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Full text of "Assessing drug abuse within and across communities : community epidemiology surveillance networks on drug abuse"



AL INSTITUTE ON DRUG ABUSE 



isessing Drug Abu 
ithin and Across 

Communities 



Community Epidemiology Surveillance 
Networks on Druy Abuse 





ARTIY1EIMT OF HEALTH AND HUMAN SERVICES 
ION AL INSTITUTES OF HEALTH 



IL 



Assessing Drug Abuse 
Within and Across 

Communities 



Community Epidemiology Surveillance 
Networks on Drug Abuse 



NATIONAL INSTITUTES 
NIH LIBRAR 



APR 2 5 



BLDG 10, 10 CENTER DR 
ESDA, MD 20392-11 




DEPARTMENT OF HEALTH AND HUMAN SERVICES 
NATIONAL INSTITUTES OF HEALTH 

National Institute on Drug Abuse 
Division of Epidemiology and Prevention Research 

5600 Fishers Lane 
Rockville, Maryland 20857 



f\T7 



This publication was written under the scientific direction of Nicholas J. Kozel, 
M.S., Associate Director and Zili Sloboda, Sc.D., Director, Division of Epidemiology 
and Prevention Research, National Institute on Drug Abuse and was produced under 
Contract No. NO1DA-6-5054 . 

All material in this volume is in the public domain and may be used or reproduced 
without permission from NIDA or the authors. Citation of the source is appreciated. 

The U.S. Government does not endorse or favor any specific commercial product 
or company. Trade, proprietary, or company names appearing in this publication are 
used only because they are considered essential in the context of the studies described 
here. 



National Institute on Drug Abuse 

NIH Publication No. 98-3614 
Printed April 1998 



Preface 



Drug abuse and addiction have a devastating impact on a commu- 
nity. They lead to increased rates of crime and violence, family disin- 
tegration, childhood developmental barriers, illness, and even death. 
Addiction is not discriminatory. It is an "equal opportunity de- 
stroyer," affecting all aspects of society. 

The National Institute on Drug Abuse (NIDA) supports over 85 
percent of the world's research on drug abuse and addiction. 
Through NIDA's research program, much has been learned about 
how drugs affect us — what they do to our brains, our bodies, our 
behavior, our relationships, our communities, and our society. Great 
strides have been made in understanding the biological, behavioral, 
social, and environmental influences that place individuals at risk for 
drug abuse and addiction. Importantly, research has also yielded 
major advances in preventing and treating drug abuse. 

Communities can play an active role in preventing and reducing 
drug use in their own local environment. Science has taught us much 
about the fundamental principles underlying successful drug abuse 
prevention, principles that can be applied locally to both evaluate 
existing prevention efforts and develop new programs. These prin- 
ciples are outlined in NIDA's science-based guide to drug abuse 
prevention, Preventing Drug Use Among Children and Adolescents-A 
Research-Based Guide, published last year. This booklet was specifically 
designed to aid communities in their local prevention efforts. 

Understanding the local environment is essential if a community 
is to successfully address drug abuse problems. It sets the context in 
which both prevention and treatment programs must operate. Re- 
search has shown that to be maximally effective both prevention and 
treatment efforts must be tailored to current local needs. However, 
local drug abuse problems are not easy to detect, quantify, and catego- 
rize. Patterns change as new drugs become available, new combina- 
tions become popular, and users experiment with new ways of ad- 
ministering drugs. 

To help communities understand their local drug abuse problems, 
NIDA has developed this guidebook. It will be a useful tool as you 
develop a drug abuse epidemiologic surveillance system to assess 
local drug abuse patterns and trends. This model can be used by 
States, counties, cities, and communities. It is based on the work of 
NIDA's Community Epidemiology Work Group (CEWG), a national 
surveillance network composed of researchers from around the 
country that has been meeting biannually for more than 20 years to 
monitor drug use and abuse trends. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse iii 



This particular model has proven to be useful in assessing local 
drug abuse patterns and trends, and especially emerging problems. It 
has been successfully applied in many States, and by countries and 
regions internationally. The information generated by the networks 
is used to alert prevention, treatment, and public health officials, as 
well as the general public, so that appropriate and timely action can 
be taken. Researchers, too, find the information useful in developing 
and assessing hypotheses explaining changes in drug use patterns 
and the characteristics of drug users. States, counties, and smaller 
communities interested in developing a surveillance network capabil- 
ity will find this guide useful. 

There is great efficiency in using data sources to assess the nature 
of the drug abuse problem in a community. Analyses of information 
gathered through these means will suggest where additional research 
is needed, which groups or areas need to be targeted for preventive 
and treatment interventions, and what questions need to be an- 
swered for both policy and programmatic decisions. However, it is 
important to note that this is but one of several approaches that might 
be used to assess the drug abuse problem at the local level. 

We hope this guide proves useful in improving the quality of the 
Nation's prevention and treatment efforts. We would welcome 
feedback from users about both its usefulness and ways we might 
improve upon it. 



Alan I. Leshner, Ph.D. 

Director 

National Institute on Drug Abuse 



iv Assessing Drug Abuse Within and Across Communities 



Contents 

Community Epidemiology Surveillance Networks on Drug Abuse 1 

What Are Community Epidemiology Surveillance Networks? 1 

Where and How Did Surveillance Networks Get Started? 2 

Why Are Networks Established? 2 

What Are the Advantages of a Network? 4 

What Sources of Information Do Networks Access and Use? 4 

How Are Local Networks Organized? 5 

How Should the First Network Meeting Be Organized? 7 

What Types of Problems are Encountered By Networks? 8 

Who Should Be Invited to the First Network Meeting? 9 

Accessing Data From Different Sources 12 

Treatment Data 12 

Treatment Episode Data Set 18 

Uniform Facility Data Set 18 

Methadone Treatment Programs 19 

Medical Examiner and Coroner Data 19 

State Data on Alcohol and Drug Deaths 21 

Underlying vs. Multiple Cause Tapes 24 

Use of Hard Copies of Death Certificates 24 

Age Limits 26 

Direct Death Causes 26 

Indirect Death Causes 26 

Uses of the Death Data 27 

Hospital Emergency Departments 29 

Drug Abuse Warning Network (DAWN) 30 

How DAWN Works 31 

How DAWN Data Are Disseminated 32 

Naional Hospital Ambulatory Medical Care Survey 32 

Hospital Data 32 

Purpose of Studying Hospital-Based Drug-Related Discharges 37 

Where Can A Network Obtain Hospital Data? 37 

Development of the International Classification of Diseases 39 

Drug-Related ICD-9-CM Diagnostic Related Groups 39 

Limitations of Using Hospital Data 42 

Information Networks Should Request 42 

Hospital Data Needs and Issue Development 43 

Outcomes of a Comprehensive Hospital-Based Drug-Use Report 44 

Law Enforcement Data 45 

Uniform Crime Reports 46 

Data from Crime Laboratories 50 

Drug Trafficking Reports 56 

Domestic Monitor Program 56 

Price and Purity Data 56 

Arrestee Drug Abuse Monitoring Program 58 

Surveys 59 

National Surveys 60 

State Surveys 61 

Local Surveys 61 

HIV/AIDS Data 62 

Telephone Hotline Data 63 

A Guide for Community Epidemiology Surveillance Networks on Drug Abuse V 



Other Useful Data Sources 64 

Census Data 64 

University Researchers 66 

Community-Level Sources 67 

Establishing and Developing Relationships with Information Sources 68 

Public Versus Private Information Sources 68 

Preparation/Making Contact 68 

Developing Relationships 68 

Key Informants 69 

Short-Term Ethnography Studies 71 

Reporting 74 

References 76 

Glossary 78 



Exhibits 

A-1 Standard Data Request Form 14 

A-2 Characteristis of Drug Abuse Treatment Admissions By Selected Primary Substances, 

Baltimore City— 1996 15 

A-3 Demographic Composition and Admission Rates of Drug Treatment Population, 

Baltimore City— 1992-96 17 

B-1 Drug and Alcohol Abuse Mortaility, Texas 22 

B-2 A Sample of Deaths from Opiate Abuse, Texas— 1992 25 

B-3 Cocaine- and Heroin-Related Deaths in Bexar County, Texas 28 

C-1 DAWN Data: Estimated Number of Emergency Room Drug Abuse Episodes/Metions, 

San Diego— 1992-96 33 

C-2 Biannual Estimated Number of Emergency Room Drug Abuse Episodes/Metions, 

San Diego— 1 995-96 33 

C-3 DAWN Data: Number of Emergency Room Mentions By Drug, Phoenix— 1993-96 34 

C-4 Suggested Emergency Department Record Layout, Drug- or Alcohol-Related Episodes 35 

D-1 Shreveport Drug Arrests 46 

D-2 Shreveport Drug Arrests— 1996 46 

D-3 Drug Arrests By County, Texas— 1994 48 

D-4 Drug Arrests By Race/Ethnicity, Texas 49 

E-1 Maryland State Police Arrests for Cocaine (HCL) 51 

E-2 Maryland State Police Arrests for Crack Cocaine 52 

E-3 Maryland State Police Statewide Cocaine (HCL) Prices— 1993-94 52 

E-4 Maryland State Police Statewide Crack Cocaine Prices— 1993-94 53 

E-5 Maryland State Police Statewide Low-Purity Heroin Prices— 1 993-94 54 

E-6 Maryland State Police Price of Heroin and Amount of Purchase 54 

E-7 Maryland State Police Statewide Marijuana Prices — 1991-94 55 

E-8 Quarterly Price Data in Dollars for Marijuana — April-June 1996 57 

E-9 Annual Price and Potency Data in Dollars for Marijuana, National Range 58 

F-1 Reported Alcohol/Drug Helpline Data, Washington State— 1990 64 



vi Assessing Drug Abuse Within and Across Communities 



Appendices 



Appendix A 
Appendix B 
Appendix C 
Appendix D 



Appendix E: 
Appendix F-1: 

