome factors plays a contributory role. We had

hoped, but not really expected, to discover one or two clear-cut

factors that could account for the lure of narcotics; but, as

usual, social causation is a complex affair."

Clausen (1961) concluded that disorganized neighborhoods with

high rates of social and economic problems produce concentrations

of narcotic problems. Koval (1960) who analyzed New York City

Narcotics Register data, reported that areas with high rates of

reported opiate use were also areas with high delinquency rates,

high rates of financial assistance and unemployment, low family

income, large percentages of out-of-wedlock births, and high rates

of health problems, including venereal disease, tuberculosis,

hepatitis and infant mortality. However, areas with high rates of

problems were not always the areas with the highest rates of opiate

use.

Nurco (1972) analyzed the ecological distribution of 833 persons

classified as narcotic addicts by the Baltimore City Police Department 1966-1968. He concluded that addicts (from this source)

were of-ten found in those areas where there was extreme deprivation, crime, and juvenile delinquency; but that narcotic addiction did not follow as closely the same pattern of "residence" as

did being a poor person, a criminal or a juvenile delinquent.

Hughcs and Crawford (1972) described the identification of 11

macro-epidemics in Chicago between 1967 and 1971, the largest outbreaks continuing"...to occur in underprivileged neighborhoods."

Their data "suggest that the majority of addicts are produced by

macro-epidemics that occur in a relatively small number of neighborhoods."

Thc strong relationship between social environment and geographic

concentrations of opiate addicts has been emphasized in all the

178
above studies. It is not clear whether certain areas "produce"

addicts; whether addicts are more "visible" in certain addresses

or whethcr addicts choose certain parts of the city in which to

live for anonymity and convenience; whether these concentrations

represent the consequences of selective contact with reporting

agencies or whether these relationships can be attributed to

various statistical or methodological problems.

The ecological correlations by Paris and Dunham, Dai, Chein et al.,

Koval and Nurco all deal with the prevalence of cases found during

a period of time without regard to the onset of the disorder.

Koval, in her analysis of Narcotics Register Data, distinguishes

persons first reported to the Narcotic Register during the study

period (first, admissions). Hughes’ Chicago studies differentiate

prevalence and incidence and consider the year of first. heroin use

reported by addicts from specified areas; but, since they do not

deal with a denominator, population-based rates of onset are missing . The distinction between incidence and prevalence (and their

relation to first admission rates) has been discussed in full by

Kramer (1957). While Hollingshead and Redlich (1958) found that

the prevalence of treated mental illnesses was related significantly to social class, "incidence" rates did not vary inversely with

social class. In contrast to other mental disorders, year of

onset of narcotic addiction can be more readily assessed and the

crucial index of incidence determined.

Secondly, in addition to the type of morbidity index, there is the

problem of major demographic differences in the distribution of

narcotic addiction. Standardization for sex, age, color and

ethnicity is essential. As well, appropriate attention must be

paid to the possible effect of geographic differences in mobility

of the numerator and denominator.

Thirdly, the method and process of ascertainment must be considered . To what extent can areal differences in morbidity result from

differentials in identification, contact with treatment agencies,

or interval between onset and contact. As the sources of ascertainment are widened, there is a parallel decrease in the information upon which the clinical diagnosis of narcotic addiction must

be based. This fourth factor of clinical confirmation of narcotic

addiction is crucial for studies based on data derived from nonciinical settings. In addition, since narcotic addiction is not

homogenious in caracteristics, severity or course, it is necessary to comnpare the clinical characteristics of addicts from areas

of high and low morbidity.

Finally a major problem in ecological research has been the attribution of social characteristics of the environment (which are

found to be correlated with morbidity) to the individual with the

disorder (the "ecological fallacy"). It is therefore necessary

to determine whether such social characteristics are also more

frequent among the individuals with the disorder being studied.

The research outlined in this paper attempts to reduce these meth179
odological problems, differcntiates prevalence and incidence,

standardizes morbidity rates by demographic characteristics;

assesses areal variation in ascertainment; recognizes clinical

variations and considers the social characteristics of individual

narcotic addicts, as well as, their environment.

SETTING

The study population is derived from the experience of the M.J.

Bernstein Institute of the Beth Israel Medical Center, New York,

which has had a large scale treatment program for narcotic addiction since 1961. The M.J. Bernstein Institute (MJBI) has had

minimum screening for suitability or selection of patients by psychological, social or geographic considerations. Although located

in Manhattan’s Lower East Side, over 45,000 individuals have been

admitted from all parts of New York’s five boroughs, and involved

in a variety of treatment approaches including detoxification,

methadone maintenance and theranpeutic communities.

The numerical relation of MJBI patients to those reported to the

Narcotics Register from other sources in New York City has been

considered in a collaborative study (Richman et al., 1971). Subsequent reports were analyzed for a random sample of 155 persons

first reported to the Narcotics Register in 1967. Fifty-five percent of this sample has reports only from law enforcement sources

up to the end of 1968; the criteria used by arresting officers in

defining an addict are not necessarily medical or clinical criteria. By the end of 1968, 25 percent of the original sample had

been admitted to MJBI; and among the persons who had been reported

from sources other than law enforcement, 61 percent had been in contact with MJBI. Contact with MJBI was highest among non-white ad

diets reported to the Narcotics Register.

The extent of MJBI contact with New York City heroin addicts is

also shown by the proportion of former MJBI patients found among

narcotic-related deaths reported by the City Medical Examiner during 19661, 1968 and 1970 (Jackson and Richman, 1971). Although the

number of deaths increased from over 300 in 1966 to over 600 in

1968 and ovcr 1, 200 in 1970, formcr patients of the Bernstein

Institute made up a similar proportion -- 18-20 percent of the total deaths reported in each of these years. Among the addicts who

died in New York City during 1970 who had been reported to the

Narcotics Register before death, one-half had been previously hospitalized at MJBI.

180
FIGURE 2

BERNSTEIN INSTITUTE CONTACT AMONG

SAMPLE OF 155 NARCOTIC USERS FIRST

REPORTED TO NARCOTIC REGISTER, 1967

181
FIGURE 3

NARCOTICS-RELATED DEATHS, NEW YORK CITY,

1960-1970, AND DEATHS AMONG FORMER MBJI PATIENTS

FOR 1966, 1968 AND 1970.

Although this research is based on New York City narcotic addicts

who have been defined by contact with a single treatment facility,

this source represents a numericaIIy significant portion of the

known population or narcotic addicts -- either in terms of drug

abusers reported to the Narcotics Register from sources other than

law enforcement, or in relation to those persons whose deaths have

been associated with narcotic use. It is not assumed that the

findings from this group of MJBI patients can be extended to all

heroin users; on the other hand, epidemiologic perspectives of

182
this clinically defined group can provide essential information

on a large segment of the known population of narcotic addicts.

METHOD

Considerable effort has been directed to developing an integrated

data system for enhancing the scope and quality of epidemiologic

information from patients (Richmarn and Moore, 1971). Since 1969,

an adaptation of the 1970 Federal Census questionnaire has been

completed by all persons entering the MJBI Admissions Unit. This

includes persons applying for detoxification or entering the Methadone Maintenance Treatment Program, referred to a Phoenix House

Therapeutic Community Induction Unit, or those referred from the

community for assessment of addiction status by the New York City

Department of Social Services.

The Census Questionnaire wording is derived from the 1970 Federal

Census, and is self-administered, as was the Federal Census. This

procedure has worked well, with few refusals and little difficulty

in completion of the questionnaire. The items are shown on Figure

III. Residence, a crucial. item for social area analysis, was verified during the early years of the study by letters mailed (Figure

IV) to the address given by the patient. Use of a self-administered Census Questionnaire in such a way is feasible, provides detailed demographic data which is specifically intended for epidemiologic research, and allows us to consider the characteristics of

those who applied for detoxification, but were not later admitted

(Figure V).

Patients were required to substantiate their identification with

documents such as birth certificate, draft cards, Medicaid cards,

etc., so that a single chart could be maintained for the various

contacts or readmissions of a patient. These Census Questionnaires

were collated for individual heroin users seen during the six

months spanning April 1, 1970 (Federal Census Day) for individuals

who had given an address within the Lower East Side Health District (Figure V). The study population comprised:

1. 350 admissions to MJBI treatment programs (detoxification

and methadone maintenance)

2. 312 applicants for detoxification not later admitted for

assessment of their addiction status

3. 70 heroin users referred by Department of Social Service

for assessment of their addiction status.

After cross-tabulating age, sex, color and health area of residence

for the 732 individuals, we calculated the age-sex-color specific

ratios of addicts/population for the entire Health District. These

Health District age-sex-color specific ratios were then applied to

the 1970 Census for each of the 13 health areas to determine the

number of Patients expected if the health area had the same fre183
FIGURE 4

184
FIGURE 5

185
quency of addiction as the Health District.

Standardized Treated Addiction Ratios for each health area were

calculated from the ratio:

Number of addicts with addresses in the health area (observed)

Number of addicts (expected) if the health area had the same

rates as the Health District

If the number of heroin addicts from a health area equalled the expected number computed from the Health District rates, the Standardized Treated Addiction Ratio would he 100. The Standardized

ratio would be 200 if a health area had double the expected number

of addicts. The Standardized Addiction Ratios calculated in this

manner represent total treatment prevalence since they include patients with addiction of any duration, first applicants, admissions and readmissions to MJBI.

RESULTS

Population Based Rates of Contact

Based on the 1970 Census, the population based rates of contact

were calculated for the six month interval centering around

April 1, 1970. These rates were higher for blacks than whites,

men than women and decreased with age. Among those aged 15-24,

about two percent of the men and one-half percent of the women

were in contact with our agency during a six month period. The

six month rates of contact are used for the social area correlates

to be described later in this paper.

Demographic differentials are shown more clearly in a later analysis. During a 25 month time period, there were about three thousand individual narcotic addicts from the Lower East. Side Health

District; rates of contact for the age group 15-24 amounted to

5.7 percent of the male whites and 11.9 percent of the male blacks.

Geographic Differentials

The Standardized Treated Addiction Ratios within the thirteen

Health Areas for the six month period ranged from two percent to

206 percent. (Over the 25 month period, the differential between

the highest and lowest Health Areas was less marked -- about a 25

fold difference). Geographic differentials persisted after standardization for age, sex and ethnicity.

period,

Within the six month study

opportunity for transiency of patients and selective mobility of the denominator was minimized and cannot account for the

wide geographic differential.

186
TABLE 1

M.J. BERNSTEIN INSTITUTE

BETH ISRAEL MEDICAL CENTER, NEW YORK

CONTACT WITH INDIVIDUAL NARCOTIC ADDICTS FROM LOWER

EAST SIDE HEALTH DISTRICT, MANHATTAN

TOTAL TREATED PREVALENCE, JUNE 1, 1970 - JUNE 30, 1972

RATE PER 100 POPULATION (1970 CENSUS) BY SEX,

AGE GROUP AND COLOR

MALE FEMALE

15-24 25-34 35-44 15-24 25-34 35-44

WHITE

Patients 860 572 134 323 132 26

Census Population 15,212 16,165 11,891 17,619 16,311 11,185

Ratio 5.7% 3.5% 1.1% 1.8% 0.8% 0.2%

BLACK

Patients 282 295 95 102 60 23

Census Population 2,378 2,270 1,482 2,541 1,921 1,520

Ratio 11.9% 13.2% 6.4% 4.0% 3.1% 1.5%

Ecological Correlates

The correlation of the six-month Standardized Treated Addiction

Ratio with various socio-economic characteristics was calculated

for the 13 Health Areas. The socio-economic characteristics were

those derived from the 1970 Federal Census by the NIMH Mental

Health Demographic Profile System for U.S. catchment areas

(Goldsmith and Unger). Pearson product moment correlations were

calculated for 103 socio-economic characteristics and found to be

significant at less than the 0.01 level for 29 characteristics,

between 0.01 and 0.05 for another 28 characteristics, and over 0.05

for 46 characteristics. Further multi-variate analyses are required since many of the social characteristics are inter-related,

e.g., the highest correlations were found for female headed households with own children; the next for children living with both

parents; then, working mothers with children; and the fourth highest correlation for female headed families with children in poverty.

DISCUSSION

The prevalence of treated addiction has been shown to be significantly related to a variety of socio-economic characteristics for

the 13 Health Areas within the Lower East Side Health District,

187
CORRELATIONS FOR SELECTED CHARACTERISTICS

WITH SIX - MONTH STANDARDIZED TREATED ADDICTION RATIOS

CHARACTERISTIC

(Number refers to order in

Unger and Goldsmith, Table 8)

RANGE WITHIN PEARSON PRODUCT

13 HEALTH AREAS MOMENT CORRELATION

(77) Female headed households with own children

(108) Poverty children

(16) Labor force unemployed

(104) Large families with low income

(25) Low occupational status, white male

(107) Disabled population unable to work

(50) Sex ratio-males per 100 females (in households)

F

9-37% 90.3

2-49% 51.9

2-12% 18.7

-70% 16.2

9-47% 13.9

2-8% 13.7

68-111 10.0

(14) Rent-non-Negro $51-$176

(39) High-school completion, white 32-76%

(95) Teen-agers not in school 8-22%

(81) Overcrowded housing 4-22%

(92) Recent movers, Negro 4-58%

(67) Large apartment structures 47-98%

(68) Rooming house and related population . . . -10%

(94) Migrants (different county than in 1965) 0-37%

(93) Mobile persons (different house than in 1965) 27-58%

... less than 1%

** p < 0.01

* 0.01 < P< 0.05

9.8

8.9

6.9

4.3

3.6

2.8

1.2

.5

.2

Correlation

Coefficient

.94 **

.91 **

.79 **

.77 **

.75 **

.74 **

.69 **

.69 **

.67 *

.62 *

.53

.50

.45

.31

.22

.13
Manhattan. As emphasized previously, this analysis includes both

first and readmissions with any duration of addiction.

Further analyses in this research project will consider:

1. Incidence within a circumscribed time period; and relation

of the time of onset to residence within the study area.

This focus upon time and place of onset is crucial for assessing the relations of onset and spread of narcotic addiction with the characteristics of the social environment.

2. Standardization for ethnicity. Further standardization

of rates will consider Hispanics, who form a significant

portion of the Lower East Side population.

3. Ascertainment. This research is based upon persons coming to a specific clinical facility. Although the relation of this source of ascertainment to other agencies has

been assessed, it is necessary to determine to what extent

areal differentials result from variation in the interval

between onset and contact, whether contact with clinical

facilities varies from place to place. Such differentials

in duration of disorder preceding first contact can be

assessed from the distribution of ascertainment intervals

(Richman, 1974, 1975).