Appendix F-2 

Appendix G: 
Appendix H-1: 

Appendix H-2: 

Appendix I: 
Appendix J: 



National CEWG Members A-1 

National CEWG Report Format B-1 

Statistical Analysis Centers by State C-1 

Method for Assessing Hospitalization Related to Drug and Alcohol Misuse by 

Youth and Young Adults D-1 

State Contacts for Uniform Crime Reports E-1 

1994 Drug-Related Arrests of Persons Over Age 17 by Age, Gender, and 

Race/Ethnicity— State of Maryland F-1 

1994 Drug-Related Arrests of Persons Under Age18 by Age, Gender, and 

Race/Ethnicity — State of Maryland F-2 

DEA Division Offices G-1 

Excerpts from 1995 Drug Prospectus Report, Criminal Intelligence Division, 

Maryland State Police H-1 

Additional Drugs of Abuse Reported by Criminal Intelligence Division, Maryland 

Department of State Police H-7 

Ethnographic Studies 1-1 

Sample Format for State Reports J-1 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



VII 



Community Epidemiology Surveillance Networks 
on Drug Abuse 

What Are Community Epidemiology Surveillance Networks? 

Community Epidemiology Surveillance Networks are multi-agency 
work groups with a public-health orientation which study the spread, 
growth, or development of drug abuse and related problems. The 
networks have a common goal — the elimination or reduction of drug 
abuse and its related consequences. 



. . . network 
members access 
existing information 
from multiple 
sources . . . 



To achieve this goal, network members access existing information 
from multiple sources including drug abuse treatment agencies, public 
health offices, law enforcement agencies, hospital emergency depart- 
ments, medical examiner and coroners' offices, and local school and 
household surveys. Members meet periodically to review, compare, 
and draw conclusions from the data. The data are reported in a stan- 
dardized format to facilitate the review and comparative analyses. 
Qualitative studies may be conducted to help members understand the 
quantitative findings from existing data sets. 

The primary objectives of the network members are to: 

• identify drug abuse patterns in defined geographic areas; 

• identify changes in drug abuse patterns over defined time 
periods to establish trends; 

• detect emerging substances of abuse; and 

• communicate and disseminate the information to appropriate 
community agencies and organizations so it can be used in 
developing policies, practices, prevention strategies, and re- 
search studies. 

Network members are individuals who are in a position to contrib- 
ute and assess information about drug use in specific geographic areas. 
They may represent agencies and organizations that have some respon- 
sibility for addressing drug abuse problems or that benefit directly from 
acquiring information about drug abuse. Researchers and other indi- 
viduals who have special knowledge about a particular issue or drug- 
abusing population also may participate. Regularly scheduled network 
meetings provide a forum for members to share, review, and analyze 
information on the epidemiology of drug abuse. 

This guide focuses on practical ways of accessing and analyzing 
diverse indicator data from a variety of data sources and on effective 
ways of reporting such data. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



Where and How Did Surveillance Networks Get Started? 

The first national level surveillance network was established by the 
National Institute on Drug Abuse (NIDA) in 1976 to assess current drug 
use patterns in major metropolitan areas across the country and to 
identify emerging trends within and across these areas. This network, 
called the Community Epidemiology Work Group (CEWG), has been 
meeting semiannually for more than 21 years to fulfill its role as a drug 
abuse surveillance system. CEWG members represent Atlanta, Balti- 
more, Boston, Chicago, Denver, Detroit, Honolulu, Los Angeles, Miami, 
Minneapolis-St. Paul, Newark, New Orleans, New York City, Philadel- 
phia, Phoenix, St. Louis, San Diego, San Francisco, Seattle, the State of 
Texas 1 , and Washington, D.C. Appendix A is a list of the CEWG mem- 
bers. Contact them for information specific to their cities and for 
additional advice on the organization of a local community surveillance 
network. 

Based on the NIDA CEWG model, State Epidemiology Work 
Groups (SEWGs) have been organized in many States. Other countries 
also have adopted the model. Similar work groups have been orga- 
nized or are under development in Asia, Australia, Canada, Central 
America, Europe, Mexico, and South Africa. Recently, a program has 
been initiated to establish surveillance networks throughout the coun- 
tries of the Americas. In addition, an International Epidemiology Work 
Group (IEWG), which represents a network of national and regional 
surveillance networks, has been established. 

National CEWG information is disseminated by the Division of 
Epidemiology and Prevention Research, NIDA, through its biannual 
report series entitled Epidemiologic Trends in Drug Abuse. Information on 
the national CEWG, its reports, and other important data sources can 
be accessed directly at http://www.cdmgroup.com/cewg. In addition, it 
can also be accessed through NIDAs Home Page 

http://www.nida.nih.gov. Clicking on organization, you will find it listed 
under Division of Epidemiology and Prevention Research. 

Why Are Networks Established? 

The primary purpose of a local surveillance network is to share 
timely and reliable information about drug abuse. What types of drugs 
are being used in particular communities? Who is using them? How are 

/ ne primary pur- ^ey being used? What are the consequences of use? How are the 

pose . . . IS to patterns of use changing? 

share timely 

and reliable Information of this type is essential to many agencies and organiza- 

information . . . tions, especially those with responsibility for planning and allocating 

resources to address drug abuse and related problems. Too often, 



1 Originally, data were reported for the city of Dallas. Currently, data produced by 
the Texas State Epidemiology Work Group also are reported. 



Assessing Drug Abuse Within and Across Communities 



Networks . . . con- 
tribute to one or 
more elements of a 
needs assessment. 



agencies plan strategies and commit resources without having up-to- 
date information about the nature and extent of drug abuse problems. 
These efforts can be wasteful and counterproductive. 

Patterns of drug use are determined not only by the availability and 
cost of different substances, but also by the dynamics and differences 
within groups, cultures, and communities. Drug abuse patterns are 
complex, constantly changing phenomena. Like a disease, they can 
quickly spread through and across communities. Drug abuse has been 
associated with increasing rates of crime and violence as well as health 
problems such as human immunodeficiency virus (HIV) infection 
which causes the aquired immunodeficiency syndrome (AIDS); other 
sexually transmitted diseases (STDs); and other infectious diseases such 
as hepatitis. If a pattern is identified early, appropriate action can be 
taken to control its spread. 

By monitoring drug abuse over time, it also is possible to evaluate 
whether programs are having any impact on particular aspects of drug 
abuse problems. 

Networks do not necessarily conduct needs assessments. Rather, 
they may contribute to one or more elements of a needs assessment. A 
needs assessment is a methodology used by administrators and plan- 
ners to determine the need for specific services in a particular geo- 
graphic area. The purposes of a needs assessment are to: 

• define the problem; 

• determine the magnitude of the problem; 

• identify the services that are currently available to address the 
problem; 

• identify the demand for services; 

• determine the gaps in service; 

• determine what additional services/resources are needed to fill 
the gaps; and 

• help prioritize the problems and services so that administrators 
and planners can determine how limited resources should be 
used. 

Surveillance networks help define and determine the magnitude of 
drug problems and provide an early warning for emerging problems. 
It is important for members to understand the specific purpose (goals 
and objectives) and limits of the network. Through this understanding, 
local networks are more likely to be successful and contribute to needs 
assessments. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



What Are the Advantages of a Network? 

The surveillance network model has many advantages for planning 



It takes minimal 
agency support and 
a few committed 
people to get a 
network started 



purposes: 



It uses a practical formula. 

It is not costly. 

It makes use of existing resources. 

It has proven to be effective. 

It provides immediate feedback. 

It works on many different levels. 

The information is useful to many agencies and organizations. 

It provides input from different perspectives. 

It establishes a network of people who share information and 

work together on common problems. 

It builds an infrastructure for further research. 



It takes minimal agency support and a few committed people to get 
a network started. Once established, the network should be self- 
sufficient. It requires the participants' time to gather and prepare 
information prior to meetings, meet periodically, and prepare informa- 
tion for dissemination following the meeting. 

Often, people who are sought as members of a network already are 
engaged by agencies or organizations involved in the drug abuse field 
and may be currently collecting data from or about drug-using popula- 
tions. In addition, their agency would probably recognize the short- 
and long-term benefits to be derived from participation in a surveil- 
lance network. The only other requirement for startup is a place to 
meet. 



Optimally, meetings should be regularly scheduled about twice 
each year. This time frame provides a sufficient time gap (6 months) to 
assess changes in drug use patterns and keep the groups active without 
placing a heavy burden on participants. At least 1 full day should be set 
aside for each meeting. 

What Sources of Information Do Networks Access and Use? 

Networks make use of multiple sources of information. Each source 
provides information about particular drug-using populations and/or 
different facets of the behaviors and outcomes of the same or similar 
populations. The information obtained from each source is considered 
an indicator of drug abuse. The direction of changes in indicators 
across time is a measure of relative change in drug abuse behavior and 
related problems rather than a measure of absolute change. Indicators 
do not provide estimates of the number (prevalence) of drug abusers at 
any given time or the rate at which drug-abusing populations may be 



. . . indicators help 
identify different 
types of drug 
abusers . . . 



Assessing Drug Abuse Within and Across Communities 



One source can 
complement and 
support another and 
help to validate 
information on drug 
use patterns 



increasing or decreasing in size. However, indicators do help identify 
different types of drug abusers, such as those who have been arrested, 
treated in emergency rooms, admitted to drug abuse treatment pro- 
grams, involved in accidents, diagnosed with HIV/AIDS, or died with 
drugs found in their bodies. 

By comparing information from different sources concurrently, 
network members can identify and learn more about different drug- 
using populations, the similarities and differences across groups, and 
perhaps emerging patterns and trends. One source can complement 
and support another and help to validate information on drug use 
patterns. 



Networks, at all levels, use many data sources: 

drug abuse treatment and intervention agencies; 

hospitals and hospital associations (which may provide data 

on drug-exposed newborns); 

State, county, and local health agencies and departments; 

school and community surveys; 

education offices and departments; 

State and county crime and forensic laboratories; 

agencies and departments that collect and report arrest data; 

medical examiner and coroner offices; 

HIV outreach programs; 

studies by university researchers; and 

drug hotlines. 

There may be many other potential sources of information, de- 
pending on the community itself. 

How Are Local Networks Organized? 

Generally, the impetus for organizing a surveillance network comes 
from an agency that recognizes the need for up-to-date information 
about drug abuse patterns and trends. The agency may be one that 
coordinates drug abuse data sources or a health planning organization. 
Sponsoring a network can be of great benefit to an agency, as it pro- 
vides that agency with important information about drug trends, 
knowledge about street use, and a network of sources to answer ques- 
tions. Any agency that deals with the general public, answers questions 
about drugs, or provides public information will find the investment in 
sponsoring a local network worthwhile. In addition, it will be possible 
to provide education and information materials and press releases to 
inform the public of current trends. 

It is best to plan and maintain small work groups so that all partici- 
pants have an opportunity to contribute to the process. Try to get 
members from different organizations and with different perspectives. 
Include the medical examiner, treatment program personnel, HIV street 



It is best to plan and 
maintain small work 
groups . . . 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



. . . arrange a small 
planning meeting of 
staff from key agen- 
cies 



outreach workers, health planners, university researchers, and local 
police officers. If the network is composed of representatives of differ- 
ent towns, cities, or counties, the reporting process should be standard- 
ized so that comparisons can be more easily made across different 
jurisdictions. 

Initially, one or two staff members can be assigned to review and 
report on potential benefits, other potentially valuable participants, and 
accessible sources of information. Representatives of other agencies can 
be contacted to determine how the information might be useful to 
them, their level of interest, and who from their agencies might meet 
the qualifications to participate in the network. This type of review 
should be completed within a 1-2 month period. 

If, on the basis of the information, it is decided to begin efforts to 
organize a surveillance network, arrange a small planning meeting of 
staff from key agencies. This meeting should include researchers and 
agency representatives who are familiar with drug abuse issues and 
sources of data and who are interested in the possibility of establishing 
a network. The meeting should be structured to: 

• establish the rationale for, and the purpose of, a network; 

• identify potential sources of data/information; 

• identify agencies and individuals with access to information; 

• identify individuals who could contribute in other ways to the 
network; 

• develop an agenda for the first meeting; 

• determine who should be invited to participate in the first 
meeting and what they should be asked to contribute; 

• establish a time and place for the first meeting; and 

• develop a plan for the second meeting, including the date, 
place, and general themes to be covered. 

A preliminary step that has proven useful is to hold a preplanning 
meeting with officials of selected organizations or agencies to discuss 
the purpose and goals of the network; how the agency or organization 
can contribute; the staff capabilities, knowledge, skills, and experience 
required to contribute; and the benefits to the agency of belonging to 
the network. 

While it is unlikely that an agency official will be a working mem- 
ber of the local network, enlisting the official's support may well 
increase the agency's participation in and contribution to the network. 
Unless the official understands the value of the network, he or she may 
not be willing to support the initiative and the investment of time by 
the agency. In addition, the official may help identify the most quali- 
fied person(s) from the agency to serve on the network. In some 
instances, it is beneficial to invite both the official and his or her data 
person to the meeting so the official can become informed of the 
benefits of the group and the data person can be involved from the 
beginning in identifying needed information. 



Assessing Drug Abuse Within and Across Communities 



How Should the First Network Meeting Be Organized? 

The first meeting is critical because it sets the stage for what the 
surveillance network will be, how it will function, and how it will be 
perceived by participants and others. 

Two interrelated objectives should always be kept in mind: 

• obtaining knowledge about drug abuse; and 

• developing and strengthening the work group. 

Care should be taken to avoid common pitfalls that others have 
encountered in planning initial network meetings. Four principles 
should be observed: 

1. Start small. Be selective in inviting individuals to attend. It is 
easy to add individuals once the needs and sources have been 
identified and to change individuals based on the strengths and 
interests of the members. 

2. Have clear, attainable objectives for the meeting. Avoid trying 
to overachieve at the beginning. 

3. Establish the agenda in coordination with other participants so 
they feel invested from the beginning. 

4. Give each participant a role to play and a contribution to make. 

The first meeting should be organized to accomplish several 
objectives: 

• Identify known and potential sources of data and information. 
Selected participants can be asked to describe particular data 
sets and to prepare and briefly present data from sources to 

Have clear, attain- which they have access. 

able objectives for • Review the types of data sources (indicators) accessed by other 

the meeting epidemiologic networks to determine if they might be obtain- 

able in your area. If they are, determine what steps should be 
taken to identify agencies and individuals who can provide 
access to each of these sources. 

• Assign participants to follow up (after meetings) and, if appro- 
priate, make contacts to find out what types of data are avail- 
able, how the data can be made available, and who is most 
knowledgeable about the data and the data sources. 

• Determine how the information from the meetings should be 
recorded, reported, and disseminated, including to whom it 
should be sent. A full report with all the information will prove 
very useful for agency planners, grant writers, and staff associ- 
ated with the network member agencies. An executive sum- 
mary that brings all the information together in a quick-refer- 

A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 7 



Surveillance net- 
works need to 
remain focused on 
questions . . . 



ence format will prove very popular with the press and the 
general public. 
• Identify current and potential sources of support for organizing 
and conducting the meeting, and producing and disseminating 
reports from the meeting. The full report should be based 
largely on the papers prepared and presented by participants, 
along with data tables. 

Surveillance networks need to remain focused on questions such as; 
What drugs are currently being used? Who is using them? Are drug use 
patterns changing from year to year? If so, how? 

What Types of Problems Are Encountered by Networks? 

It is easy to get sidetracked, especially when extraneous information 
is presented. As in any work group, individuals who participate in 
network meetings have self-interests. They are likely to have different 
backgrounds and different frames of reference. It may not always be 
clear to them what is expected. If each member is sent the specific 
format for the presentation in advance, it will be easier to keep the 
meetings on track and to get the information in a form that is compa- 
rable with that submitted by other members. Appendix B is a copy of 
the format used by the national CEWG. 

It must be kept in mind that there is limited time to address the key 
questions and achieve the network's objectives. It is therefore impor- 
tant for the persons coordinating or chairing network meetings to 
define carefully what information participants need to present and to 
keep the meetings focused. Tell each member in advance the time limit 
for the oral presentation. 

Another problem is the turnover in members and finding members 
who are interested in the network and are willing to commit to the 
process and collect and report on the information on a continuing basis. 
The network coordinator should understand that part of the job is an 
ongoing search for new members and persons who have the time to 
participate. It is a good policy to routinely call the agency directors to 
thank them for the past participation of their staff, inform them that 
another meeting is planned, explain the importance of their agency's 
participation and the benefit to the agency, and request that the par- 
ticular staff member be given time and support to prepare the report 
and participate in the meeting. At times, the director will not know that 
a meeting has been scheduled, and the local network member will be 
assigned to another task and be unable to attend the meeting or not 
have time to gather the needed data. 



. . . define clearly 
what information 
participants need to 
present and keep the 
meetings focused 



8 



Assessing Drug Abuse Within and Across Communities 



Who Should Be Invited to the First Network Meeting? 



One of the primary 
objectives of the first 
meeting is to identify 
individuals who are 
in the best position 
to contribute infor- 
mation . . . 



. . . find out who 
would be the most 
appropriate person 
to participate in the 
first network meeting 



The first meeting should be considered a planning session. The 
organizers should emphasize that the individuals who attend this 
meeting will not necessarily be permanent members and they are not 
obligated to attend future meetings. One of the primary objectives of 
the first meeting is to identify individuals who are in the best position 
to contribute information to the network planning process. If a na- 
tional CEWG member is located in your State, or if there is a planner at 
the State Alcohol and Drug Abuse Agency who is knowledgeable about 
sources of data, invite them to the first meeting. 