4 . Clinical characteristics. Psychological symptoms, multiple

drug abuse and demographic characteristics are inter-correlated (Richman, 1975). The characteristics and concomitants of

various clinical types of narcotic addiction must be considered

in assessing social factors in onset and spread.

5. Individual significance of ecological correlations. Since many

of the socio-economic characteristics being studied are known

for the individual, it will be possible to consider whether

environmental characteristics related to morbidity are also

significant in the individual patient. To determine the generalizability of social correlation to a variety of regions, the

expanded project includes four other geographic areas in Manhattan and Queens.

6 . Spread. A crucial question in the epidemiology of narcotic

addiction is the definition and assessment of spread and delineation of the social factors correlated with diffusion of

the disorder from place to place and person to person, as well

as the individual factors involved with transmission and perpetuation of narcotic addiction.

189
SUMMARY

Narcotic addiction is concentrated in certain places and among

particular social groups. Heretofore it has not been possible to

assess which environmental factors are critical for the initiation of narcotic use, its transition to narcotic addiction; and

subsequently, entry into treatment or whether there are environments which select those particularly prone to social deviancy

while others migrate out. There are few systematic descriptions

of the social and environmental distribution of narcotic addicts.

This paper describes the initial results of assessing the characteristics of the social environment (1970 Federal Census) of 3,000

individual narcotic addicts from the Lower East Side of Manhattan

who were treated at the Beth Israel Medical Center.

Pearson correlations between treated addiction ratios and 1970

Census characteristics were calculated for 13 health areas. Gut

of 103 socio-economic characteristics from the NIMH Mental Health

Demographic Profile System, 29 were statistically significant at

p < 0.01 and 28 at 0.01 < p < 0.05. Highly significant correlations were found for households with children, female headed (r =

.94, F = 90.3) and population in poverty (r = .89, F = 41.7). Correlations with density (over 1.01 persons per room) or population

mobility (residing in different house five years ago) were not statistically significant.

This paper has outlined some of the methodological and theoretical

problems of ecological studies of narcotic addiction, and emphasized the need for concentration on the socio-dynamics of diffusion. Methodological problems include consideration of the time

and place of onset; demographic standardization; ascertainment differentials; clinical characterization; and assessment within individuals of ecological correlations.

AUTHOR

Alex Richman is Professor of Psychiatry, Department of Psychiatry,

Beth Israel Medical Center and Mount Sinai School of Medicine,

New York, N.Y. The assistance of T. Dubrow, N. Beauchamp Palmer,

E. Gonzalez, P. Zappel, and M. Dunlap is acknowledged. The cooperation of B. Rosen, Biometry Branch, Office Program Planning and

Evaluation, NIMH in supplying the Small Area Profile data is very

much appreciated. This research is supported by Research Grant

Number 00666-02 from the National Institute on Drug Abuse.

REFERENCES

Chein, I., Gerard, D.L., Lee, R.S., Rosenfeld, E. The Road to H.

New York: Basic Books, Inc., 1964.

190
FIGURE 6

191
FIGURE 7

192
FIGURE 8

193
FIGURE 9

194
Clausen, J.A. Drug Addiction in Merton, R.K. and Nisbet, R.A.

(eds.) Contemporary Social Problems. New York: Harcourt, Brace

World, 1961.

Dai, Bingham. Opium Addiction in Chicago. Montclair, New Jersey:

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Dunham, H.W. Epidemiology of Psychiatric Disorders as a Contribution to Medical Ecology, Archives General Psychiatry, 14:1-19, 1966.

Faris, R.E. and Dunham, H.W. Mental Disorders in Urban Areas.

Chicago: University of Chicago Press, 1939.

Goldsmith, H.F. and Unger, E. Social Areas: Identification Procedures Using 1970 Census Data, Lab Paper No. 37. Mental Health

Study Center, NIMH, May 1972.

Hollingshead, A.B., and Redlich, F.C. Social Class and Mental

Illness. New York: John Wiley, 1958.

Hughes, P.H. and Crawford, G.A. Epidemiologic Field Projects to

Reduce the Incidence and Prevalence of Heroin Addiction in Chicago, Journal of Psychedelic Drugs, 4:95-98, 1971.

Jackson, G.W. and Richman, A. Risk Factors in Mortality of Narcotics Addicts, presented at the 99th Annual Meeting of the

American Public Health Association in Minneapolis, Minnesota,

October 11-15, 1971.

Koval, M. Opiate Use in New York City. Narcotics Addiction Control Commission and New York City Narcotics Register, 1969.

Kramer, M. A Discussion of the Concepts of Incidence and Prevalence as Related to Epidemiologic Studies of Mental Disorders.

American Journal of Public Health, 47:826-840, 1957.

Nurco, D.N. An Ecological Analysis of Narcotic Addicts in Baltimore. International Journal of the Addictions, 7:341-353, 1972.

Richman, A., Fishman, J.J., Bergner, L. and Patrick, S.W. A Narcotics Register -- Some Perspective on Multiple Reports. Social

Psychiatry, 6:179-185, 1971.

Richman, A. and Moore, R. Integration of Data Systems in a Treatment Center for Narcotics Addiction, presented at the Thirty-third

Annual Scientific Meeting of the Committee on Problems of Drug

Dependence, National Academy of Sciences-National Research Council,

February 16-17, 1971. Proceedings II: 1220-1265, 1971.

Richman, A. and Richman, V.V. National Estimates of the Prevalence of Narcotic Addiction, Proceedings of the Social Statistics

Section of the Annual Meeting of the American Statistical Association. New York, 1973, 380-385.

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Richman, A. The Incidence and Prevalence of Narcotic Dependency

in the United States -- A Review of Current Epidemiologic Information. Heroin Dependency: Social, Medical and Economic Aspects

(Stimmel, B., ed.), 1974.

Richman, A. and Richman, V.V. Epidemiologic Assessment of Changes

in the Onset of Narcotic Addiction, presented at the Annual Meeting of the Committee on Problems of Drug Dependence of Division

of Medical Sciences of the National Research Council-National Academy of Sciences, Mexico City, March 1974, Proceedings.

Ross, A.R., Ecology and the Statistical Method. American Journal

of Sociology, 38:507-522, 1933.

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Institutional Data—CODAP

C. James Sample, Ph.D.

The presentations under the topic of data systems have focused on

the ability of the various recurring reporting systems to contribute information on the epidemiology of drug use or abuse. The

Client Oriented Data Acquisition Process (CODAP) represents another, and possibly the most useful, of these various recurring reporting systems. This system, as revised in November 1974,* is

a required reporting system for all drug abuse treatment units

sponsored by NIDA, VA and BOP.** Reports are received monthly from

approximately 1,800 treatment units. The coverage is extensive

and the compliance in reporting is improving significantly because

of pressure on the treatment units by the funding agencies.

CODAP was not designed for extrapolation nor for the study of

the incidence and prevalence of drug abuse. The system does, however, have the ability to offer some insights into these issues,

principally by providing the information for onset analysis. It

is not my intention to discuss the contribution of CODAP to onset

analysis or any other particular approach. However, I will use

this example to demonstrate the major weakness of epidemiological

extrapolations from CODAP. Data generated at the treatment unit

level is based on a particular population, namely clients who, for

any reasons, find it necessary or advantageous to enter treatment

for a drug problem. Consequently, utilizing CODAP information

*CODAP system was revised again in September 1976.

**The five input forms that comprise the system are attached.

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for extrapolations to the drug using population requires that a

number of assumptions be made.

FIGURE 1

The chain of events shown in Figure 1 demonstrate our major problem in this area. The expressed logical chain of events from

first use of a drug, through continued use and finally to treatment provides the basis for the onset analysis. What is missed,

of course, by gathering this information at the treatment level

is the information on individuals who initiate drug use but never

enter treatment. Like DAWN and DEA arrest data, CODAP requires

an institutional capture point. Only survey methodologies, which

have their own problems, avoid this particular problem.

Use of this example should not be interpreted as a criticism of

onset analysis from this data. Quite to the contrary, onset analysis, as I am sure will be discussed by Dr. Mark Greene who is our

next discussant, has provided extremely useful insights into the

problem. My particular concern is to emphasize that data from any

self-reporting, recurring data system is based on a very particular population. In this case this population consists of drug

users who enter treatment.

The revised CODAP system was designed first as a drug abuse treatment management tool and secondly as a research tool. These two

objectives are complementary as they should be. Here we are focusing on the research potentials of the system. The self-reporting, recurring nature of this system offers an alternative as well

as an additional method to gather information. Once operational,

the self-reporting nature of CODAP, as compared with survey methods,

is relatively inexpensive to maintain and provides extremely current information. Reports are produced 45 days after each report

month (i.e. , reports on the treatment activity in January are published by March 15). This enables rapid identification of changes

in factors effecting the treatment population. Because of the

coverage of the system, sensitivity to drug abuse trends in small

areas is possible. This is a factor so often stressed in analysis

of drug use and abuse trends in the United States.

eralize from one part of the country to another. CODAP’s coverage

We cannot genis sufficiently extensive that these generalizations are not necessary.

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These are some of the extremely useful points of the system. However, the problems mentioned by Dr. Sells yesterday with reference

to the DARP reporting system are also present in CODAP. The same

problems of reliability and consistency are always present in a

self-reporting system. This leads to difficulty in interpretations

of trends which is a major focus of this conference. It is compounded with the present reporting system by a number of factors,

e.g., the fact that it is only a federal reporting system. The

question then becomes what percent of the total universe is accounted for by the federal clinics -- and there does not seem to

be a sound current estimate. Secondly, less than 100 percent of

the reporting units are actually reporting, although as mentioned

earlier, the reporting rate is improving. Our best estimate now

is that we have increased reporting from about 60 percent of those

expected to somewhere between 80 percent and 90 percent. The difficulty in obtaining a sound estimate of the percent of clinics

actually reporting is a function of accurately establishing the

denominator -- which has been a problem. We are still carrying

information in our files on many programs such as LEAA and HUD

Model Cities Programs which report infrequently and have not been

pressured by their funding sources to report. So we have somewhat

less than 100 percent of the expected. Thirdly, there is a discontinuity in reporting. A clinic that reports this month may not

report next month. There has been some fluctuation. However,

over the last three or four months, this has changed significantly

because of NIDA’s increased insistence upon reporting by their

clinics and actually linking it to the funding criteria.

The fourth factor, and possibly the most disturbing influence affecting the ability to extrapolate from CODAP data, is the reliability of the data as a result of NIDA’s insistence on treating

particular drugs of abuse. NIDA has strongly communicated the

policy decision that clinics are not in business to treat alcoholics, marihuana users and primary prevention clients. This policy

decision is reasonable from NIDA’s viewpoint. The result of this

policy is that clients admitted to treatment that fall into one of

these three classifications are under-reported and the relative

magnitude of heroin, barbiturates, polydrug use, etc., is over-reported. The funding decisions are, in these cases, affecting the

distribution of drugs reported and the extent of this bias is not

known.

In order to make a reporting system effective and provide reliable

and consistent data, a couple of things have to be present. First

of all, I think the system has to reflect reality. The revised

CODAP system does this. At least that is the reaction we have

had from the treatment programs over the last two and a half months

when we have been training clinic level personnel. Secondly, we

have to develop, I think, a better feedback mechanism to the local

programs. Unless we are able to provide useful data to the programs, the reliability of the data that we receive will be less

than what we would like. The present rate of reports accounts for

approximately 100,000 clients in treatment at any one time. So the

volume of reports is substantial; in terms of numbers to extrapelate, there are certainly sufficient numbers there. I have attempt199
ed to cover the major problems in extrapolating CODAP data. The

major issue of the hidden population of drug users (i.e., those

that never enter treatment) cannot be solved by any self-reporting,

recurring data system.

Most of you are familiar with the CODAP system as implemented in

May of 1973. I urge you to become familiar with the new system.

I am sure that it will have data that all of you can use and profit from. This is particularly important because the research and

epidemiology data items have been expanded and refined. The reporting rate is increasing and our feedback loops are better,

which should also increase the reliability and consistency of the

data. However, as Dr. Sells said yesterday, there is not a speech

for all occasions. This is also true with reporting systems.

AUTHOR

C. James Sample is Senior Research Economist, System Sciences,

Inc., Bethesda, Maryland.

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Applications of Indicator Data (Epidemics)

Mark H. Greene, M.D.

I have a topic that might strike many of you as bizzare, having

heard the list of problems and difficulties in interpreting the

data obtained from various sources of what we call indicator data.

My topic implies that these data can, in fact, be used; many of

you may be skeptical about that. I think, though, we are really

not faced with the choice that Ira Cisin mentioned, that is, probability samples on one hand and bits and pieces that don’t fit

together on the other. My own personal feeling is, and I suppose

it is not surprising since it is what I spend most of my time doing, that there is a middle ground and if judiciously applied,

many of the bits and pieces do in fact fit together. And you can

learn a great deal from trying to put the bits and pieces together

if you are careful about how you collect the bits and pieces. Our

experience began in the District of Columbia and has since expanded to field visit in 14 cities around the country. I would like

to share with you, not so much the data, as some of the difficulties we encountered in trying to use the various sources of information.

Before I go into the specific indicators that we have tried to

evaluate, all of which really have been discussed previously in

yesterday’s and today’s sessions, I would like to mention just a

few guidelines that we have used in this enterprise. In the first

place, it has never been our claim, and I do not think we really

feel, that our approach to the problem enables us to describe reality with absolute perfection. This is an attempt at trying to

understand what is going on in the community; it is an attempt

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to approximate reality as best we can. I think it is clear from

the discussions that have preceded my comments, however, that

there are many problems in using the various sources of data and

this can only be regarded as a rough approximation of reality.

But I think that, again as Ira Cisin mentioned, there may be more

important information to gather than precise head counts. Rough

approximations may in fact give you very valuable information for

planning and intervention purposes. Our experience has been based

on heroin use as a model, but I think with minor modifications the

sources of data that have been used can be applied for non-parenteral and non-opiate drug use as well.

Our approach has been to try and use a set of indicators, rather

than rely on any one, and my answer to Dr. Richard’s seventh question "What is the best indicator of drug use?", is I do not think

there is a best indicator. If you rely on only one, you are in

very dangerous territory. It is difficult enough relying on a

package of them, but I think when you put together a series of indicators, if there is consistency in the kind of data that you

collect, you can feel more comfortable about the conclusions that

you draw. Therefore we rely on a set of indicators and not just

one. Our data have been collected using data as they are available at the local level. We have not undertaken special studies

in an attempt to assess the problem.