The first meeting should include individuals (generally agency 
representatives) who are capable of providing information about 
different sources of data, including the following: 

Survey Data 

If not yet known, find out if any relevant local surveys have been or 
are currently being conducted or planned. These would include 
household, school, and special population surveys that provide 
information about substance use. Every State Alcohol and Drug 
Abuse Agency has received a contract from the Substance Abuse 
and Mental Health Services Administration (SAMHSA), Center for 
Substance Abuse Treatment (CSAT), to perform surveys in the State, 
so contact the State to find out who is in charge of these surveys. In 
addition, some States have contracts from other Federal agencies to 
perform surveys. In some instances the State agency has done the 
surveys, while in other States a university or survey research firm 
has done the surveys. If a relevant survey has been or is being 
conducted, invite the Principal Investigator or another person who 
can describe the data collected. 

Drug Abuse Treatment Data 

If not yet known, find out which agencies collect information about 
drug abusers entering, undergoing, and/or leaving treatment. 
Every treatment program that receives funds from the State Alco- 
hol and Drug Abuse Agency is required to report data to the State. 
Which local drug abuse treatment programs participate in the State 
system and which are required to report client data to county and 
city coordinating agencies? Find out who in the coordinating 
agencies is responsible for coordinating these efforts. Contact these 
individuals to find out who would be the most appropriate person 
to participate in the first network meeting. 

Law Enforcement Data 

If not yet known, find out which agencies, departments, or offices 
collect drug use data on local arrestees charged with criminal 
offenses, including drug violations. Drug violations, including 
arrests for possession and/or trafficking, are reported by counties 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



. . . find out what 
types of data related 
to drug use are 
collected, and who 
coordinates such 
efforts . . . 



and States. Several different State offices can be contacted to 
determine sources of arrest data. These include the Uniform Crime 
Report Office, the Statistical Analysis Center, the Law Enforcement 
Planning Office, and the Attorney General's Office. In some in- 
stances, the same arrest will be reported by the local police, the 
State police, and Federal agents, so inquire about possible duplicate 
reporting and overlap. Other law enforcement data which can be 
very useful include information on price and purity of drugs 
confiscated. Try to find out which levels of law enforcement agen- 
cies are included in a report. State Statistical Analysis Centers 
assemble statewide criminal justice statistics, act as a clearinghouse 
for statewide crime information and statistics, and issue periodic 
reports. The names, addresses, and telephone numbers of center 
offices in each State are listed in Appendix C. 



Hospital Data Pertaining to Drug Use 

If not yet known, contact the State, county, and city health depart- 
ments to identify individuals who can provide information about 
relevant hospital data sources. If the geographic area covered by 
the network is relatively small, it may be appropriate to contact 
administrators of each hospital to find out what types of data 
related to drug use are collected, and who coordinates such efforts 
within or outside the hospital. 

AIDS Cases and HIV Seroprevalence Data 

HIV/AIDS is a reportable condition in all States and territories in the 
United States. The HIV/AIDS Surveillance System, established by 
the Centers for Disease Control and Prevention (CDC), monitors 
the incidence and demographic profile of AIDS cases and describes 
the modes of HIV transmission among infected persons. State and 
local health departments conduct active surveillance. Standardized 
case report forms and software (HIV/AIDS Reporting System) are 
used to produce local tabulations and to report cases monthly to the 
CDC. Currently, all 50 States, U.S. territories and possessions, and 6 
major cities report through the CDC surveillance system. One of 
the objectives of surveillance is to identify changing patterns in the 
modes of HIV transmission. The local health department office 
responsible for HIV/AIDS surveillance should be contacted to find 
out who is the best person to report relevant information at the first 
network meeting. Examples of information could include the 
percent of injection drug users who have contracted the virus and 
the number of cases where HIV has been transmitted heterosexu- 
ally. Look for trends associated with trading drugs for sex and 
increases in those racial/ethnic, age, and sex categories that may be 
related to drug use and risky sexual behavior. 

In addition, the Ryan White Act requires regional data collection 
and needs assessment for HIV programs, and the local group that 
coordinates the Ryan White funds will have valuable information. 



10 



Assessing Drug Abuse Within and Across Communities 



Health Data 

Since substance abuse also is related to numerous health conse- 
quences, such as tuberculosis and sexually transmitted diseases, the 
State, county, or city health departments will have information on 
the number of individuals who have these diseases and the preva- 
lence rates for these diseases in your local area. Contact the health 
department to get the statistics and to obtain information from the 
street outreach workers who seek out persons with these diseases. 
In some instances, certain outreach workers concentrate on drug- 
using populations while others will concentrate on prostitutes and 
commercial sex trade workers. 



These reports may 
include students 
who were suspended 
or dropped out of 
school because of 
drug use 



School Data 

Some school systems, including colleges and universities, maintain 
records on the number and types of drug use problems identified 
by schools. These reports may include students who were sus- 
pended or dropped out of school because of drug use. In addition, 
many schools have used their Federal Safe and Drug Free Schools 
grants to fund surveys, and, in some States, the Center for Sub- 
stance Abuse Prevention (CSAP) has funded the State Alcohol and 
Drug Abuse Agency to conduct surveys of school students. If a 
relevant survey has been or is being conducted, invite the Principal 
Investigator or another person who could describe the data col- 
lected. 



Community-Level Data Sources 

At the community or neighborhood level, data/information sources 
can be obtained from smaller entities. Be careful to check that this 
information is not already included in reports from the various 
State agencies. These are some suggested local sources of data: 



local hospitals; 

treatment programs (both public and private); 

health clinics; 

community mental health centers; 

schools; 

local Police Department or sheriff's office; 

criminal justice and correctional agencies; 

HIV and STD outreach workers; 

needle exchange programs; 

university researchers; 

medical examiners and coroners; 

recreation facilities; and 

pharmaceutical associations. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



11 



Accessing Data From Different Sources 



Treatment Data 

Data about drugs used prior to entering treatment are generally 
collected from clients entering treatment programs. If information 
about the names and locations of drug abuse treatment programs is not 
currently available to network members, this information can be 
obtained from the State Alcohol and Drug Abuse Agency. A listing of 
treatment programs also is likely to be found in the yellow pages of 
local telephone directories and from directories obtainable from 
mayor's offices or chambers of commerce. Most publicly funded 
programs are required to collect and report admission data to the 
States, and the States report it to the Federal Government. Each State 
will have its own name for its client data system. 

These data have limitations. Drug abusers entering treatment are 
not representative of drug abusers in the community. They represent 
individuals referred to drug treatment by criminal justice agencies 
because they were arrested or incarcerated, they are clients referred 
from other sources (e.g., family, church, school), or they can be self- 
referred clients. Usually they have been using drugs for a number of 
years prior to entering treatment, and their admission to treatment will 
not be a sign of the emergence of a new drug or new epidemic, but a 
sign that the client who began using 10 or 15 years ago is now suffi- 
ciently impaired to the point of wanting and needing treatment. 

Also, individual drug abuse treatment agencies may be structured 
to treat particular types of drug abusers, although client populations 
may change over time. In recent years, changes in insurance coverage 
and managed care have had an impact on these programs and the 
types of clients served. In addition, information is often reported only 
by publicly funded programs, and the types of clients who can afford 
private treatment will not be represented in the information submitted 
to the State agency. Try to obtain information from the private pro- 
grams to supplement the information from the public programs. 

In contacting drug abuse treatment programs to determine if client 
data are available, several things should be kept in mind: 

• Information that would potentially make it possible to identify 
an individual client cannot be divulged under penalty of 
Federal law, so programs cannot provide the information that 
might be desired except at aggregate or summary levels. 

• Treatment programs are in the business of treating clients; not 
surprisingly, staff see treatment as their primary obligation. 
Often these staff do not see the potential benefits of research 
and are likely to feel that any attempt to obtain client data is 
another demand on their limited time. 



1 2 Assessing Drug Abuse Within and Across Communities 



Intake data generally 
include specific 
information about 
drugs used . . . 



• The task of treating drug abusers is very difficult and requires a 
considerable investment of time and resources. 

• The HIV/AIDS epidemic has added considerable pressure on 
staff and programs, especially those programs that serve clients 
at high risk for this disease (e.g., injection drug users). 

• Most treatment programs have limited resources and an ongo- 
ing need to identify and secure additional financial resources. 

• The current emphasis on managed care has placed considerable 
pressure on treatment programs to reduce the length of services 
provided and reduce costs. 

Exhibit A-l is a standard format that could be used to make data 
requests. 

By quantifying treatment data, it is possible to identify the types of 
drug problems reported by different types of clients. Intake data are 
particularly useful to epidemiologic networks because these data 
generally include specific information about drugs used prior to seek- 
ing admission to treatment. Typically, programs distinguish the pri- 
mary, secondary, and tertiary substances used by individuals entering 
treatment. The primary drug is usually the drug that the client feels is 
causing him/her the most serious problems. Specific drug data, along 
with client demographic data, can provide a great deal of information 
that will enable networks to track drug use patterns and trends within 
specific geographic areas. 

Exhibit A-2 is an example of how drug abuse treatment data can be 
quantified for a particular geographic area and what can be learned 
from such data. This exhibit was used by a member of the national 
CEWG to report Baltimore City treatment indicator data at the Decem- 
ber 1997 CEWG meeting. 

These data show the demographic characteristics of different types 
of substance abusers admitted to Baltimore City publicly funded 
treatment programs in 1996. As can be seen: 

• 53.2 percent of the 14,613 clients reported heroin as the primary 
drug of abuse. 

• 21 .3 percent reported cocaine as their primary substance (of 
these, 76.6 percent are crack abusers). 