I think mentioning the local level leads to another major point

and that is, in my personal opinion, that there are enormous

hazards involved in trying to make broad generalizations about

trends at the national level based on the kinds of data sources

that we have available right now. Dr. DuPont and I argue at great

length about this sort of thing. My own personal feeling is the

best we can do is to make a reasonable assessment of what is going

on locally, at the community level; that is feasible. To then

extrapolate from there to what is going on nationally is a very,

very difficult process and I think vividly illustrated by what

happened when people over-generalized from what was going on in

the East Coast over the past couple of years, suggesting that it

was going on everywhere when, in fact, it was not going on everywhere. It was a regional phenomenon. And here is one of the major

problems I think in using CODAP for example, as a source of data.

Take, for example, the year-of-first-use distribution, which I

really believe properly handled can be a very powerful tool at the

local level. To collect data from hundreds of programs around the

country and then display the year-of-first-use distribution for

the entire country and try to draw inferences about national trends

in heroin use is really stretching the data inappropriately. I do

not think it should be done. We focused at the micro level, at the

community level, and not at the national level.

Finally -- and this may be difficult for those of you who are accustomed to at least trying to deal with more precise measures, with

good sampling techniques and extrapolations from your sample to

the general population -- our approach has been to look more at

the relative trends in use rather than absolute trends. I think

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the preoccupation with trying to find out whether there are 568,000

or 569,000 heroin users in the country is a waste of time. It does

not give you information that is useful from a planning point of

view; really what you need to know is something that is fairly

crude -- is the problem getting better or worse and in what parts

of the community is the problem getting better or worse and what

segments of the population are at greatest risk’? So we focus on

relative trends and not absolute trends and try not to get dragged

into the debate of how many users of "x" there are in the community today.

With that as sort of a background, we have looked at the indicators that have previously been discussed. Primarily these include drug-related deaths, drug-related hepatitis, law enforcement

data of two types (property crimes and drug-related arrests),

treatment data -- primarily year of first use with information on

age, race, and sex of those admitted to treatment, data from emergency rooms where it has been feasible to obtain them, and information regarding buys and seizures.

That leads me to make one comment on the point that Lee Minichiello

has made and Carl Chambers has mentioned too; that is, the availability of drugs is really a key issue in the studies that all of

us are involved in. I think insufficient attention has been paid

to that issue in our deliberations here today. My own personal

experiences over the last couple of years have led me to believe

that it may well be the major factor in determining use patterns;

people back home will not be happy to hear me say that, but that is

the way I really feel. The information that you can obtain from

buys and seizures can be very helpful in assessing availability,

particularly of heroin, but also of other drugs as well. John

Newmeyer did not mention the source of information that most people

have fairly readv access to in this regard and that is law enforcement buys and seizures which circumvent the need for exposing both

the client and the clinic to the risk of making purchases in the

illicit market. In fact, local, state and federal law enforcement

agents are in the process of making undercover buys on a regular

basis and these data can be obtained. The purity of heroin at the

street level has to be carefully defined because where you are buying in the distribution system makes a very big difference as to

what the purity and cost will be. However, I think it is a reliable indicator of how available the drug is. Changes in that purity have been associated with other indicators to suggest that

heroin is more widely or less widely available. In our travels

around the country, we have found, much to our distress? that many

localities in fact do not bother to analyze for the purity of the

drug, and that is a tremendous loss of data. They simply do a

qualitative analysis to find out whether opiates are or are not

present in the sample they have submitted and do not do a quantitative analysis to determine what the heroin purity is. This would

be one of the recommendations I would make to whoever makes policy

at this level; this is a very valuable source of information. Currently, state and local seizures and buys in general are not analyzed because the DEA does not have the laboratory facilities to

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undertake that; some way ought to be explored to see how they

might be more fully utilized.

Q: How often do you have to make buys to keep track of trends?

Dr. Greene: I don’t know the answer to that, to be honest. Most

of my experiences are from the District where buys are being made

on a regular daily basis. There may be an average of anywhere

from 30-50 buys per month in the District and we collect the data

on a monthly basis. In fact, this is a lower number now than

it used to be. It used to be in the range of 100-200 buys a month

when the heroin market was wide open in the city. You get into

problems in terms of the statistical significance of observed

changes when you are dealing with relatively small samples there.

So we usually end up aggregating the data on a quarterly basis to

try and get around some of that. In general though, at the street

level, the buys fall into a fairly narrow range, and when the range

changes, it usually means that it is because the market structure

has changed -- so that kind of variability has implications. The

other law enforcement data we have looked at have been attempts to

draw some connection between property crime and addiction in heroin

use in the community. We have had a very difficult time making

any sense out of this at all. I think this is so primarily because

we have approached it in a crude fashion and the kind of association that probably does exist is much more complicated than we have

been able to demonstrate. In fact, when we compare our incidence

curves to the property crime curves in the cities we have visited,

in some places it seems to fit, and in others it does not seem to

fit at all. I think we are just not clever enough to understand

exactly what the relationship is. I hope that Dr. Savitz's work

offers the opportunity to elucidate the relationship a lot more

clearly than we have been able to do so far.

On the other hand, drug-related arrests, particularly in our surveys -- i.e., heroin arrests -- have been a fairly valuable source

of information. If you take into account local law enforcement

policy, the changes in the numbers of arrests and in the demography of the arrestees have seemed to move in conjunction with

what has been seen at other observation points in the system --

in treatment, among those who are dying, and among those who show up

in emergency facilities. So in our experience, property crime data

as they exist are not of much help, but heroin-related arrests are.

You have to be careful when you are dealing with these kinds of

data for all the reasons that Dr. Savitz mentioned and also, because what constitutes a drug arrest varies a lot from place to

place. In some places all drugs are lumped together; in some

places "narcotics arrests" so-called also include marihuana and in

other places it does not; in some places it is "opiates," and includes cocaine in addition to heroin and the narcotics and in other

places it does not. You have to be quite careful on how you collect these kinds of data.

We have had a lot of discussion about the hepatitis indicator. My

own personal feeling is that, again, if you can get data in which

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drug-related cases of antigen positive serum hepatitis are reported,

you have a very valuable indicator of parenteral drug abuse. Most

communities, however, do not collect data in this way. In fact,

we are in the midst of very dramatic and rapidly changing developments in the hepatitis field, such that it is now possible to very

specifically make the diagnosis of hepatitis B where it was not

five years ago. Many physicians have never had any interest in

the entity of hepatitis B. So that situation is changing rapidly.

At the moment, most communities do not collect the data in the

form that is usable for this purpose. It is a shame, but that is

the way it is.

The emergency rooms, again, in a few instances have provided very

valuable information; but repeatedly in places where we have evidence of wide spread of the drug, the people in the emergency rooms

claim that they are not seeing any problems related to heroin.

They are not seeing stupor or coma in young people, let along anything they diagnose specifically as heroin overdose. They are not

using the drugs that are standards in the treatment of opiate overdose and in view of the evidence that we have that there has

been opiate use in these communities at a fairly extensive level,

these observations raise serious questions about what is going on

in the health care systems in these communities. These cases must

be occurring and they must be being called something else. This

is another area which I think merits further exploration.

Q: What sort of hypothesis do you have about the problem of the

non-appearance of the expected cases in emergency rooms?

Dr. Greene: There is a variety of explanations. I guess it could

relate to the sophistication of the user; if the drug is tested

by administering a small dose before taking the whole dose, you

can avoid some of the problems. If the drug is not taken in conjunction with other drugs, you may not get into trouble. The

quality of the heroin that is available in the community probably

also has an effect. It is possible that people are using relatively low potency heroin and not getting into actual pharmacological

overdose situations, although when the potency changes they can

get into trouble, particularly people who do not have opiate tolerance.

Dr. Gottschalk: I think another reason is that friends do not like

to bring those cases into the hospital. They will bring barbiturate cases, but they try to give them milk and other good things to

cure them at home -- so they end up in the coroner’s office.

Dr. Greene: The point that I was about to make is that this is a

major social problem, I think, in that the policy of many emergency

rooms around the country is to report people who are seen for drugrelated episodes to the police. The local clients who might potentially use this source of health services are aware of this and,

therefore, go to any lengths they can to avoid showing up there.

We have not looked at enough places to be able to draw that conclusion on a hard and fast basis. On the anecdotal basis, it ap210
pears that that is the case.

In Pensacola, Florida, for example, which is one of the communities

where this kind of policy does exist, we visited all three hospital

emergency rooms and they claimed they had never seen a case; they

have never used naloxone. The treatment program has treated hundreds of people over the past couple of years for heroin use, but

the emergency room had never seen an overdose. There were deaths,

too, that we were able to glean out of their medical examiners’

records by going through and picking out the fairly characteristic

ones.

Dr. Khalil: Isn’t it almost impossible to get an overdose with

heroin, to cause heroin death itself? When you consider that the

package may contain about eight milligrams or so of heroin, it

would require the person to be independently wealthy to afford to

kill himself with heroin.

Dr. Greene: Yes, I think that relates to what I said before. Potency of what is available in the street certainly influences that

and in times of higher availability, there is a greater degree of

variability as to what the individual buys in the streets. The

chances of encountering an unexpected high dose package of heroin

is much greater at a time of good availability than at a time of

restricted availability. Over the past year (1973), for example,

in Washington, when the heroin purity in the street was running

about two percent, and the average number of milligrams in the

street level bag was perhaps three or four milligrams -- barely

enough to get you and me high -- we have five heroin deaths during

the entire year as opposed to 40 or more deaths in the years before that. This year the purity has gone up to four percent over

the past six months and already we have 12 deaths through the first

10 months of the year, over twice what we had last year. I think

potency clearly has a major imput.

Dr. Sells: How many communities do you monitor? Do you have a

standard program or do you try to trouble shoot where you get information that your services or your attention are needed?

Dr. Greene: The only community that I personally have been involved with monitoring on a regular basis is the District of

Columbia. The other 14 cities that we have visited have been oneshot situations , part of an effort to understand the utility of the

various sources of data and also to assess some of the questions

about whether heroin use was spreading into smaller communities.

They are not being done regularly.

Dr. Sells: In effect, you are operating what might be called a

demonstrative program.

Dr. Greene: Yes, I think so. That brings me to another sort of

general point and that is, we are not talking about predicting

problems. What we are talking about is monitoring a community in

a way that allows you to detect problems at as early a stage as

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possible and is feasible; prediction is another goal entirely. I

think monitoring -- surveillance, if you want to use the epidemiologic term -- of drug use trends is possible on an on-going basis

and the kinds of data sources we have used have been very sensitive to local changes in drug using behavior. We have written and

published a good bit on how this has helped us understand the problem of methadone abuse in the city, and the problem of amphetamine

abuse. All of these things show up in the kind of monitoring system that combines treatment data, emergency room data, overdose

data, law enforcement information, and hepatitis data, if you can

get it. I think a fundamental consideration is that you realize

that each of these sources of information has very serious limitations and that you are on tentative ground all the way.

You have to use common sense, restraint and good judgment in how

you interpret the data and not jump off the deep end in predicting

what is going on. We usually wait anywhere from three to six

months before taking any change in the indicators seriously. But

at least with the heroin situation, they all move together. This is

the sort of thing that is hard to swallow. As a scientist, it

makes me very uncomfortable to be dealing with such soft sources of

information. But it seems to work. We have been able to document

very significant changes in use both up and down, with multiple

indicators simultaneously, not only in our community, but in other

communities. John Newmeyer's experience in San Francisco has been

very similar. Let me make just one last comment and then throw it

open to further questions.

It is my own personal feeling that the year-of-first-use distribution obtained from a sample of addicts, whether it is treatment

based or law enforcement based, when properly used can be one of

the most powerful tools in analyzing local trends and incidence.

I have to double underline "when properly used." Alex Richman has

written a great deal about the many problems involved in interpreting this kind of data. There are variations and confounding that

can be introduced by a wide variety of variables, from the standard demographic shifts to changes in the use of other drugs and

changes in the kinds of services that are available. At least in

the District of Columbia, we have been able to take almost all of

these into account and have gotten repeatedly the same kind of results. In our experience in the other communities in the 14 cities

that we visited over the past six months, we have found that the

variations observed in the year-of-first-use distribution almost

always have an explanation. There appear to be very distinct problems at a micro level within each community, such that you can

demonstrate, I think, separate spread within a white community and

a black community and within different race and sex specific groups

within a community as well. Residence specific incidence plays

a role, so that when you have a year-of-first-use distribution that

assumes an unusual configuration, there is almost always a good explanation and an explanation that says something important about

what is going on in the community. But, of course, you do have to

take into account the many possible confounding variables that can

influence this sort of thing.

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AUTHOR

Mark H. Greene is Medical Epidemiologist, Special Action Office

for Drug Abuse Prevention, Executive Office of the President,

Washington, D.C.

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DISCUSSION

Dr. Newmeyer: We found it useful to take all the 1974 year-offirst-use data that came in the fall of 1974, look at it carefully

demographically and so forth, and compare that with similar 1971

year-of-first-use data that we saw in the fall of '71. I think

you get a true early warning system on trends.

Dr. Greene: This has been one area where there has been some confusion depending on how you slice the data. I think probably the

most effective way to look at this is to use onset cohorts -- people who have begun use in the same year -- rather than admission

cohorts. We originally began to do this and subsequently shifted

because the admission cohort is a much more heterogeneous group

of people. The people who were admitted in 1973 included people

who had been using for 40 years as well as people who had begun

six months ago. There can be very striking differences within

this group. The other thing I did not mention was that in using

year-of-first-use data, we tried to take into account one of the

major problems in using that information from a treatment source

-- that is, the problem previously referred to regarding lag between onset of use and entry into treatment. Only a relatively

small proportion of any group of people who begin heroin use in a

particular year will enter treatment during that same year. For

example, if one looks at our admissions now for people who began

use in 1974, one will find relatively few in number, unless something very unusual is happening. What we have tried to do is develop a correction factor to plug into the year-of-first-use distribution based on how onset cohorts have behaved in the past. I

know you have done the same kind of thing -- that is, taking all

people who began use at a certain point and seeing how long it

takes them to come into treatment. We have done this for about a

dozen programs that have been in existence long enough to give

them enough data to make this kind of determination and we have

developed a correction factor that has its own problems, but we

are trying to take into account the factor that there is this delay of several years between beginning and entry into treatment

that can affect year-of-first-use as an index.

Dr. Sells: The year-of-first-use is an interesting idea. I assume this is the first use of any illicit drug?

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Dr. Greene: It is heroin particularly, not any drug; but it could

be done for any drug.

Dr. Sells: In our files, we have both data items available but by

inference. We infer it because we have date of birth and age at

first use, and are therefore able to compute it. I am not sure

the results would have been the same if we had asked them in what

year they first used. Apart from this however, I want to make the

observation that the onset statistic is probably one of the fairly

large number of variables that are very actively inferred from age.

If you have someone who has been using for 30 years, the chances

are he is older than someone whose year of first use was this year.

Generally speaking, it is possible to make much more use of that

age as a variable than is commonly realized. I think that is important. When you are dealing with problems of this kind, you may

run across data sets that would be helpful in which the specific

item is not available but can be inferred on the basis of the correlate years.

Dr. Greene: Yes, we have used the trends in the age of first admission among the treatment clientele as one of the indicators.

Given what we know about onset of use, you can infer what the

trend should look like if incidence were high or low. In fact,

that fits with the other data we have used. Another one is simply

the proportion of people who are below a certain age -- below age

18 or below age 21 -- depending on the program admission criteria,

of course. Large proportions of young people are more suggestive

of a current problem.

Dr. Chambers: I have two questions. The first one deal with age

at first use vs. age of first continuous use. What does that do

to the data when you cut it both ways, instead of the first? My

intuition would lead me to believe that age of first continuous

use would be better, considering how some segments of the country

go through experimentation stages.

The other question involves the concept of community. I and a

number of people have gotten into trouble in the past projecting

national trends from rather diverse data pools from around the

country. -The concept needs to be locally-defined. I am a little

concerned about what local really means.

Dr. Greene: As far as your first question is concerned, we have

not run our data by continuous use, so I cannot tell you how it

looks. Clearly, time elapses between one and another. I think

conceptually though, first use, at least as an incidence indicator,

makes better sense from a logical point of view. In the first

place, it avoids the problem of having to decide what continuous

means. In the second place, to the extent that the communicable

disease analog holds, we are really talking about exposure to the

opportunity to take heroin, so that in terms of an incidence measure, what you really want to know is, when did that happen for the

first time? Looking at the natural history of the disease is a

different question. I think first continuous use data can give

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you helpful information, but as an incidence indicator, I think

year of first use makes more sense -- it is cleaner. The first

time someone uses heroin is a fairly memorable occasion; you do

not have to get into the problem of when were they strung out,

when were they addicted (and what does addicted mean?), how many

times do they have to use it for it to be continuous and that

sort of thing. So it is just a cleaner piece of information, I

think.

We have not really explored the various problems of how to define

community. I think there is no question even within the smaller

communities we have visited -- the cities in the size range of

50,000 or 150,000 -- that there are variations even within the

community, from one neighborhood to another and from one ethnic

community to another, that make it difficult to see the whole

thing as a homogeneous unit. In fact, I think one of the major

criticisms of the study that we have done in these 14 communities

is that we have been too simple-minded regarding how we have defined a given metropolitan area. We have, for example, neglected

the influence of nearby large cities that may give a city with

relatively small population many of the characteristics of a community of much larger population density. I am not very experienced at this and it is clearly something that has to be looked at.

Dr. Richman: I am delighted to hear Dr. Greene describe or emphasize the need to look at onset cohorts rather than admission cohorts because it is quite fundamental to the whole concept of

year-of-first-use. On the other hand, looking at a cohort of people who have come into treatment, in order to get some assessment

of what is happening in the community, namely incidence, is not

only a critical but fatal error. I think it can be underscored

that what is being dealt with there is something that requires

a term other than incidence. Jack Elinson points out quite appropriately that my standardized addiction ratio is really a standardized treatment addiction ratio. Fine, that makes a better

acronym -- S.T.A.R. not S.A.R.! Similarly, year-of-first-use does

not deal with incidence within the community. It might be called

inferential hypothesis about what might be happening out there --

if that makes an acronym -- but it should not be called incidence,

even for planners.

Dr. Greene: A lot depends on where you stand as to how you use

these kinds of terms. When I talk about incidence strictly defined epidemiologically, I usually call it an incidence rate. However incidence in general tends to be used in a fairly loose fashion. When you are talking about cases per 100,000 per unit population over a given period of time, you are talking about an incidence rate and I have never claimed that our methods give you

any insight into rates at all. We are talking about relative

trends and a measure of onset. It is an indicator, it is not a

direct measure.

Dr. Lettieri: I have one question and one commentary amplification.

With some of the indicators Dr. Greene mentioned, particularly the

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one of drug-related deaths, or overdose deaths, the use of potency

to explain that phenomenon belies the issue. I do not think anyone will argue that pharmacologic overdoses can occur. I have

seen one that was a clear-cut pharmacologic overdose -- the case

of Janis Joplin who wound up taking a 16 percent solution rather

than her typical five percent, unknowingly. That, I think, constituted a clear overdose. However, the concept of overdose is not so

much how strong the drug is. I think the issue is really the clinical judgment, the looseness, if you will, of the medical examiner

in determining in fact what is an overdose. That regrettably has

to be determined clinically by how tolerant he thinks that individual was. Often that data is rather loose, aside from bodily measures. So it is not so much the fact of taking four percent or two

percent, but rather how tolerant that individual is; and tolerance

regrettably is not well defined -- it is a judgment. Therefore,

the measure of potency, I think, belies this issue.

Dr. Greene: I am not sure whether or not your comment is intended

to raise the question of the physiology of death in narcotics victims. Are you saying that most of them are not dose-related pharmacologic overdose deaths?

Dr. Lettieri: No they are not. In New York, Baden would argue

that most of the cases he sees do not seem to be clear pharmacologic overdoses and yet the only cause he can point to seems to be

heroin. There is one resolution to that and although it is a debatable issue, it is the only conceptual explanation I have ever

seen that I could half-way buy. That is that one can lose one’s

tolerance for heroin very quickly. In other words, having been

off heroin for as short as three days, taking a standard dose

might in fact be equivalent to an overdose. That may help us explain why Halpern and Baden have said overdose death victims do

not seem to have taken more than they usually take. What we need

to look for then is, how long has it been since the last time they

took it.

Dr. Greene: I am not sure that that is correct. I would say that

the New York experience is subject to question. It has never been

systematically analyzed. They did not have toxicologic verification of presence or absence of the drug, at least during the period

when they were writing most of their papers. Many of those cases

were never autopsied. The overdose was designated as the cause of

death on presumptive and circumstantial evidence in many cases.

They are just beginning to systematically look at their case material, so there are real questions about what their experience

means. People who have recently studied cases of individuals who

have died with no other determined cause of death, and have performed careful toxicologic analysis including blood morphine levels,

which is a relatively new technique that has only been available

on a general basis for perhaps four or five years, have found a

very strong correlation between blood morphine levels and those

cases that are called heroin overdose deaths. There have been

several epidemiologic studies including our own that have shown a

very strong correlation between heroin overdose deaths and the

potency of the heroin preparations that are available in the com217
munity. That has been observed in Washington, Atlanta, and in

Texas, and there are several studies that make correlations betweeen blood morphine levels and the diagnosis.

Dr. Lettieri: What level is used? Is there an index? That is

what I am trying to get at -- what level constitutes an overdose?

Dr. Greene: It is not a clear-cut situation and my own personal

feeling is that somebody dies in conjunction with taking heroin

for a whole variety of reasons. It is a multifactorial etiology.

The kind of things that weigh into whether a given person dies or

not include his level of opiate tolerance, the root of administration, the dose, the presence or absence of other drugs, the rate

at which the medication is administered; if it is given intravenously, perhaps the diluents that are also present in the material,

and the underlying metabolic status of the individual himself --

whether he is a slow metabolizer of certain drugs or not, whether

he has underlying hepatic pathology or not. All of these things,

in some way that is difficult to quantify, weigh in to determine

whether any given individual is going to die or not when he takes

a particular dose of heroin.

Dr. Lettieri: Has any medical examiner been able to get all that

data? All I am arguing is that often, most of that data are not

available, and the element of confusion is more in the judgmental

process.

Dr. Greene: I think the studies from the District of Columbia and

Atlanta go into pretty good detail on circumstances surrounding

death, and reliable toxicology on other drugs. I may be contradicted on this, but my impression from everything I know is that

the cases are very well investigated. In fact, we have been able

to show that at least 55 percent of the people who die have histories that strongly document abstinence from opiates in the period prior to death, either because of incarceration, hospitalization, or voluntary attempt at abstinence or withdrawal. Therefore,

I think a substantial number of them probably are lacking opiate

tolerance at the time they die,

to document.

maybe many more than we are able

Dr. Lettieri: It would be very useful, I should think, if Dr.

Luther in the Washington office would put some of his guidelines

for other medical examiners, such as levels, in writing. As far

as I know, and I have been very interested in the problem, it has

never been documented. And there is so much variance.

Dr. Greene: I think the question as to the precise blood level

that may be required to cause death is really not the issue. The

diagnosis is a clinical diagnosis and it requires experience and

judgment. To simply say that if you find someone who has 20 micrograms percent of morphine in his blood means he is an overdose

victim is far too simplistic, unfortunately. I think you really

need someone who is skilled in medical-legal death investigations,

who has an interest in the problem and is careful enough to rule

218
out the other causes of death before he makes the diagnosis of an

overdose.

Dr. Lettieri: It would be good if someone would make it a bit

more explicit.

Dr. Greene: It is in the literature. We published two papers on

it.* The people in Texas, from Dallas, and the people in Atlanta

have also published their research experiences. In all of these

our system is described.

Dr. Lettieri: I am not medically trained and I have listened to

Dr. Michael Alexander from CDC talk about hepatitis and then I

have heard Dr. Greene’s comments about it and I am not really

clear now. Can we clearly identify serum type B hepatitis? If

I understood Dr. Alexander, he was saying "No, there is a lot of

noise in the system" and you are saying "Yes, we have a new technique."

Dr. Greene: There are now specific laboratory tests for making the

diagnosis of hepatitis B. It is called the hepatitis B associated

antigen. It is something that was a laboratory procedure until

about two years ago and is now available on a mass basis from the

clinical laboratories all over the country. As far as we can tell,

it’s specific for this kind of hepatitis -- serum hepatitis, long

incubation hepatitis, the type traditionally associated with parenteral drug abuse. The problem is in the reporting system, in that

the morbidity and mortality weekly reporting system that Dr.

Alexander described only receives from the states a list of how

many cases of type A, type B, and type unspecified have been reported; they do not know whether the type B cases were verified

through the use of this test or not. There are many cases that

are called type A, for example, in which the test was never done;

they might, in fact, be type B and misclassified. So there is a

lot of confusion in the reporting system because this test is

something that has only recently been introduced on a wide scale

and there is no analogous test for type A. Type A cannot be diagnosed specifically in the laboratory.

Dr. Lettieri: Would it be fair to say that only when we start using this rather specific test, that is, only when this new test

is widely used, will we be able to have a bit more confidence in

using hepatitis as an indicator and that everything in the past

*M. Greene, J.L. Luke, and R.L. DuPont. "Opiate Overdose Death

in the District of Columbia -- I: Heroin-Related Fatalities."

Medical Annals of the District of Columbia 43, (1974):175-181.

M. Greene, J.L. Luke, and R.L. DuPont. "Opiate Overdose Death in

the District of Columbia -- II: Methadone-Related Fatalities."

Journal of Forensic Sciences 19, (1974):575-584.

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is essentially debatable?

Dr. Greene: There may be a little bit of a middle ground. I

think clearly the use of the test will enhance the reliability of

the data, but the two forms of hepatitis are epidemiologically

fairly distinct. The major problem is one of improving reporting

and getting the reporting physicians to pay attention to these

characteristics that would enable them to say this is A or B.

There are places, however, where that is now done, so there are

some states in which a more detailed reporting form, for example,

is used. In fact, there is a second reporting system at the CDC

that looks at a portion of the total MMWR sample in which information on antigen possitivity, history of parenteral drug abuse, and

history of exposure of other causes of hepatitis are listed. So

in some places the data are already in a form that make them reliable. The problem, as with many of these indicators, comes when

you try to extrapolate on a national basis from these kinds of data.

Dr. Gottschalk: I just want to endorse what Dr. Greene is saying

about the use of toxicological data. You cannot just find the

level that will tell you exactly what happened and what the causes

were. You have to have all kinds of other data from other systems.

I would like to add that in these determinations, it is also important in toxicological examinations to find out what the blood

level of morphine is in the urine, because in the cases of deceased individuals, the time of finding the body is terribly important. In cases that have died, it is quite possible that there is

very little found in the blood but a fair amount of time has

passed and the morphine levels in the bile or in the urine are

quite high. As a result, it gets to be a complicated matter and

takes somebody that is well versed in the use and interpretation

of all the data available to make the kinds of determinations Dr.

Greene is talking about.

In our experience with both psychiatric emergency admitting rooms

where there is intake of 800 patients a month, and general medical emergency rooms where there is intake of about 1500 per month,

in addition to coroners’ and medical examiners’ data, it does not

seem to matter whether or not that state or county or city has a

law that it is necessary to report that the person has had narcotics. I think it is something in the culture or subculture of the

narcotic users and addicts that they try to take care of their

problems themselves. It does not seem to make much difference if

there is a law or not, they are still very anxious about going to

any authorities.

Lastly, when you speak about year-of-first-use, naturally nobody

thinks of the year-of-first-use in terms of whether or not they

were active or passive participants, that is, whether the individual might be in utero. But if you look at the broad rubric of the

epidemiology of drug abuse, you do have to consider whether or not

the fetus was exposed to sex hormones, tobacco, or other psychoactive drugs. The data are now beginning to accumulate that if a

fetus is exposed to stilbisterol or other substances, it might

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have a higher possibility of having a cancer. or as you know, in

some of the data, if a mother smokes, a child is liable to have a

lower birth weight and there may be other complications. These

are, in a sense, ramifications of drug abuse. We do not know, and

this should be researched, what are the long-term effects, not the

short-term effects, of the use by the mother of various types of

psychoactive drugs. If one takes any kind of medication, say a

barbiturate, that influences and activates the development of various liver enzymes which break down other substances faster, within weeks after taking such a drug, you might have much more tolerance. That is because the enzymes have been activated. Liver

enzymes work on these metabolites and break them down faster, so

that one can take a large dose of phenothiazine or some other related drug and not have a very high blood level. Blood levels, as

it is known now, of those given standardized doses per kilogram of

body weight, vary extremely widely. Evidence is more and more

solid that the effects of those drugs and hence any propensity or

proclivity to continue taking those drugs, is related to those

blood levels. This is a research question. What are the longterm effects which are not known yet -- the memory, if you will,

the enzyme level of somebody’s reactability to various psychoactive drugs -- if they were exposed to these drugs when they were

a fetus? It is strange in a way, but it is turning out to be very

important with various drugs and their long-term effects and hence,

their adverse long-term effects. The dose factors are going to

have to be explored more and more.