• 11.7 percent fell into the "alcohol with other drug" category. 

• 11.5 percent reported marijuana as their primary drug of abuse. 

Much more can be learned about each type of primary drug abuse 
category from this exhibit. For example, more than half (51.8 percent) 
of the heroin abusers snorted the drug (primary route of administra- 
tion), and 48.2 percent injected it. Individuals who snorted heroin were 
more likely than injectors to be African-American (94.2 vs. 78.3 percent), 
female (49.5 percent), and younger. Only 26.8 percent of the snorters 
were 35 years of age or older, compared with 65.7 percent of the injec- 
tors. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



13 



Exhibit A-1: Standard Data Request Form 



CEWG Site 

Characteristics of Clients Admitted to Treatment 
From to , 1994 



MONTH 



MONTH 



Total number of treatment admissions, excluding alcohol only: | 






Alcohol-in- Stimulant/ 
Combination Cocaine Heroin Marijuana Methamphetamine 

(Exclude Alcohol Only) 


Total N: 






















(Use to derive percen 

Gender: 


age 


s) 




























Male 




/o 




% 




% 




% 




% 
























Female 




% 




% 




% 




% 




% 


Race/Ethnicity: 






















White 




% 




% 




% 




% 




% 
























African American 




% 




% 




% 




% 




% 
























Hispanic 




% 




% 




% 




% 




% 


Other 






















1. 




% 




% 




% 




% 




/o 


Other 






















2. 




% 




% 




% 




% 




% 


Age at Admissioi 


i: 




















17 and under 




% 




% 




% 




% 




% 
























18 to 25 




% 




% 




% 




% 




% 
























26 to 34 




/o 




% 




% 




% 




% 
























35 and older 




0/ 

/o 




% 




% 




0/ 

/o 




% 


Route of Adminis 


tratior 


: 


















Smoking 




% 




% 




% 




0/ 

/o 




% 
























Sniffing 




% 




% 




/o 




/o 




% 
























Intravenous 




% 




% 




/o 




% 




% 
























Other/multiple 




% 




% 




/o 




% 




% 


Secondary Drug: 
































Type of Drug 


























































% 




% 




/o 




% 




% 


Tertiary Drug: 
































Type of Drug 


























































% 




% 




0/ 

/o 




% 




9/ 

/o 





































SOURCE: National Institute on Drug Abuse, 1996. 



14 



Assessing Drug Abuse Within and Across Communities 



EXHIBIT A-2: Characteristics of Drug Abuse Treatment Admissions By Selected 
Primary Substance, Baltimore City — 1996 



Drug Use 


Total 


Alcohol 
(with drug) 


Heroin 


Cocaine 


Marijuana 


Injected 


Snorted 


Crack 


Other 


(Number of Admissions) 


(14,613) 


(1,704) 


(3,741) 


(4,027) 


(2,384) 


(728) 


(1,686) 


Primary Use of Substance 


100.0 


11.7 


25.6 


27.6 


16.3 


5.0 


11.5 


Other Substances Reported* 
















None 


27.1 


- 


18.8 


33.7 


42.4 


25.3 


40.5 


Alcohol 


26.3 


- 


26.2 


22.2 


37.5 


40.2 


44.4 


Cocaine 


41.4 


58.0 


72.5 


51.3 


- 


0.1 


14.4 


Marijuana/hashish/THC 


18.9 


50.3 


9.4 


18.9 


23.7 


27.1 


0.1 


Heroin/opiates/synthetics 


10.8 


27.0 


3.3 


2.0 


19.7 


41.4 


7.8 


Demographic Characteristics 


% 


% 


% 


% 


% 


% 


% 


Gender 
















Male 


59.6 


74.3 


56.5 


50.5 


48.1 


70.2 


85.9 


Female 


40.4 


25.7 


43.5 


49.5 


51.9 


29.8 


14.1 


Race/Ethnicity 
















White 


16.9 


24.7 


20.9 


5.4 


16.2 


22.1 


22.0 


African-American 


82.1 


73.6 


78.3 


94.2 


83.1 


76.1 


75.7 


Hispanic 


.06 


.09 


.06 


.02 


.05 


.08 


1.5 


Other 


0.4 


0.8 


0.2 


0.1 


0.3 


1.0 


0.9 


Age at Admission 
















<18 


7.3 


14.5 


0.5 


0.2 


0.5 


0.3 


45.4 


18-25 


14.3 


13.5 


5.9 


18.0 


9.7 


12.3 


32.2 


26-34 


37.6 


28.0 


27.9 


55.0 


47.0 


36.6 


13.8 


35 + 


40.8 


44.0 


65.7 


26.8 


42.8 


50.8 


8.6 


Average Age at Admission 


32.4 yrs. 


31 .9 yrs. 


37.4 yrs. 


31.3 yrs. 


33.6 yrs. 


34.7 yrs. 


21.4 yrs. 



* "Other substances reported" 
SOURCE: National Institute o 



adds to more than 100 percent because it includes secondary and tertiary substances, 
n Drug Abuse, 1997. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



15 



. . . treatment data 
have been useful in 
identifying drug 
abuse patterns and 
trends and emerging 
drug problems 



Most of the primary heroin abusers reported using other drugs. 
Cocaine was, reportedly, used by 72.5 percent of the heroin injectors 
and 51.3 percent of the snorters. Marijuana was more popular among 
the heroin snorters (18.9 percent) than the injectors (9.4 percent). 

The Baltimore City data show that there are important differences 
within and between drug categories. Although treatment data of this 
type are limited, much can be learned about different populations 
entering substance abuse treatment. 

It also is useful to know where clients are seeking treatment live. 
Some treatment programs serve clients who live in a particular geo- 
graphic area that, while others accept clients from distant areas. Infor- 
mation that would identify an individual client is confidential, so it will 
not be possible to obtain addresses or even ZIP code information on 
individual clients. The local program should be able to aggregate the 
client information and provide data on the number of clients who live 
in each ZIP code, area, census tract, or block numbering area (BN A). 
Maps of ZIP code areas, census tracts, and/or BNAs for specific geo- 
graphic areas can be obtained by calling the U.S. Bureau of Census 
Customer Service number: (301) 457-4100. The information can be 
ordered in a variety of formats at the following address: U.S. Depart- 
ment of Commerce, U.S. Bureau of the Census, PO. Box 277943, Atlanta, 
GA 30384-7943. 



It also is possible to compare data from the same sources at different 
time periods to determine changes in drug use patterns and popula- 
tions. Historically, treatment data have been useful in identifying drug 
abuse patterns and trends and emerging drug problems. These data 
are generally a good indicator of the types of drugs being used in 
geographic areas over time, but check with your sources to make sure 
an upswing in admissions or a shift in drug patterns is not due simply 
to the startup of a new and specialized treatment program. As an 
example, the Texas Legislature funded a criminal justice treatment 
initiative that resulted in a very large number of arrestees, prisoners, 
and probationers being referred to treatment. Some of these clients 
were severely addicted, while others were not yet addicted to heroin or 
cocaine. This influx of a significant number of males and clients who 
were not yet addicted to "hard drugs" resulted in a major change in the 
drug use patterns that was caused by funding policies rather than shifts 
in the use of drugs on the street. Exhibit A-3 is an example of how 
treatment data can be analyzed over time to assess drug abuse trends. 
This exhibit was used to report Baltimore City treatment indicator data 
at the December 1997 CEWG meeting. 

As can be seen in Exhibit A-3, changes in client characteristics were 
not substantial over time. However, the rates of use (per 100,00 popula- 
tion) were substantial for some primary drugs of abuse. 

There were significant increases in rates of heroin use between 1992 
and 1995 and in rates of marijuana/hashish use between 1992 and 1996. 
Rates of heroin snorting increased significantly from 1993-1995. 



16 



Assessing Drug Abuse Within and Across Communities 



EXHIBIT A-3: Demographic Composition and Admission Rates of Drug 
Treatment Population, Baltimore City— 1992-96 





1992 


1993 


1994 


1995 


1996 


(Number of admissions) 


(12,447) 


(13,165) 


(13,988) 


(14,772) 


(14,613) 


Demographic Characteristic 


% 


% 


% 


% 


% 


Gender 
Male 
Female 


63.0 

37.0 


58.9 
41.1 


58.5 

41.5 


56.6 
43.4 


59.6 

40.4 


Race/ethnicity 
White 

African-American 
Hispanic 
Other 


19.0 
80.2 
0.4 
0.4 


19.6 
79.4 
0.6 
0.4 


18.4 
80.6 
0.5 
0.5 


17.3 
81.4 
0.8 
0.4 


16.9 
82.1 
0.6 
0.4 


Age at Admission 
<18 
18-25 
26-34 
35 + 


4.6 
19.4 

41.6 
34.4 


4.7 
19.4 

41.7 
34.1 


5.9 
18.0 
41.0 
35.1 


6.6 
16.1 
39.8 
37.6 


7.3 
14.3 
37.6 
40.8 


Admissions per 100,000 
Population Aged 12 + 


1,879 


2,015+++ 


2,181 +++ 


2,349 +++ 


2,372 


Primary Substance 
Alcohol with secondary drug 
Cocaine 

Smoked (crack) 

Injected 

Snorted 

Other 
Marijuana/hashish 
Heroin/opiates/synthetics 

Injected 

Snorted 

Other 
PCP 

Stimulants 
Methamphetamine 
Amphetamine/stimulants 
All other 


314 

572 

312 

141 

112 

6 

70 

890 

575 

285 

30 

9 

2 

« 

2 
22 


295 

569 

381 +++ 

88 — 

94-- 

6 

100 +++ 

1,023+++ 

586 

407 +++ 

29 

12 

• 
* 

16- 


278 
564 

401 

79 

78- 

6 

144 +++ 

1,173+++ 

600 

535 +++ 

38++ 

9 

ft 
* 

12 


247 — 
535- 

410 

57 — 

64-- 

4 

220 +++ 

1,328+++ 

622 

670 +++ 

36 

8 

* 
* 

11 


277++ 

505- 

387- 

52 

60 

6 

274 +++ 

1,300 

607 

654 

39 

7 

1 

* 
ft 

9 



* Less than 1 per 100,00 population. 