Mr. Romm: It seems to me that this problem relates to non-illicit

drugs as well; it is not limited only to psychoactive drugs.

Dr. Gottschalk: Absolutely. In fact, I think of drug abuse not

in terms of the illegal ones, but in terms of the drugs that are

extant, some of them which are very useful.

Dr. Kramer: However, if you look at genetic effects too, and there

is evidence that some of these psychoactive drugs may in some way

affect chromosomes, you may indeed get involved with the genetic

effects of the use of drugs, which again affect the fetus, which

again may have some relation to production of certain enzymes, etc.

Dr. Gottschalk: Year-of-first-use may go back pretty far!

Dr. Newmeyer: Regarding property crime statistics, I found that

one is able to set a maximum figure on the number of addict thieves

that must be out there based, not upon the police reports of crimes,

but upon the recent data we have on the number of crimes a sample

of the general public reports having happened to them. By making

a string of assumptions we can get a figure that tends to set an

upper limit on the number of thieves there might be. This is

available in a report.*

*John Newmeyer and Gregory L. Johnson. "Estimating Opiate Use

Prevalence in San Francisco: Feasibility Studies." SAODAP, Executive Office of the President, Washington, D.C. 1973.

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Q: Are most of these thieves addicts?

Dr. Newmeyer: At most 50 percent.

Dr. Chambers: I have a lot of difficulty using official crime

statistics to describe, predict or to do anything else with. when

you look at the rates of victimization, and you look at the rates

of self-reported criminal involvement of addicts, neither one of

them looks anything like the official statistics. The use of official statistics to describe what is happening seems highly questionable. I have never been able to use official crime statistics

for anything other than to generate hypotheses.

Dr. Savitz: You have to be very cautious in the use of LEAA data

on victimization. They have not as yet indicated the methodologic

limitations of the data, in spite of attempts to secure that information. But the data are being used in many cities for political purposes. There are limitations to crimes known to the police,

crimes known to the victims and crimes known to the criminal --

that is, self-reported types. There are advantages in official

statistics; they are the smallest. There are too many doubts in

people’s minds to use victimization statistics. There is also

enormous doubt concerning the validity of the self-reported statements made by people when they are reporting about events that

could put them into jeopardy should they become known to other

people.

Dr. Josephson: Having chaired one conference on the epidemiology

of drug use and now having attended this one, I am a little bit

more puzzled than ever as to just what epidemiology means in this

context. I thought that epidemiology had to do with the research

discipline intended to help us understand and prevent disease and

illness and help with problems. I think that what has not been

said here and the implications of the kind of research being discussed here, whether surveys of households, or people in treatment,

or monitoring of police and other records, if that all assume a

kind of medical model which is naturally taken from the traditional

epidemiological discipline in public health. The implication, of

course, is that drug use is a disease. We have not talked about

that part, however. The implications of the moral and political

considerations are very serious. Dr. Kramer just spoke of possible chromosomal damage. There is no question that some forms of

drug use lead to disease; some diseases lead to drug use. But,

drug use per se is not a disease and probably most people who use

drugs, since that includes most people in this society, are not

diseased for doing so. I think we have to be careful about the

application of these models for thinking about such problems. It

carries over, for example, into all our discussions about contagion, about epidemics of drug use -- all of these adapted almost

unquestioningly from traditional epidemiological consideration of

infectious diseases in particular. There is, of course, a kind of

infection going on, but it is a social contagion rather than some

other kind.

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I think we tend to forget that not only is man a drug using animal,

he is also a drug inventing animal. Karl Marx said that religion

is the opium of the people; some people have corrected him by saying the opium is the the opium of the people. What this really

adds up to is that the discussions tend to get very technical and

we tend to concentrate on technical questions of data collection

and interpretation, but I think what we really are talking about is

not a health problem so much as a moral issue. This is a truism

by now; we would not be here if it were not a moral and therefore

a political issue. The real question for epidemiologists and anybody else who is concerned about drug use and how any society

might or should or can respond to it, is to search for ways in

which we can better accommodate both the society at large and also

those who are using drugs, some harmfully and some not so harmfully, i.e., two different patterns of drug use. I suppose here

the model that comes to mind is the attempt of various societies

to accommodate to the use of alcohol. Various policies have been

adopted to control, to limit, to prevent, to treat; but nevertheless, in many societies, not all, accommodation has been made in

the sense of accepting certain levels of this particular form of

drug use, and this, I think should be considered in some of the

implications of the research we are doing. I think we should also

remind ourselves that the danger of the sort of medical model in

the epidemiology of drug use is the implication -- again, we come

back to the moral question -- that we must and can do something

about it. I am only suggesting that there are many issues in

which we not only have difficulty in pointing out the extent and

dimensions of the problem, but for which we also have difficulty

in trying to determine just what and if anything can or should be

done about it. I will end by saying that one of the things that

can be done about it is nothing. It is not the only thing but it

is one of the things to be done about the drug problem. Some elements in society have, indeed, done little or nothing about it.

I am not recommending that, but I think we need to remind ourselves of some of these dimensions and alternatives.

Dr. Kramer: The paramedical model for epidemiology really responds to the public health model, where you are manipulating variables that deal with the characteristics of the host, agent, and

environment. Epidemiology has been successfully applied to noninfectious diseases as you know -- cancer, cardio-vascular diseases, etc. It has also been applied to accidents. So I think

a lot depends on getting some clarification on some of these terms

and what we are trying to get at.

Dr. Josephson:

diseases.

My only point was that we have only mentioned the

Drug use is not a disease.

Dr. Kramer: Accidents are not a disease either. It may be a disease of society if you want to call it that, but it is not a disease. It is a disability, a defect, a characteristic and you are

trying to study its distribution on the population in some way.

Dr. Cisin: Exactly -- you are talking about a condition or an

event which the society decides is undesirable. Certain diseases

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that we now consider undesirable have in the past or in other

societies been considered desirable conditions, for example, epilepsy among the Greeks. All I want is a definition of what a

society will consider desirable and what a society will consider

undesirable.

Dr. Kramer: That is another issue. It has nothing to do with the

study of the condition.

Dr. Cisin: Absolutely -- the societal decision as to what is

desirable and undesirable is irrelevant to the techniques that are

used to study how to stamp out what we in our stupidity or wisdom

decide is desirable and undesirable in the society.

Dr. Richards: I chose the word "epidemiology" for this Conference

with a distinct knowledge of its shortcomings. In fact, I have

written a few words on the subject.* I think it has real limitations; it implies a medical model which should not be used for behavior in the usual sense. There are other models, such as models

of technological change or consumer behavior; there are a lot of

other models from the social sciences that have not been explored.

Therefore, any time we use the word epidemiology, I think we have

to do so with tongue-in-cheek.

*"The Measurement of Prevalence, Incidence and Patterns of Drug Use

in the United States" -- CENT0 Seminar on the Epidemiology of Nonmedical Drug Use, Turkey, October 6-11, 1974.

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IV. CURRENT ESTIMATES, RANGES,

AND TRENDS

225
Trends and Projections

Carl D. Chambers, Ph.D.

I am in kind of a bind. We sat here all day yesterday and said we

do not know how to describe what is currently going on or what has

gone on in the past. Dr. Cisin has told us about the problems in

getting the kind of data that I typically gather, and yet I have

been asked to give you projections on what is going to happen

tomorrow or the next day. In spite of that, I am going to do it

anyway.

I fully agree with everything that Dr. Cisin said and I would like

to reinforce some of the points he made. It’s getting more difficult to do survey research, but I do not think it is impossible to

do it. I think it is necessary we continue to do our survey research, it being one of the best data pools available for long

range intervention planning. However, I do think consumers go

astray with survey research results in that they attach too much

"hardness" to the numbers that we give them. Instead of using

them as "problem indicators," they want to talk about those projections as if they were an actual census of real people. If your

survey shows up 7,291 people from a projected base, they put that

into their planning books as 7,291 people who do something. Unfortunately, the consumer extracts the numbers without including

the qualifiers which are contained in the text. As survey researchers we are going to have to train those who receive our results

how to utilize those results better. I think we have been a little remiss in the past.

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Our survey research group has now done roughly 30,000 general population household interviews. There are 17 separate studies each

one done with the same basic instrument and approximate methodology throughout. In addition, we have a data base of approximately

3,000 interviews collected over the last two years with active

"involved" users -- we call them high frequency users -- on the

street and we have approximately 1,000 interviews with "skid row"

residents. We recently completed two family studies -- one involving 50 families, in a small rural town with a population base

of 2,500 -- roughly 270 families -- and another family study of approximately 280 farm families -- rural residents living on farms

in the midwest.

It is from this data base I would share what I believe the trends

are and what I think we have to look forward to. (The data is

available for secondary analysis either through me or through the

clients we’ve had. The Institute of Defense Analysis has just

completed such a supplemental study of our surveys.) In the area

of prevalence and current use I will start out by simply sharing

with you what, in the area of illicit drugs, we found in the District of Columbia, our most recent survey. We completed the survey

30 days ago and delivered the product two weeks ago. More than

anything I have seen in the past three or four years, these survey

data support an earlier statement about availability influencing

prevalence and incidence. For example in the category of "ever

used marihuana," we get a prevalence figure of 27 percent in the

population 15 years old and above. For "current use," roughly 14

percent of the base population has smoked marihuana in the last 30

days. That compares with the reported figure of around five percent.

In order to provide you with a comparative base, let me share with

you data obtained from Iowa with the District of Columbia data.

Both surveys were done with the same basic methodology and instrument.

(Washington, D.C.

Interviews) (Iowa Interviews)

Ever Used Last 30 Days Ever Used Last 30 Days

Marihuana 27% 14% 8% 3%

L.S.D. 4% .6% 1% .1%

Amphetamines 5% .8% 2% .4%

Cocaine 7% 2% 2% .3%

Heroin 3% .4% .3% .1%

Our survey data suggest that some 15.9 percent of the population

residing within the boundaries of the District of Columbia (age

14 and above) is currently using one or more of the illicit

drugs . . . translated to a projected number of people, this would

be some 90,000 persons. The vast majority of these people are

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users of marihuana. These findings highlight one of the more significant trends in drug abuse. There exists an ever expanding

group of citizens who smoke marihuana on a fairly regular basis

but who do not use any other illegal drugs. Although these marihuana smokers may have experimented with other drugs at some time

in the past, most appear to use only marihuana and alcohol in any

long term pattern of social or recreational use. For example, in

the District of Columbia we found 60 percent of all current and

regular users of marihuana did not use any other illegal drug.

Not unexpectedly, we found the majority of marihuana smokers were

not students. By and large they are people who began experimenting during their earlier years and have continued to do so as they

grew older. They do pose some interesting planning problems for

those who write our laws and those who are called upon to enforce

them.

Combining our general population surveys and our attempts at penetrating the subcultures, let me give you what I think is the drug

problem, if we indeed have a drug problem, in proportion to what

heroin use is in the country. Using heroin numbers as your comparative base: We believe that there is as much LSD use as there

is heroin use. We believe there is approximately twice as much

use of amphetamines -- methamphetamine, speed, whatever you want

to call the stimulants other than cocaine -- as there is heroin

use. We believe there is four times as much cocaine use as heroin

use. And finally, we believe there is approximately 40 times as

much regular marihuana use as there is heroin use.

Most of the surveys we have done are done for planning purposes and

for clients other than the federal government. People responsible

for planning want to know how to "rank" their drug problems and

where they should make their interventions.

he way to discuss intervention is to discuss which of the drugs

used has the highest progression risk, i.e., once you have begun

experimentation, the risk of continuing on to regular social/recreational use, and then continuing on to dysfunctional use. If you

compare "ever use" figures with people who continue that use, you

find that marihuana has the highest progression risk of any of the

drugs, at least to the level of regular social/recreational use.

To interpret data for planning purposes, however, is very touchy.

For example, if you apply the same technique with alcohol, it

would probably show up as the drug with the highest progression

risk. But nevertheless, I think it is fruitful to at least rank

the drugs by progression risk. Our data would suggest that you

can rank marihuana as first, amphetamines as second, cocaine as

third, heroin as fourth, the sedatives as fifth, and the psychedelics as sixth. There is very little evidence of such progression

with the solvents and inhalants. However, we may miss this progression as we rarely go below age 14 in our surveys, missing the

younger group who is most at risk for currently using inhalants or

solvents.

As most of you know, our surveys probe for the use of all psychoactive substances rather than focusing only on the illegal drugs.

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These include the prescription drugs, the over-the-counter drugs,

alcohol and illegal drugs. If I were to project what our next

major drug problem will be, I would suggest it will be adolescent

abuse of alcohol. In fact, our data indicate "the problem" has already arrived.

Applying Cahalan’s index to our data, we find adolescents in the

age group 14-17 are at least proportionately represented among

heavy daily drinkers and in some geographic areas are already overrepresented. As epidemiologists we have become concerned with a

correlate trend . . . the mixing of alcohol and other sedatives among

these younger drinkers.

One of the reasons we pursued our family studies was to try to look

at correlations between parental use patterns and adolescent patterns. We found a direct correlation between parental drinking

and the amount of drinking, and adolescent drinking and the amount

of drinking. We did not find a correlation between parental use

of psychoactive substances other than alcohol and adolescent experimentation of psychoactive substances. I don’t know how that

matches with Denise Kandel’s study population of New York City

adolescents.

Dr. Kandel: That fits in very well. We find there is a very

slight correlation between parental use of psychoactive drugs and

kids use of illicit drugs. Parental use of alcohol is much more

important. But we found a slightly curvilinear relationship. I

do not know if you found this also: at the very highest levels of

parental alcohol use (those parents who say they use it daily),

there seems to be a slightly lower proportion of kids who are using alcohol themselves, but that proportion is still higher than

in the families in which their parents don’t drink alcohol at all.

Dr. Chambers: Let me indicate some of our other correlations. We

did find a positive correlation between adolescent use of cigarettes and subsequent use of illicit drugs. We found no correlation between adolescent drinking and adolescent use of other psychoactive substitutes. Almost everyone drinks, whether they use

illicit drugs or not.

Q : Are you doing anything at all about partitioning your samples

according to demographic and other breakdowns in order to determine the patterns of variation in the population?

Dr. Chambers: Yes, we normally group data by social class as

measured by observation, and social position as measured by family

income, parental education, etc., as well as by various labor force

categories and of course sex, age and race.

Q: Can you say anything about those variations?

Dr. Chambers: There are variations. People who misuse legal

psychoactive drugs are more likely to be in the middle and upper

classes; part of that is artifact because they are more likely to

be the ones who seek out physicians. However, the same amount of

229
chemical coping occurs in the lower classes, but I think it is

occurring with alcohol and, to a certain extent, with the OTC

drugs.

Dr. Sells: There is one point I would like to check. In our

data, we have been very much impressed with the significance of

the heavy use of wine as a correlate to deviance, etc. I wonder

if you have anything to add to that?

Dr. Chambers: The only thing that we have is that the pop wines

have essentially changed the patterns of drinking for people under

21. In the past, when you could not drink legally until 21, whoever looked the oldest in a group would go in and buy a half pint

of Four Roses and four people would hide in a car and get drunk on

it. Now a kid can drink at 18, so 14 and 15 year olds have full

access to alcohol and in most places, they can even buy it at grocery stores, etc. The pop wines are the major consumption for the

age group; they move from that to beer. They drink pop wines because they taste good. It is not like when I had the experiment

with alcohol at 14 and 15, and the darn stuff didn’t taste good.

I really had to pretend I liked it. I think with the pop wines,

you do not have to do that any more. They do taste good and people soon learn you can use them in a variety of ways. The most

popular being in combination with sedatives. Such combining is

not entirely new. For example, we knew 10-15 years ago that you

could take marihuana and heated wine and alleviate heroin withdrawal distress by simply staying knocked out.

Let me move back to the question of availability. We have studies

everywhere except the far West Coast and we have found heroin, cocaine, the psychedelics, and illicit amphetamines to be available

everywhere. Even the smallest rural communities in Iowa, Arkansas,

Mississippi, etc. can have heroin and cocaine if they want it.

The sources are there and we don’t know what forces there are or

what buffers an individual has on whether or not he can openly experiment with those drugs as he does in our more populated areas.

If you look at the recent data from SAODAR and the Drug Council,

there is evidence that heroin is showing up in the smaller cities.

I think the smaller cities are running "behind" in a variety of

drug abuse patterns, not only heroin use. I felt for a long time

that we had a real decrease in LSD use but recently it appears to

be coming back. I think we are finding a new group of people who

are experimenting with LSD and this may not represent an increase

in use but may only be a different group. The reason it looks

like an increase is because we are looking at different places now

than we looked in the past. I think if we looked nationwide or

looked at some central four or so points across the country, we

would find the LSD incidence pattern has been fairly stable. I

think most of the drug use patterns are fairly stable; I think

that the rate of experimentation and the incidence of progression

to the social use of drugs probably will be found to be fairly

stable.

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We detected one pattern of abuse which I earlier predicted to be

one of the next abuse patterns -- that is, the abuse of anti-depressants. The truckers and the kids were abusing them in the midwest and the south. And I said, once we don’t have amphetamines

any more everybody is going to get on to Elavil and have a good

time. I am not sure if that is occurring or not occurring. Once

I picked it up and began to ask about the pattern, I got too many

people telling me "Say, that sounds like a good idea." I felt a

little reluctant about participating in the spreading of a drug

pattern around the country. I felt we were actually showing people

a new drug they- could abuse, and so I have quit asking about it.

Similarly, I quit asking if there were any thefts of veterinary

supplies, etc., in rural areas because people replied "Gee, I

didn’t know that vets had those kinds of drugs around."

In the area of misuse of the legal prescription psychoactive drugs,

we find as many as 20 percent to 40 percent of all regular users

misuse these drugs, e.g., don’t have a prescription or do not take

them as prescribed. As has everyone else, we find women about the

age of 25 to be the primary consumers and the primary misusers of

these drugs. Divorcees and widows, regardless of employment status,

are most at risk for this pattern of abuse.

We have found considerable misuse of over-the-counter stimulants,

tranquilizers and sedatives. I think this abuse pattern is going

to be a major health issue in the near future. Primary consumers

of these drugs appear to be people on fixed incomes. As the economy worsens -- and I cannot help but feel that it is going to -- I

think people who have been going to physicians and using prescription drugs will be switching to the OTC drugs, and they are not

being as "careful" with these drugs as they were with their prescription counterparts. If you will look at DAWN’s emergency room

statistics (and our Miami metropolitan area statistics correspond)

the major increases in overdoses have involved the over-the-counter

drugs. I do not know if such has been occurring across the country although I suspect it has. We have a very large fixed-income

population in the Miami area, and we have always had a high consumption of the OTC drugs which may bias my perception. However,

I do think we are going to find OTC abuse becoming a major problem.

One of the final things I would like to share with you are the

"problems" we pursue when we interview; for example, has the respondent ever had an adverse reaction to drugs -- physical or psychological; have there been any problems in the family (self-defined by the respondent) -- trouble with the police or on the job,

etc. It is relatively astonishing to me the number of people in

our population who have already had problems in the family, problems with the police and on the job as a result of drugs or alcohol use. For example, in one statewide population study which is

representative of all our studies, we found the following:

231
From From

Using Drinking

Drugs Alcohol

Have had trouble in the family 6% 11%

Have had trouble with the police 2% 5%

Have had trouble on the job 2% 5%

I share the concern of our Canadian colleague, Dr. Rootman, as to

whether or not we are actually going to address the problems that

drugs cause or the drugs themselves; I am more inclined to say we

ought to begin to think about the people who are having problems

with drugs and not be terribly concerned about which drug it is.

One final note that I would address to those people who have policy making and planning powers. In the subcultures we have been in,

and we have been in a variety of them across the country, about

one-fourth of our active drug users do not know of any treatment

program in their community. Outreach is not terribly effective in

most places in the country. Yet outreach does work and I would

demonstrate the ease with which it does by sharing with you one

of the problems I had as a researcher involving a study in Detroit.

I was trying to do a longitudinal study of active users in the subcultures. I would identify an individual and then relocate and reinterview him in 60 days, relocate and reinterview him in another

60 days to see what life style and drug consumption changes had

occurred. The people I hired as guides or field workers to assist

in the project happened to have been outreach workers who wanted

to do this as a means of supplementing their income. They were

very effective on the street. The problem was that within the

first 30 days, everybody I had identified they had recruited for

their program making it impossible to do longitudinal work. I

finally fired some very effective interviewers, and found people

who would not recruit all of my respondents into treatment programs. Outreach is possible and I begin to think about how some

of our epidemiological data point to those things. In addition

to the 25 percent who knew of no programs? an additional 25 percent of our respondents had so many negative feelings about the

current treatment delivery system that they would not go into

treatment. We are, I believe, losing one-half of the people who

would accept treatment if treatment were available and acceptable

to them.

AUTHOR

Carl D. Chambers is Executive Vice President, Resource Planning

Corporation, Miami, Florida.

232
DISCUSSION

Dr. Rootman: I would like to support Carl Chambers' point about

the rural areas. In 1971 I was involved in a large study in rural

lAlberta (Canada). We found that essentially, the patterns of use

were no different in rural Alberta than in metropolitan Toronto

and metropolitan Montreal at approximately the same time, except

that in Alberta, there was much higher alcohol use, glue and solvent use at the same period.

We found in our studies based on the Bureau of Dangerous Drugs and

Narcotics Registry, that the highest incidence rates for narcotic

abuse or recognized narcotic abuse in Canada, in 1973, were not in

metropolitan Vancouver, but in some of the smaller communities in

the interior of British Columbia. It would suggest perhaps a

spreading out into the rural areas, not only the case in the United

States but in Canada.

Dr. Sells: You mentioned the aversion of going into treatment. I

have the impression from the DARP file that an overwhelming proportion of the patients are in treatment under coercion rather

than as volunteers.

Dr. Chambers: I have felt for a long time that as long as a person is able to support his habit and the police are off his back

and his source remains fairly constant, why go into treatment? It

is only when his family begins to hassle him or he losses his

source or the police have identified him, that he comes into treatment. The thing that concerns me, in spite of this, is that the

bulk of our treatment delivery system is stereo typical. It is

narcotic-oriented, and I think the whole narcotic picture is shifting. I think we are getting a pattern of social/recreational use

of heroin much greater than we had in the past, and therefore, new

data is showing a resurgence of heroin use. In the early '60's

the dominant philosophy was that you could not "chip" around with

heroin. I have become convinced, however, that most people can

"chip" around with heroin and indeed they do so. To take that individual and place him into a treatment delivery system based upon

hard-core narcotic addiction is inappropriate for him and he knows

it. If you ask him what he wants instead, he can not tell you.

There is the example of Moffet's study in Philadelphia where recently initiated addicts were detoxified with methadone, as part

of the standard detox program. On follow-up, a significant number

233
of them had adopted methadone as their drug of choice, because it

was simply better than what they had before. There is always that

risk of giving somebody something better than he has had before.

Dr. Elinson: I would like to point out that one of the simplest

concepts, namely "current use" has been defined as "a period of

30 days" and as "the lack of intention never to do it again." I

just want to remind the group that this is where we are with respect to defining what appears to be even the most simple terms in

area research.

Dr. Abelson: I would like to add to that by pointing out a concept which gave us equal difficulty, and which we by no means feel

we have solved, and that is the communication of the notion of nonmedical use of prescription drugs to a household population. The

term non-medical by itself is certainly a precise one in ordinary

survey communication. The operational definitions which we concluded go part of the way -- it is all right to ask people if they

have tried any of these drugs just to see how they feel. But there

comes a time when this is really quite illogical, because making

oneself feel good can easily be interpreted as also related to

need. I am just starting to get around the edges of this. At any

rate, I would like to point out that the notion of non-medical use

is by no means an easy one or one that we think everyone will accept or respond to in the same way.

There are two or three other points I would like to make. One is

that in getting through a catalog of drugs with the household population, we really have a big trade-off. The trade-off is in what

all of us who are craftsmen in this field believe is some of the

higher parts of our art -- that is, the development of the interview experience through the initial acceptance by the respondent

of the interviewer, to the point of increasing interest, to a point

of being able to ask questions of respondents which truly might

have been "turn-offs" at the start, but no longer are at this stage

in the interview. In other words, the development of the interview as an art form and its distinction from what the PTA might

do if it wanted to poll its members is something in some part that

has to be abandoned when there is this necessarily repetitious

kind of catalog of experience that we are looking for.

I would like to tell you a little about an experience that we had

with the first study that we did for the Marihuana Commission in

which, as a matter of curiosity (it was not part of our charge) we

included some questions on the hard drugs. We then pulled the 55

questionnaires where there was reported heroin usage and tried to

examine those questionnaires clinically. Incidentally, this is

one of the things that I would recommend -- that is, to identify

quantitatively segments of the consuming drug public and then examine samples of those questionnaires in a clinical fashion, as

though one is looking at one protocol at a time to see what can be

learned from it, even though the questions are fairly superficial.

Starting with a kind of a priori semi-intuitive notion of what else

234
should have been said in this interview of 55 heroin users to indicate their heroin experience, we succeeded in getting that list

down to 12 people whom we were certain of and the remainder whom

we were not at all certain of. In turn, this led us to a form of

analysis which we have already used and intend to examine for its

use again in this new study, simply because there is so much repetitive data. That is, using a set of techniques developed by

Sam Messick about 10 or 15 years ago in connection with test development to score each question for each respondent and develop

a set score -- that is, the likelihood that the response was part

of a pattern -- as compared with the content score, and then examine the relative contribution to the total response of the set

and content components. By themselves, I would not recommend that

one go with just these two indicators for each question, but with

other data, they worked out fairly well for us.

Lastly, I think one of the larger contributions to total variance

and to error variance may be the over-reactive way in which we

communicate to respondents that the information we are looking for

is so sensitive that we surround it with an enormous number of

privacy type devices to insure the respondent that in no way will

that questionnaire become public. The fact is that we do and it

is true, but I wonder what the impact of that is on the interview.

235

V. CURRENT EPIDEMIOLOGY

PROGRAM AND

RECOMMENDATIONS
Current Program Dimensions

Richard Myrick, Ph.D.

I have passed out two pieces of paper and I will deal first with

the one with the date November 1974* in the upper right hand corner. This is a matrix which shows what grants we have. The problem with classifying grants is you can either classify them by

drugs -- but as soon as you do, you discover that somebody is dealing with a whole lot of different aspects of one drug -- or you

can think about them as by topics -- and you discover that somebody has got one topic but he is dealing with a whole series of

drugs under that one topic. This is what has led us to make a

matrix which shows topics down the left side and drugs across the

top. This particular matrix gives you the number of grants funded

with FY 74 funds; FY 74 is the 12 month period that ended June 30,

1974, and it shows how many grants there are in each of these different topics and each of these different drugs. One of the advantages of making a matrix is that it shows you in some areas we

have a great many projects going on. For example, under Mechanisms of Action where it meets the Opiates column, you will see

that there are 10 grants there. On the other hand, you can see

just to the left of that under Mechanisms of Action and Hallucinogens, there are no grants. Hence, this matrix leads people who

are planning our program to look at both empty cells and very

crowded cells to see whether indeed we should be having as many

*See Attachment 1.

238
projects as we are, if the cell is crowded; or if the cell is

empty, or has a small number, maybe we should have more emphasis

in that area. You can see by looking in line 1, Epidemiology and

Surveys, in the next to last column on the right, that we have

nine projects total, as of June 30, 1974. That means that there

are nine Epidemiology grants funded with FY funds. For your general interest, the dollar value of those is $1.35 million. You

can calculate the percentage of that if I tell you that is out of

a total of 204 projects and a budget of $17.6 million; so you can

see that Epidemiology is getting a little under a tenth of the

grant funds here. This does not show you contracts. We also have

as of June 30, 1974, six contracts dealing with Epidemiology and

they are valued at $350,000. That is because only one-half of

them drew at FY 1974 funds, but this gives us a total of $1.7 million in Epidemiology. By way of contrast, you can look at the

bottom line at the extreme right hand column and see what the program was a year and a half earlier, as of January 1973. You can

see, for example, that there were only five grants in the Epidemiology field then, and only a total of 142 grants in all. You can

also see by comparing the two bottom lines in the two right hand

columns, how much the program has shifted. Generally speaking,

the major change that has occurred in the program was that a year

and a half ago, we were somewhat under fire for putting too much

money into marihuana and not enough into opiates, so there was a

big push to put money into opiate research then. Now, the wind

has shifted and we are busy getting more money into the marihuana

field.