+/- Significant increase/decrease over previous year=s rate: + + +/--p<.01;+/-p<.05. 

SOURCE: National Institute on Drug Abuse, 1997. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



17 



Treatment Episode Data Set 

The Treatment Episode Data Set (TEDS) is administered at the 
Federal level by the Office of Applied Studies (OAS) of the Substance 
Abuse and Mental Health Services Administration (SAMHSA) and can 
be accessed at http://www.samhsa.gov. 

TEDS collects the following anonymous information on each client: 
date of admission; number of prior treatments; source of referral; date 
of birth; gender; race/ethnicity; education level; employment status; 
primary, secondary, and tertiary substance problems; usual route of 
administration for each problem substance; frequency of use; age of 
first use; and services provided. Additional data can be collected on 
diagnostic code, psychiatric problems, pregnancy at time of admission, 
veteran status, living arrangements, primary source of income or 
support, health insurance, expected source of payment for treatment, 
marital status, and time waiting to enter treatment. The local program 
or the State Alcohol and Drug Abuse Agency should be requested to 
generate tables on client characteristics from the TEDS data. 

Uniform Facility Data Set 

The annual Uniform Facility Data Set (UFDS) survey, which was 
previously known as the National Drug and Alcohol Treatment Unit 
Survey (NDATUS), is another source for sociodemographic information 
on clients in various programs. UFDS is an annual Federal survey 
administered by the State Alcohol and Drug Abuse Agency. In some 
States, reporting by all programs is mandatory, while in other States 
reporting by private programs is optional. UFDS, which is adminis- 
tered by OAS, is available at http://www.samhsa.gov. The Web site will 
have information aggregated at the State level, but it will not have the 
information reported by each program. 

The local program fills out information on the UFDS form based on 
the operations and clients in treatment on a particular day, such as 
September 30. The form collects information on the number of clients 
by race/ethnicity, gender, age group, and treatment modality, (e.g., 
detoxification, residential, outpatient, methadone). The form also 
collects information on the capacity of the program; ownership; licen- 
sure status; qualifications of staff; kinds of services provided (assess- 
ment, therapy, testing, health care, transitional, continuing care, and 
community outreach); availability of services targeted to special groups, 
such as women or youth; and revenue sources. It does not provide 
information on which drugs were being abused by the clients, but it 
does show the differences in characteristics between the public and 
private programs. Until 1995, the form was in triplicate so the local 
programs could keep a copy of the completed questionnaire and the 
State also could keep a copy, so it should be easy to get historical infor- 
mation on local programs. Since 1995, the form was not on triplicate 
paper, so it might be more difficult to obtain information on the indi- 
vidual programs unless the State or each of the local programs kept 
their own copy of the form. 

1 8 Assessing Drug Abuse Within and Across Communities 



Methadone Treatment Programs 

Another source of data can be the reports that local methadone 
maintenance programs file with the State methadone licensing authori- 
ties each year. This information will vary by State, but it probably 
includes information that is not collected elsewhere. Some States have 
a methadone registry that also can provide information on heroin 
addicts. 

In reporting treatment data at a network meeting, it is important to 
have a standardized format so that participants can easily assess the 
information. If there are sufficient numbers of clients, it is possible to 
distinguish drug use patterns by age, ethnic group, and gender. It also 
is useful to include data from prior years so that comparisons can be 
made to determine relative change in drug use patterns and drug-using 
populations, as well as changes in program capacities. 



Medical Examiner and Coroner Data 



Death investigation 
practices vary 
considerably among 
jurisdictions 



Medical examiners and coroners (ME/Cs) are responsible for inves- 
tigating sudden or violent deaths and for providing accurate, legally 
defensible determinations of the causes of these deaths. Information 
provided by ME/Cs plays a critical role in the judicial system and in 
decisions made by public safety and public health agencies. The 
records of ME/Cs, which provide vital information about mortality 
patterns and trends in the United States, are an excellent source of data 
for epidemiologic networks. 

Death investigation practices vary considerably among jurisdictions 
(whether State, county, district, or city). The most noticeable difference 
is that some jurisdictions use the medical examiner system, while others 
use the coroner system. The type of system used may be uniform 
throughout a State or may vary from county to county within a State. 
Medical examiners may have State, district, or county jurisdiction. 
Usually they are appointed and must be licensed physicians; some are 
expert forensic pathologists. In comparison, coroners or justices of the 
peace may have district or county jurisdiction, are usually elected, and 
need not be physicians. Many are required only to be of a minimum 
age (often 18) and a resident of the county or district. 

Often, ME/Cs or members of their staff will be interested and active 
participants in a network, because they need to know what drugs are 
on the street and changes in purity or combinations that could be 
causing a series of overdose deaths. 

A second variation in death investigation practices involves which 
deaths are actually to be investigated. About 20 percent of deaths in the 
United States are investigated by ME/Cs, although the percentage 
varies by State. The guidelines for which deaths are to be investigated 
also vary widely by jurisdiction, but most jurisdictions require that the 
following deaths be investigated: 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



19 



• deaths caused by homicide, suicide, or accidental causes such as 
motor vehicle crashes, falls, burns, or the ingestion of drugs or 
other chemical agents; 

• sudden or suspicious deaths (e.g., due to sudden infant death 
syndrome [SIDS]) and unattended deaths; 

• deaths caused by an agent or disease constituting a threat to 
public health; 

• deaths that occurred while the decedents were at work; 

• deaths of people in custody or confinement and of those institu- 
tionalized for reasons other than organic disease; and 

• deaths of people to be cremated. 

The thoroughness of death investigations (and as a result, the 
completeness of death investigation records) also varies from case to 
case. Sometimes a postmortem examination may consist of only an 
external examination of the body. The record of a complete death 
investigation, however, includes the following items: 

• the initial report of the death made to the ME/C office (e.g., by a 
family member, police officer, or attending physician); 

• a determination of circumstances surrounding the death; 

• findings of a scene investigation; 

• findings of a postmortem examination or autopsy; 

• results of laboratory tests to determine the presence of drugs, 
toxins, or infectious agents; and 

• certification of the cause and manner of death. 

Until recently, death investigation information was not readily 
available to the public health community or to other human resource 
programs. Making this information more available is one of the goals of 
the Medical Examiner and Coroner Information Sharing Program 
(MECISP). In 1986, because of the lack of uniformity in death investiga- 
tion policies, the frequent lack of communication between jurisdictions, 
and the need for more widespread distribution of death investigation 
data, CDC established the MECISP These are the primary goals of the 
MECISP: 

• to improve the quality of death investigations in the United 
States and to promote the use of more standardized policies on 
when and how to conduct these investigations; 

• to facilitate communication among death investigators, the 
public health community, Federal agencies, and other interested 
groups; 

• to improve the quality, completeness, management, and dis- 
semination of information on investigated deaths; and 

• to promote the sharing and use of ME/C death investigation 
data. 



20 Assessing Drug Abuse Within and Across Communities 



The death certificate 
is submitted . . .to 
the State health 
department . . . 



Through financial and technical support, the MECISP helps ME/C 
offices to collect, manage, and disseminate data. The MECISP also 
publishes a directory that describes death investigation laws and lists 
the contact persons for all ME/C jurisdictions in the United States. 

Information about the MECISP and ME/C data can be obtained from 

Surveillance and Programs Branch 

Division of Environmental Hazards and Health Effects 

National Center for Environmental Health, Mail Stop F35 

Centers for Disease Control and Prevention 

4770 Buford Highway, NE 

Atlanta, GA 30341-3724 

State Data on Alcohol and Drug Deaths 

R. T. Ravenholt (1984) published a widely used listing of causes of 
deaths due to alcohol or other drugs, and this listing has been updated 
by the Department of Health and Human Services (U. S. DHHS 1987) 
and the National Institute on Alcoholism and Alcohol Abuse (NIAAA) 
(Dufour and Caces 1993). Because of changing drug use patterns and 
diseases, different versions of the list exist. Exhibit B-l is the list as used 
by the Texas Commission on Alcohol and Drug Abuse (TCADA) in 1996. 

Causes of death are listed on death certificates, which are filled out 
by local doctors, coroners, and justices of the peace, among others. In 
some jurisdictions, the certificate must be filled out by trained medical 
personnel such as pathologists or medical examiners, while in other 
locations, elected officials with no formal training fill out the certificate. 
This variation exists not only among the States, but also within local 
jurisdictions. Discrepancies and nonreporting can occur for various 
reasons. In some jurisdictions, the staff of the medical examiner will not 
be consistent in their reports; one will specify the exact drugs involved 
while another will denote only "drug abuse," even though the toxico- 
logical reports are available. In other instances, to spare the feelings of 
the family, the coroner will not mention drugs on the certificate. In an 
area where suicide has a negative religious connotation, the death 
certificate will not mention drugs or suicide as a motive. There is no 
way to tell how widespread such underreporting is. 