It is complicated to try to put together our dollar amounts and

our program amounts. For example, in FY 1974, although we had 204

projects funded with FY 74 funds, we had 166 additional ones which

were not funded with FY 74 funds. They were either carried forward from a previous year, or they may have expired, or some may

still be going on. Just to give you a rough feeling for budgets,

in FY 73, the grant program was $16 million and in FY 74, it was

$17 million; and at the moment, for FY 75, it is scheduled to be

nearly $21 million.

Macro Systems and Jack Mendelson have prepared two books for us

which describe our program.* One of them has a list of all drug

research that is funded by the federal government. It is listed

by researcher and the principal investigator.

Q : Does that include alcohol research as well, or is alcohol not

a drug for that purpose?

A: It is not a drug in this case.

*Drug Research Directory FY 74; and Federal Supported Drug Research, 2 vols. SAODAP, Washington, D.C.

239
Q : Is there a similar list for the alcohol projects?

A: No.

Volume 2 of the Macro-Mendelson publication also has all kinds of

pie charts, showing how the money was spent one year and how it

is going to be spent in another year, organized by agencies and by

drugs. I really just wanted to flash it by you so you would know

that it does exist -- if you want to get information about specific studies, you get one of these volumes and if you want the whole

federal effort, particularly in dollars and number of projects,

you get the other.

Now lastly, there is a second page of the handout which is labelled

A Trellis....* Over the weekend there was a story in the newspaper that the people who operate one of the radio telescopes had

beamed a message out to a distant star. It said that it was going

to take 24,000 years for the message to get there and if the fellows out there who get it can figure out what we are saying and

send a message back, we will have an answer in 48,000 years. Anyway, this is the way I sometimes feel when I watch the money that

is being poured into drug abuse research in terms of getting an

answer back. We see lots of research happening, and we are told

now that heroin is on the increase. But it should not be on the

increase after everything we have been doing! It should bc more

on the decrease. Maybe it is that the 48,000 years have not yet

passed, and maybe by then it will be decreasing. In any event this

trellis is a device for keeping track of our program and some of

the program analysis efforts that we make. If you begin at the

lower left hand corner, you will see the word "List" and it says

Report No. 201. That is an IBM printout that you can get that

lists all our projects for all the years. The purpose of that is

to answer general inquiries and generally give the administrators

of the program some idea of what is going on.

Moving to the second column, you can see it says "List" again.

This is because the list that we use for Categorization is not the

same list, or at least it does not contain the same kind of data.

It is drawing on the same kind of projects, but it may in one case

be all parent projects and in another case, all projects funded in

just one fiscal year. We have a person named Nancy Schwartz who

puts them in categories. The categories, generally speaking, agree

with the topical area and the drug area that I showed you earlier.

Then we have still another kind of analysis which is in column 3

and that says "Mendelsohn," under the word "Fiscal," that refers

to these green documents that I showed you. Again, he is using

all of the federal efforts so his list is different from the other

lists. He also has a different category scheme, but he does tell

you how the program breaks out in fiscal categories.

*See Attachment 2.

240
As you get towards columns 4 and 5, you begin to get out of the

administrative aspect of this effort and into the scientific aspect where Nancy Schwartz provides summaries of projects and we

respond to requests from people who want to how what it is we

have going. Then periodically, our staff pulls together what is

going on. That is column 5 where we attempt to assess the progress of our projects. With regard to column 6, Macro Systems held

a conference to identify gaps and overkills. They came up with

long lists of things where they thought there was too much effort

and other things where they thought there was not enough effort.

Columns 7 and 8 address the social utility of drug abuse research.

These were pipe dreams on my part. We have yet to really determine the relevance of research to the real world of drug abuse.

We have in some of our clinical projects. But in the last part,

the idea of examining social indices and getting the final payoff of our program -- this is something that has the least amount

of our efforts. We spend most of our efforts making lists of our

projects, way back in column 1. I guess I should have put the

48,000 years across the bottom of this to show the time lapse before we ever begin getting the payoff.

AUTHOR

Richard Myrick is Research Psychologist? Division of Research,

National Institute on Drug Abuse, Rockville, Maryland.

241
November 11, 1974

NATIONAL INSTITUTE ON DRUG ABUSE

Division of Research

ANALYSIS OF THE GRANTS PROGRAM

ATTACHMENT 1
A Trellis Demonstrating Different Levels of

Program Analysis

ATTACHMENT 2
Interpretations and Policy Implications

Helen Nowlis, Ph.D.

I have some problems. In addition to the topic announced, Louise

Richards asked me if I would try to summarize. I look at my

watch and realize we still have two important speakers and topics

to go, so I think my summary will be very brief.

I always have a great deal of difficulty with these conferences.

Sometimes I describe it as being in an adolescent identity crisis,

and other times I describe it as being schizophrenic, because my

whole background has been in research and it is only in the last

three years that I have attempted to get involved in policy and

program implementation. So I have difficulty in keeping these two

things separate.

I would like to talk first from my research point of view. We have

been hearing at least three things in the last two days. One is

that this conference has been organized around a methodology and

it is quite clear that everyone here does not mean exactly the same

thing by that methodology. We have heard about it from the practitioner’s point of view. We have heard about it from the theoretical point of view. We have heard about it from a mathematical

or a statistical point of view, and we have heard about it from a

pragmatic point of view. I think the point I would like to emphasize, and it is not too different from what Eric Josephson said

a little while ago, is that any methodology is only as good as the

skill with which it is applied to an appropriate problem. I think

we have raised considerable issues about the skill with which we

have applied the methodology and I trust that Dr. Kramer will

244
talk about this some more; and I think there have been important

issues raised about the appropriateness of its use for certain

purposes. We have heard about the dangers of extrapolating from

inadequate data. We have heard about the fact that any statistic is only as good as the validity and the reliability of both

the numerator and the denominator. We have been cautioned about

the various terms and techniques that are used in epidemiological

research, and cautioned to make distinctions among prevalence and

incidence, point incidence, point prevalence, interval, etc. We

sit here and discuss this and I think most of us understand what

we are discussing, but the thing that most people look at is the

end product. I would like to suggest that among the consumers,

there are very, very few people who understand what it is that

goes into the projection or extrapolation. Somehow or other, maybe because of all the work that has been done -- the touting of

political polls, surveys, household surveys and the great accuracy

with which we can predict things -- the great majority of people

have far greater faith in the result than any of us do or than

they should. Almost never does anyone who is going to use the

materials, outside of the methodologically sophisticated, look at

the basis from which the figures came. I think we have gotten into some very difficult positions as a result of that.

After all, in epidemiology, we are dealing primarily with statistics. But in the real world, we are dealing with people. I think,

as Lloyd Johnston and Gail Crawford and Lee Robins have pointed

out in a sort of indirect way, that it is possible to use these

data vis a vis real people, but not in terms of national surveys,

probability samples, or extrapolations. I have often wondered

exactly why it is, as the question has been raised several times,

that we have this desperate need to get national figures and

national trends. They are no help to me as I try to design programs and relate to individuals, to individual school systems, to

teachers, to students, to community programs -- no help at all.

I often wonder if we are not trying to deal with the whole problem

of drug abuse as if it were a disease, an infectious disease, and

not a social problem. Because once we say social problem and once

we say human behavior, we must take into account the characteristics of all human behavior -- a) it is motivated, b) it is variable, and c) it is multiply determined. I can’t figure out how

national trends and extrapolations are going to help me in dealing

with that kind of thing. I can begin to look at the implications

of some of the studies either that take homogeneous samples --

because that tells me something about a group of people -- or that

deal with correlates, whether they be antecedent, simultaneous or

subsequent.

There are some cases in which we have a technique in search of a

problem and other cases in which we have a problem in search of a

technique or a methodology. I think we have to be very, very careful how we balance those two out. This whole thing gets, as these

last two days have shown, very confused by the lack of clarity of

definition, whether it is in terms of our methodology or whether

it is in terms of the phenomenon we are concerned with. It bothers

235
me terribly to throw all marihuana use, cocaine use, heroin use,

stimulant use, and sedative use into one bag as if they were various forms of influenza or something like that, because it is not

helpful. Different people are using different drugs, at different

frequencies, under different conditions, for different reasons.

And if I am going to try to address those problems or in any way

intervene, whether by prevention, intervention, treatment, or rehabilitation, I have to deal with people and not with statistical

extrapolations. I often wonder why we have this desperate need,

as someone put it yesterday, to count noses. I would conclude

that it was more in an effort to justify legal, social, and moral

positions, then it is to intervene in behavior which is at least

potentially destructive. The other things, which Dr. Rootman also

mentioned, is why are we not more concerned with the destructive

effects of use of any substance rather than with nose counting of

users?

After I talk like this, people ask "How can you stand to be in this

business, don’t you get discouraged?" I don’t get discouraged. I

think if we do a good job at whatever we do and make it very

clear, as we certainly have done today, that there are limitations

of whatever methodology we use, that we can contribute to a total

picture. I long ago gave up being terribly concerned about whether

this particular substance was up or down, whether alcohol was moving in or heroin was moving out, or that marihuana was going up.

If you are dealing with behavior, which involves the use of substances to modify mood, feeling, and behavior, you don’t have to

get involved with specific substances except as use reaches the

point where there are medical complications. At the level of prevention, nobody has ever used drugs. Or if they have, they have

only experimented with it. We must deal with it as a social problem, not as a medical or a disease problem. That does not mean

that we can not learn something from the behavior of other conditions. But I find very little help in planning programs, implementing programs, forming specific programs from these models.

We have reached the stage where we deal with what we call prescriptive action. That is, for any given community, what is the problem, what are the resources, and what -- from a smorgasbord of

strategies, techniques, methodologies -- is most appropriate for

solving that problem involving those people in that community?

Now this is a long, long way from national trends. One thing that

bothers me is that I do not find out about these trends until the

year after they have occurred and, by that time, they may have

changed. It is a pretty shaky ground on which to plan. I want

you all to keep doing studies. I want to be aware of them, but in

terms of their helpfulness in dealing with the potentially destructive behavior involved in the use of a great variety of substances,

it does not help me. I am delighted that you have had this conference. I am delighted to be here. All I am saying is that it

may be fine for social decision-making, but not as the basis for

intervention.

246
AUTHOR

Helen H. Nowlis is Director, Division of Drug Education, Health

and Nutrition, Office of Education, Department of Health, Education and Welfare, Washington, D.C.

247
Relationships Between Mental Health and

Drug Abuse Epidemiology

Morton Kramer, Sc.D.

Before discussing the topic assigned to me -- the relationship between mental health and drug abuse epidemiology -- I should like

to comment on the essential role of epidemiologic research in our

efforts to prevent and control disease, disability and major social problems. These comments were stimulated by the remarks of

the prior speaker, who seemed to have doubts about the importance

of such research.

Epidemiological profiles of diseases and disabling conditions for

the U.S. as a whole -- and their variations among regions, States,

counties, cities and other geographic subdivisions serve many important purposes. Data on the size of these problems, their costs

to the Nation and their social impact are essential to the process

of getting the support of Congress, State legislatures and local

governments to establish programs to prevent and control these

problems and provide the funds and manpower needed to implement

them. Planners need such data to develop strategies for attacking

these problems. Evaluators need baseline and other types of data

to measure the effectiveness of efforts to combat these problems.

These include incidence, duration and severity of disability, mortality rates and related indices. The uses to which such epidemiologic data are put have been admirably summarized by Morris.*

* Morris, J.N. Uses of Epidemiology (Second edition). Baltimore,

Maryland: William and Wilkins Company, 1964.

248
1. To assess changes over time in incidence and prevalence of

diseases, the disability they cause and their mortality.

2. To diagnose the health of the community and the conditions

of the people, to measure the dimensions and distribution

of the problems of disease and disability, to define health

problems for community action and their relative importance

and priority for action, and to identify vulnerable groups

needing special protection.

3. To study and assess the health services with a view to

their improvement.

4. To estimate individual risks, on the average, of acquiring

various diseases and conditions.

5. To identify syndromes.

6. To complete the clinical picture and describe the natural

history of chronic disease.

7. To provide clues to causes.

These uses are relevant not only to efforts to combat disease and

disability, but also to parallel efforts to eradicate the many social problems that play a major role in creating the conditions

in which disease and disability thrive and hamper our efforts to

prevent and control them. Indeed, it is a vicious circle because

disease and disability -- inappropriately attended and controlled

-- perpetuate and exacerbate social problems and vice versa.

A careful discussion of the relationship between mental health

and drug abuse epidemiology requires more time than I have available to me in the closing minutes of this conference. Basic to

such a discussion are operational definitions of drug abuse and

mental health. These are needed to specify types of relationships,

study designs for elucidating the relationships, and data collection instruments and procedures for acquiring the data needed to

compute the various indices. Since the types of relationships to

be considered have not been specified, I will suggest a few that

might be considered.

For this illustration, I will assume the following: (a) the operational definition of drug abuse has been agreed upon; (b) a subgroup of drug abusers are persons who would be classified as drug

dependent; (c) the definition of drug dependence is that given

in the American Psychiatric Association’s (APA) manual on Mental

Disorders (DSM-II) which includes dependence on such substances as

opium, opium alkaloids, synthetic analgesics, barbiturates, cocaine, cannabis sativa, amphetamines and other psycho-stimulants;

(d) the mental disorders other than "drug abuse" are those defined

249
in the APA Manual (DSM-II) .* The problem before us then is to

investigate certain relationships between the occurrence of drug

dependence and mental disorders other than drug dependence in a

defined population of persons. Let us specify that we have a

catchment area of population size N and we wish to classify its

residents on two major axes: (1) Presence or absence of mental

disorders other than drug dependence; and (2) presence or absence

of drug dependence as in the following four-fold table:

Mental Disorders Drug Dependence

(Excluding drug dependence) Present Absent TOTAL

Present N 1

Absent N 2

TOTAL N 3 N 4 N

To proceed further, it is necessary to specify the types of questions to be answered from this table. If we are merely after a

point prevalence count, i.e., the number of persons as of a specified date (given point in time) who have a specified characteristic, then we would need case finding procedures for determining

which of the residents fall in each of the cells of the above fourfold table. It would then be possible to determine the proportion

of the population of the catchment area as of a given date (e.g.,

July 1, 1974) that are: (a) both drug dependent and have another

mental disorder; (b) drug dependent only; (c) with other mental

disorder only; or (d) neither drug dependent nor with other mental

disorder. The marginal totals provide the data needed to provide

the point prevalence rates of drug dependence and other mental disorders. This is only one type of prevalence count. Other types

of prevalence questions might be asked. For example, how many

residents of the catchment area have bad an episode of drug dependence and/or mental disorder in the past 12 months? Answers

to such a question provide the interval prevalence rate; i.e., the

number of persons who have experienced episode(s) of illness (es)

any time during the past 12 months. This is called an interval

prevalence rate, i.e., the proportion of the population who have

experienced an episode of illness at any time during an interval

of time.

The above prevalence measures (point or interval) can be computed

specific for age, sex, race, type of mental disorder, type of

*American Psychiatric Association. DSM-II Diagnostic and Statistical Manual (2nd edition). 1700 Eighteenth Street, N.W.,

Washington, D.C., 1968.

250
substance on which the person is dependent, marital status, living

arrangements, etc.

Referring again to the four-fold table, we can ask other questions.

What is the prevalence of drug dependence among persons known to

be: (a) schizophrenic; or (b) to be suffering from a major affective disorder, i.e., manic depressive disorder (bipolar depress ion), manic dissorder only, or depressive disorder only (unipolar

depression)?

Or, given persons known to be drug dependent, what is the prevalence of organic brain syndromes among them?

Still other questions can be asked, such as: given persons who

have a major affective disorder but are not drug dependent as of

the survey date, what is the incidence rate of drug dependence

within some defined period of time, e.g., one year following that

date. That is, how many persons with a specified mental disorder

become drug dependent for the first time during a defined interval

of time?

We can also raise questions about the extent to which persons in

the cells of the above four-fold table are receiving services either

for their drug dependence, their other mental disorder, or both.

Are these services being rendered by personnel in a single facility? Are these services being coordinated? Or, how many persons

receive services for drug problems in one facility and services for

schizophrenia in another facility? Again, are these services being coordinated?

Many questions can be asked relating to the incidence and/or prevalence of various physical illnesses; e.g., cancer, cardiovascular diseases, tuberculosis, nutritional deficiencies, accidents,

suicide among persons who are classified as drug dependent. Or,

vice versa, i.e., how persons with a specified illness became drug

dependent.

Since the interrelationships that can be investigated are many, I

would urge that, if we are serious about exploring them, and I

hope we are, then a committee should be established to specify the

important questions to be answered about the reciprocal relationships between drug dependence and other types of mental disorders,

the types of services required by these persons, the extent to

which they are receiving them, and their effectiveness.

Persons doing field surveys and evaluative studies related to mental disorders have developed case finding techniques, designs for

evaluation of effectiveness of services, etc. Persons working

in the drug abuse field have developed techniques for similar purposes. A mechanism is needed to assure that there is a frequent

interchange of information among these investigators. To illustrate, the Division of Biometry has developed a demographic profile system which provides for each of the 1,500 mental health

center catchment areas (established in the U.S. under the community

251
mental health centers regulations) a series of 107 social indicators. These indicators define types of high risk population for

mental health, other health and social problems. Certainly, such

data should be of value to persons planning drug abuse services.

In addition these population data provide denominators for a whole

series of morbidity rates. What we lack are the numerators. Indeed, a major problem that must be resolved to carry out the types

of research specified above revolves around the development of

reliable, valid, sensitive and specific case finding procedures

for drug dependent persons and for persons who have mental disorders (e.g., schizophrenia, affective disorders, psychoneuroses,

organic brain syndromes, etc.). Another illustration of work going on in the mental health area is a study which the Biometry

Division is funding jointly with with in New York State. ‘The

Director of Statistical Services for the NYS Department of Mental

Hygiene is studying the patterns of use of services for mental

health, alcoholism and drug abuse in a selected number of catchment areas in the State ranging from very rural to highly urbanized populations and relating the use patterns to demographic variables and diagnosis and to service networks available in each

area.

I would urge that we pool our knowledge and experience to develop

a series of studies that would be mutually beneficial. From what

I have heard today, you have acquired extensive experience in community surveys. I would hope that, in the future, those of you ,

conducting such surveys might find it possible to add to your instruments questions that would be of value to those of us who are

concerned with the epidemiology of the other mental disorders and

planning programs for the delivery of services to prevent and control disability associated with these disorders and evaluating

their effectiveness.

In the mental health field, we have developed a body of techniques

for collecting and analyzing data for monitoring the delivery of

mental health services. Those of you actively involved in delivering services to drug abusers and drug dependent persons have developed similar techniques for monitoring and evaluating these

services. I would urge that we pool our knowledge. This can only

be done by developing collaborative arrangements for exchange of

information and mechanisms for planning studies that will investigate the many inter-relationships between mental disorders and

drug dependence and the delivery of services to the persons suffering from these disorders.

AUTHORS

Morton Kramer is Director, Division of Biometry, NIMH.

252
Program Gaps and Future Direction

William McGlothlin, Ph.D.

The assignment that Louise Richards gave me was to talk about

Gaps and Future Direction. I think we all have been talking about

gaps in the field of epidemiology the last couple of days and I

am not presumptuous enough to try to provide a super list. Instead, I direct my comments more in the context of what I see as

the major focus of this conference on epidemiology -- that is,

the measures of incidence, prevalence and trends -- rather than

some of the broader aspects of epidemiology such as etiology, natural history and the characteristics of the higher risk groups.

One thing that seems to me to have largely been ignored is the

benefit of looking at the epidemiology of alcohol use. It has always seemed to me illogical to separate drug use and alcohol use.

Beginning at the NIH level there is a tendency to discourage

rather than encourage what could bc valuable interactions and insights we could obtain from the much better established, longer

existing programs in the study of alcohol. I look at the Canadian

Addiction Research Foundation which merges these two in a way that

I think is quite beneficial. I do not have any particular familiarity with the alcohol research literature, but to the extent

that I have looked into it, I am impressed with the way that one

can get insights about the other drug epidemiological issues by

looking at work in this area. One example I will point out concerns epidemiological surveys in alcohol use. We would not pay

much attention to an alcohol study which only dealt in frequency

of alcohol use -- which lumped all daily users of alcohol together,

for example. Yet, we do this routinely with regard to drug use.

253
We seldom attempt to collect data on the amount of use. A few

years ago we talked in terms of ever-used vs. not ever having

used. Now we talk about frequency of use and we talk about recreational, casual users and daily users. I think this rather crude

approach has partly grown out of our considering the non-socially

approved drugs as a moral issue, and, therefore, we tend to think

of those who are and those who are not.

It is interesting to note that in other countries, not nearly as

advanced as we are in methodological techniques, the little literature there is frequently reports the amount of use. Opium is almost always referred to in number of grams per day, and similar

data are often presented for cannabis use. I think if we are going to describe drug use quantitatively rather than qualitatively,

we will certainly have to extend our measures to include amount

used and not just frequency.

There is a similar problem with regard to defining opium dependence. We talk about the number of opiate-dependent individuals

as though it is continuous, rather than the intermittent phenomenon which is more frequently observed in this culture. Another

thing I think we need to do is look at larger models of the factors

affecting drug use. I particularly agree with the fact that we

have neglected to give sufficient emphasis to the role of availability of drugs in determining use. This is rather peculiar inasmuch as we have adopted the epidemiological model, namely, the

host and the agent; yet we are only concentrating on the host and

ignoring the agent. I just mentioned the fact that opiate use is

often, in this culture, intermittent rather than continuous and

apparently this is due to an interaction with availability and

other restrictions imposed by prevention attempts. In countries

where opiates are used under conditions of acceptance, once dependence occurs, it does usually seem to be a continuous rather

than an intermittent phenomenon, but in this culture, the low habits that we observe are explained by the availability of the drug;

the on and off use also seems to be related to availability. Similarly, the maturing-out phenomenon is not typically observed in

other cultures where the drug is freely available and used under

conditions of acceptance. This is one example of the need to look

at drug use in a larger context, at least in terms of both the

host and the agent.

Incidentally, availability seems to influence the recent patterns

of cocaine use as well. I have wondered why some of the older

literature describes cocaine as being a very highly reinforcing

drug; one which is hard to give up and one which quickly produces

a strong psychological dependence. What I have heard about the

more recent use of cocaine seems to show a much more casual pattern of use. I have talked to a number of people who use cocaine

in this fashion, and they have reported that, indeed, if they have

a supply of cocaine, it is difficult to stop until one has used up

the supply. But, because it is so expensive, intermittent patterns

are pretty much imposed by the expense and unavailability of the

drug. So here is another apparent case where one can not really

254
look at the demand and use patterns without also considering the

question of availability.

I was interested to note what Mark Greene had to say about using

the data on incidence of use among treatment populations on a local rather than national basis, because I was under the impression

from the last conference that I attended that this peaking of incidence in the late 60’s or early 70’s was a nationwide phenomenon.

Wile I could understand the development of the middle class drug

epidemic in general -- it spilling over into heroin use among the

white youth -- I was unable to use a similar interpretation among

lower socio-economic minority groups which seemed to display a

similar peaking of incidence at this time. Apparently, from what

has been said in the last couple of days, this is a more complicated phenomenon -- more tied to the examination of local data.

I just want to add a couple comments on future directions. From

what I have heard here, the trend seems to be more towards collecting recurring trend indicators rather than the one-shot prevalenceincidence measures -- and I think this is all to the good. I have

always found the little post card size survey that is annually

reported on San Mateo high schools to be one of the most interesting pieces of data available -- mainly because it has been conducted now for seven years and it can make some useful observations

of what is occurring over time. I think probably, on a dollar for

dollar basis, NIDA got more for its money with this project than

perhaps any other that it has funded. I think it started out around $5,000 or $6,000 a year. So I just want to emphasize, from

my point of view, that measures of trends, collected in a standard

fashion and reported on a regular basis, are one of the more important aspects of drug epidemiology. I also think that there is a

need to gear these studies very much to evaluation of public policy and the planning of treatment programs. I think that probably

with the reduced funding that is likely to come about in the next

few years, this aspect will receive a stronger emphasis, because

I think it is pretty clear that the fund giving agencies have in

mind to use these types of epidemiological data primarily for evaluation and planning purposes.

Lee Robins mentioned one other aspect about the future of doing

this type of work -- the confidentiality problems. Sources of

data for doing good surveys are drying up because of some very restrictive confidentiality requirements which have exceeded reason

in many instances. Usually nothing at all is really reported on

the individual. It is group data, but the restrictions placed on

the data collection are very serious in terms of limiting future

epidemiological research in the drug area. Perhaps one of the outputs of this conference should be a plea for a unified stand on

some recommendations for confidentiality regulations which more

adequately balance the risks and benefits.

One personal thing. I have been frustrated that much of the data

that has been described by Mark Greene and others is not more

widely available, at least to people working in epidemiology. I

255
do not feel I am able to provide constructive criticism without

having a broader understanding of what the data are. I do not

know exactly how to bring it about, but I would like to see things

like CODAP and DAWN data, and hepatitis data, and drug-related

death data provided in a form that more of us could use.* Otherwise we really do not have a basis to evaluate some of the things

that arc being reported and to evaluate some of the conflicting

conclusions we have heard at this conference.

One final thing. I have felt for some time, as a lot of you have,

that for broader epidemiological work -- other than measures of

incidence, prevalence, and trends -- the longitudinal study is

essential, and I think that from all appearances the funding agencies have also recognized this. I think we are going in the right

direction in having a number of longitudinal studies in the drug

area.

*CODAP and DAWN data are now available on a quarterly basis from

NIDA.

AUTHOR

William McGlothlin is Professor-in-Residence, Department of

Psychology, UCLA, Los Angeles, California.

256
CONCLUSION

Louise G. Richards, Ph.D.

I have come to the realization that a better title for this conference would have been "The Measurement of the Extent and Nature

of Non-Medical Drug Use." This would have avoided the problems

inherent in the concept of Epidemiology and the fear of "nose

counting" with nothing more illuminating involved. We have however, addressed ourselves to the broader terms not supplied in the

title. I would not want to say that the size of the problem is

the only consideration or the most important aspect. The purpose

of gathering numbers is not merely to have data to take to Congress

but to allow everyone to examine the conceptualizations and signify

the order of this phenomenon compared with other phenomena in our

lives. We have produced an awful lot of caveats here these two

days, and I am delighted because this is what we wanted and expected. This is the best group I can think of who are capable of

living with those caveats and striving for even greater sophistication. Thank you.

257
monograph series

1 FINDINGS OF DRUG ABUSE 6 EFFECTS OF LABELING THE

RESEARCH "DRUG-ABUSER" - AN INQUIRY

An annotated bibliography of Author: Jay R. Williams, Ph.D.

NIMH and NIDA-supported extra- Analysis and review of the

mural grant research 1967-74 Literature examining effects of

Volume 1, pp. 384; Volume 2, pp.377 drug use apprehension or arrest

on the adolescent. pp. 39

2 OPERATIONAL DEFINITIONS IN

SOCIO-BEHAVIORAL DRUG USE 7 CANNABINOID ASSAYS IN

RESEARCH 1975 HUMANS

Editors: Jack Elinson, Ph.D. and Editor: Robert Willette, Ph.D.

David Nurco, Ph.D. Articles describing current

Task Force articles proposing developments in methods for

consensual definitions of con- measuring cannabinoid levels in

cepts and terms used in psycho- the human body by immunoassay,

social research to achieve oper- liquid and dual column chromaational comparability. pp. 167 tography and mass spectroscopy

3 AMINERGIC HYPOTHESES OF

techniques. pp. 120

BEHAVIOR: REALITY OR CLICHE? 8 Rx 3 TIMES/WK LAAM -

Editor: Bruce J. Bernard, Ph.D. METHADONE ALTERNATIVE

Articles examining the relation Editors: Jack Blaine, M.D. and

of the brain monoamines to a Pierre Renault, M.D.

range of animal and human Comprehensive summary of

behaviors. pp. 149 development of LAAM (levo4 NARCOTIC ANTAGONISTS: THE

alpha-acetyl methodol), a new

SEARCH FOR LONG-ACTING

drug for treatment of narcotic

addiction. pp. 127

PREPARATIONS

Editor: Robert Willette, Ph.D. 9 NARCOTIC AUTAGONISTS:

Articles reporting current alter- NALTREXONE

native inserted sustained-release Editors: Demetrios Julius, M.D.

or long-acting drug devices. p.45 and Pierre Renault, M.D.

5 YOUNG MEN AND DRUGS: A

Progress report of development,

preclinical and clinical

NATIONWIDE SURVEY studies of naltrexone, a new

Authors: John A. O'Donnell, Ph.D. drug for treatment of narcotic

et al. addiction. pp. 182

Report of a national survey of

drug use by men 20-30 years in

1974-5. pp. 144 258
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