The death certificate is submitted by the local official to the section 
of the State health department that is responsible for handling birth 
and death data. This certificate may be submitted immediately, or there 
may be a significant lag. In some instances, a completed certificate will 
be submitted, while in other instances, the cause of death will be shown 
as "pending," and an amended certificate will be issued later after 
toxicology or pathology reports have been received. Because of the lag, 
it may take 6-10 months to get the complete data for the previous year. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



21 



Exhibit B-1: Drug and Alcohol Abuse Mortality, Texas 



Alcohol Mortalities 


Direct Causes 


Percentage 


Age 


Alcoholic psychoses (291) 


100% 


>10 


Alcohol dependence syndrome (303) 


100% 


>10 


Alcohol abuse (305.0) 


100% 


>10 


Alcoholic polyneuropathy (357.5) 


100% 


>15 


Alcoholic cardiomyopathy (425.5) 


100% 


>15 


Alcoholic gastritis (535.3) 


100% 


>15 


Alcoholic fatty liver (571 .0) 


100% 


>15 


Acute alcoholic hepatitis (571.1) 


1 00% 


>15 


Alcoholic cirrhosis of the liver (571 .2) 


100% 


>15 


Alcoholic liver damage, unspecified (571.3) 


100% 


>15 


Excessive blood level of alcohol (790.3) 


100% 


>15 


Alcohol poisonings (E860.0-E860.1) 


100% 


>15 


Indirect Causes 


Percentage 


Age 


Respiratory tuberculosis (01 1-012) 


25% 


>35 


Cancer of the lip, tongue, oral cavity, pharynx (140-149) 


50%* 


>35 


Cancer of the esophagus (150) 


75% 


>35 


Cancer of the stomach (151) 


20% 


>35 


Cancer of the liver and intrahepatic bile ducts (155) 


15% 


>35 


Cancer of the larynx (161) 


50%** 


>35 


Diabetes mellitus (250) 


5% 


>35 


Essential hypertension (401) 


8% 


>35 


Cerebrovascular disease (430-438) 


7% 


>35 


Pneumonia and influenza (480-487) 


5% 


>35 


Diseases of esophagus, stomach and duodenum (530-537) 


10% 


>35 


Other cirrhosis of the liver (571 .5-571 .6) 


50% 


>35 


Acute pancreatitis (577.0) 


42% 


>35 


Chronic pancreatitis (577.1) 


60% 


>35 


Motor vehicle accidents (E810-E825) 


42% 


>0 


Other road vehicle accidents (E826-E829) 


20% 


>0 


Water transport accidents (E830-E838) 


20% 


>0 



*The percentage is 40 percent for females. 

**The percentage is 32 percent for females. 

SOURCE: Texas Commission on Alcohol and Drug Abuse, 1996. 



(continued) 



22 



Assessing Drug Abuse Within and Across Communities 



Exhibit B-1 (continued) 



Indirect Causes 






Percentage 


Age 


Air and space transport accidents (E840-E845) 






16% 





Accidental falls (E880-E888) 






35% 


15 


Accidents caused by fires (E890-E899) 






45% 





Accidental drownings (E910) 






38% 





All other accidents (E867-E869, E900-E909, E911-E92S 


, E980) 




25% 


15 


Suicides (E950-E959) 






28% 


15 


Homicides (E960-E969) 






46% 


15 


Drug Mortalities 


Direct Causes 






Percentage 


Age 


Drug psychoses (292) 






1 00% 


10, 64 


Drug dependence (304) 






100% 


10, 64 


Nondependent abuse of drugs (305.1-305.9) 






100% 


10, 64 


Drug withdrawal syndrome in newborn (779.5) 






100% 


0,64 


Accidental poisoning by drugs, medicaments, and biologicals (E850-E859) 


100% 


10, 64 


Heroin, methadone, other opiates and related narcotics, and other drugs causing 
adverse effects in therapeutic use (E935.0-E935.2, E937-E940) 

Suicide and self-inflicted poisoning by drugs and medicinal substances 
(E950.0, E950.4) 


100% 
100% 


10, 64 
10, 64 


Homicidal poisoning by drugs and medicinal substances 


(E962.0) 




100% 


10, 64 


Injury undetermined whether accidentally or purposely inflicted frorr 
drugs, medicaments, and other (E980) 


i poisoning by 


100% 


10,64 


Human immunodeficiency virus infection (042-044) 






19% 


10, 64 


Viral hepatitis B (0.70.2-070.5) 






13% 


10, 64 


Viral hepatitis non-A, non-B (070.4-070.5) 






21% 


10, 64 


Acute and subacute infective endocarditis (421) 






14% 


10, 64 


Homicides (E960.0-E961) 






28% 


15, 64 



*The percentage is 40 percent for females. 

**The percentage is 32 percent for females. 

SOURCE: Texas Commission on Alcohol and Drug Abuse, 1996. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



23 



Nosologists at the State health department classify the death 
certificate according to the World Health Organization's International 
Classification of Diseases (ICD-9), 3rd Edition. While the classifications 
differentiate among types of drugs, the use of the words "acute intoxi- 
cation" will result in one classification, while the use of "toxicity" will 
result in a different classification. Exhibit B-2 is a shortened list of the 
1992 deaths involving alcohol or other drugs in the State of Texas, and it 
shows the impact that different terms have on the ICD coding of deaths 
involving the same drug. The wording from the death certificate is 
entered in the "AOD Cause from Death Certificate" column. 

Underlying vs. Multiple Cause Tapes 

After all death certificates have been received and classified, the 
information is computerized. Two different computer tapes are nor- 
mally available from the National Center for Health Statistics (NCHS) 
and the State health departments. One tape is based on the Underlying 
(or primary) Cause of Death. The Underlying Cause of Death is de- 
fined as "(a) the disease or injury which initiated the train of events 
leading directly to death, or (b) the circumstances of the accident or 
violence which produced the fatal injury." A second computer tape 
includes Multiple Causes of Death. This tape not only provides the 
underlying (or first) cause, but also additional or multiple cause codes. 
A maximum of 20 causes of death can be captured on a record for 
multiple cause purposes. While the Multiple Cause Tape is more 
complex to handle, it is recommended for use, because many alcohol- 
and drug-related deaths are not recorded as the underlying (or first) 
cause. 



. . . the Multiple 
Cause Tape is.. . 
recommended for 

use . . . 



The Multiple Cause Tape will provide more substance abuse data. 
As an example, the computer record for a person who is intoxicated 
and dies in an automobile accident may list the first cause as an injury 
and the secondary cause as intoxication or alcohol abuse. In addition, 
the Underlying Cause Tape does not pick up the information from the 
amended death certificate. It will show "799.9 — Pending." Notice that 
in exhibit B-2, the ICD codes for the first cause of death is listed in the 
"Cause Death" column; these same ICD codes are shown in exhibit B-l. 
This further demonstrates the value of searching through the Multiple 
Cause Tape. 



In comparing the Underlying and Multiple Cause Tapes, staff at 
TCADA found in 1992 that the number of direct alcohol deaths in- 
creased from 993 to 1,533, the number of indirect alcohol deaths in- 
creased from 6,459 to 7,582, and the number of direct drug deaths 
increased from 473 to 1,952. 

Use of Hard Copies of Death Certificates 

If possible, obtain from the health department actual copies of 
death certificates, which mention specific information on the sub- 



24 



Assessing Drug Abuse Within and Across Communities 



Exhibit B-2: A Sample of Deaths from Opiate Abuse, Texas— 1992 



FILENBR 


AOD CAUSE FROM DEATH CERTIFICATE 


CAUSEDTH 


DEATHCNTY 


RESCNTY 


106187 


alcohol and drug abuse 


303 


COMAL 


COMAL 


120279 


alcohol/drug abuse 


303 


DALLAS 


DALLAS 


62213 


IV drug abuse-cocaine, opioids 


303 


HARRIS 


HARRIS 


94347 


chronic ETOH and drug abuse 


303 


NUECES 


NUECES 


53045 


ETOH & IV drug abuse 


303 


TARRANT 


TARRANT 


21095 


acute mixed drug intox-cocaine, heroin, 
salicylate 


410 


TARRANT 


TARRANT 


109591 


IV drug abuse 


420 


HARRIS 


HARRIS 


40417 


IV drug use 


421 


BELL 


BELL 


118110 


IVDA 


421 


TRAVIS 


TRAVIS 


6640 


narcotic/alcohol addiction 


422 


TRAVIS 


TRAVIS 


53605 


IV drug abuse 


429 


DALLAS 


DALLAS 


114776 


ETOH & IV drug use 


703 


CAMERON 


CAMERON 


60013 


IV drug abuse 


703 


HARRIS 


HARRIS 


95012 


IVDA 


1177 


TARRANT 


TARRANT 


36241 


ETOH & IV drug abuse 


1550 


DALLAS 


DENTON 


4136 


alcohol & drug abuse 


1550 


HARRIS 


HIDALGO 


45247 


acute and chronic narcotism 


3049 


ARANSAS 


ARANSAS 


95378 


intravenous narcotism 


3049 


BEXAR 


BEXAR 


77462 


heroin addiction 


3049 


GUADALUPE 


GUADALUPE 


103314 


acute and chronic narcotism 


3049 


NUECES 


NUECES 


6776 


drug & alcohol abuse 


3059 


BEXAR 


BEXAR 


5625 


drug abuse 


3059 


DALLAS 


DALLAS 


20624 


intravenous drug abuse 


3059 


DALLAS 


DALLAS 


36039 


narcotic abuse 


3059 


DALLAS 


DALLAS 


92142 


illicit drug abuse 


3059 


HARRIS 


HARRIS 


41357 


ETOH/IVDA abuse 


3059 


NUECES 


LIVE OAK 


65085 


drug abuse 


3059 


TARRANT 


TARRANT 


80985 


IV drug abuse 


3059 


TARRANT 


TARRANT 


96580 


IVDA 


3059 


TARRANT 


TARRANT 


93748 


drug abuse 


3059 


TRAVIS 


TRAVIS 


85663 


IV drug use 


3249 


BEXAR 


BEXAR 


112648 


alcohol and drug abuse 


3453 


JEFFERSON 


JEFFERSON 



SOURCE: Texas Commission on Alcohol and Drug Abuse, 1996. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



25 



. . . many deaths are 
listed as IVDA, with 
no particular drug 
specified 



stances involved in deaths, such as inhalants, heroin, narcotics, cocaine, 
intravenous drug abuse (IVDA), etc. While death certificates are public 
records, identifying information about the decedents should be blacked 
out and not used in reports. 

Codes that are routinely requested for copies of death certificates 
include 304.6, 305.9, 850.0 through 858.9, 862.4, 869.2, 869.8, 950.0, 980.0, 
and 980.4. Inhalant deaths that resulted from industrial accidents are 
excluded. However, the computer tape is used to generate a listing of 
all cases with direct drug death codes, and this listing should be 
matched against the hard copies to obtain a more precise listing. By 
entering the wording on the actual certificates, it is possible to see how 
different coroners categorize deaths (exhibit B-2). 

One of the major problems is that many deaths are listed as IVDA, 
with no particular drug specified. Because of such classifications, the 
only solution may be to create a listing that includes all the categories 
that could be considered "hard drugs," including IVDA (e.g., cocaine, 
heroin, other opiates). County of death, rather than county of resi- 
dence, is used to map the distribution of such drugs. County of death 
will provide insight as to where people go to obtain and use their 
drugs. 

Age Limits 

Ravenholt (1984) used deaths only where the age was 15 or above, 
which is probably too old, given that the average age of first use of 
alcohol in Texas is 13.5 according to the school survey and 12.7 for youth 
entering treatment. DAWN uses only deaths of persons older than 6. If 
there is no lower limit, then the data is skewed because of accidental 
overdoses of aspirin or other pills swallowed by toddlers. An upper age 
limit of 65 is used because examination of the copies of death certifi- 
cates showed many very elderly persons dying primarily from advanc- 
ing age, but in many instances digitalis or other prescribed drugs were 
shown as secondary causes of death. Exhibit B-l shows the upper and 
lower age limits that TCADA uses. 

Direct Death Causes 

Direct causes are deaths in which 100 percent of the cases can be 
directly attributed to alcohol or drugs. 

Indirect Death Causes 

Ravenholt (1984) also listed causes of death where a proportion of 
the deaths could be attributed to alcohol or drugs. The indirect drug 
death list is quite outdated, since it allocates only 20 percent of homi- 
cides to drug involvement. This is probably too low a proportion, given 
the recent relationship between crack cocaine and violence. It is diffi- 
cult to determine the percent of homicides or other violent deaths 
associated with crack cocaine. In 1995, TCADA used a causal factor of 
28 percent, based on a 4-year study of toxicology screenings for drugs 



26 



Assessing Drug Abuse Within and Across Communities 



(cocaine, heroin, and others) and alcohol on homicide victims in Bexar 
County, Texas. Since the drug scene has changed in the past decade, 
particularly in terms of increased violence, an even higher percentage 
of drug-related homicides maybe documented later. 

Using the Multiple Cause Tape will require prioritizing the causes of 
death in terms of direct vs. indirect causes. If a person committed 
suicide by an overdose of alcohol, then the death is classified either as a 
direct cause (overdose of alcohol) or as an indirect cause (suicide). 
Priority should be given to searching the data files first for direct causes 
and then searching the remaining records for indirect causes. 

The list of indirect death causes developed by Ravenholt (1984) do 
not include AIDS-related categories, and work needs to be done to 
develop the proportions of deaths caused by AIDS-Related Diseases 
(ARD) that involve substance abuse. In many instances, if ARD causes 
are included in the computerized data set, then it is easy to match the 
copies of the death certificates that mention drugs as one of the mul- 
tiple causes. The proportion of ARD deaths that indirectly involve drug 
abuse will vary by State based on the rates of transmission by risk 
category; the Texas proportion is shown in exhibit B-l. 

Uses of the Death Data 

One of the most frequently asked questions concerns the number of 
persons dying from alcohol and drug abuse. Epidemiology networks 
can use the Ravenholt (1984) categories to get an annual listing, the 
direct and indirect alcohol deaths, and direct drug deaths. The rates for 
deaths involving alcohol or other drugs can then be compared by 
county or sub-State planning region on a per 100,000 population basis. 

Looking at the characteristics of persons who die from one particu- 
lar drug or class of drugs can show a very different drug abuser than is 
seen in treatment or arrest data. For example, in Texas, the overdose 
death data provide insight into needs that are not normally seen in 
other areas. Looking at the characteristics of persons who die from 
overdoses of depressants or "downers" can show a substance abuse 
problem among women who overdose on these drugs combined with 
alcohol, often as suicides. Death certificates indicating inhalant abuse 
show a very different picture from that shown by other data sources. 
According to Texas school surveys, inhalant abusers were young (pre- 
teen or early teens); they were equally likely to be male or female; and 
Hispanic youth reported the highest lifetime use (26 percent), followed 
by Anglo youth (24 percent) and African-American youth (16 percent). 
Adolescent inhalant abusers entering treatment were young (average 
age of 14.7 years), male (78 percent), and Hispanic (84 percent). 

Yet overdose death data for Texas present a very different picture. 
From 1990 through 1993, an average of 15 deaths involving inhalants 
were reported each year. Persons who died of inhalants were male (94 
percent) and Anglo (90 percent), and the average age was 26 years. The 

A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 27 



most common substance mentioned on the death certificates as the 
cause of death was freon, with an average of six deaths per year, and 
there is a pattern of abuse by air conditioning mechanics and techni- 
cians. The other common substances were toluene and trichloroethane. 
Trichloroethane can be contained in typewriter correction fluid, trans- 
parent tape, or spot remover. In addition, nitrous oxide was the cause 
of at least one death per year. 

Analysis of overdose deaths where methadone was mentioned 
showed that in Texas in 1991 through 1994, 86 percent of the decedents 
were Anglo and the average age was 35.8 years, whereas only 38 
percent of the addicts entering publicly funded treatment were Anglo 
and the average age for this group was 38.9 years. 



. . . death data 
involving alcohol or 
other drugs are 
difficult and complex 
to work with . . . 



In summary, death data involving alcohol or other drugs are diffi- 
cult and complex to work with, but they are integral to assessing trends 
and patterns in the community. An essential point is that multiple drug 
abuse indicators must be analyzed in order to obtain an accurate 
picture. Single indicators may present a specific and somewhat biased 
view. 

An example of the type of forensic data that can be obtained is 
shown in exhibit B-3, which depicts cocaine- and heroin-related deaths 
reported over an 8-year period in a Texas county. In this case, the 
medical examiner is very interested in drug abuse patterns, and he has 
tracked this information over the years. 



EXHIBIT B-3: Cocaine- and Heroin-Related Deaths in Bexar County, Texas 



Year 


Cocaine 
Only 


Heroin 
Only 


Cocaine/Heroin 


Total deaths 
(Cocaine & heroin) 


Percentage of total 
drug deaths 


Total deaths 
(Toxic cause) 


1987 


7(27) 


7(9) 


13(2) 


27 (38) 


(30%) 


71 


1988 


8(38) 


23(3) 


12(9) 


43 (50) 


(54%) 


102 


1989 


14(29) 


25(12) 


9(7) 


48 (48) 


(51%) 


93 


1990 


6(34) 


20(5) 


7(13) 


33 (52) 


(52%) 


64 


1991 


15(74) 


17(4) 


6(12) 


38 (90) 


(49%) 


78 


1992 


27 (82) 


12(5) 


6(22) 


45(109) 


(45%) 


100 


1993 


14(67) 


22(8) 


9(8) 


45 (83) 






1994 


23 (68) 


33(3) 


14(10) 


70(81) 


(72%) 


113 



SOURCE: Bexar County Forensic Science Center, Bexar County, TX, 1995. 
NOTE — Numbers in parentheses are non-overdose, "incidental" detections. 



28 



Assessing Drug Abuse Within and Across Communities 



Trauma centers are 
specially equipped 
and staffed emer- 
gency departments 
designated by 
level . . . 



Hospital Emergency Departments 

The American Hospital Association defines an emergency depart- 
ment (ED) as "an organized hospital facility for the provision of un- 
scheduled outpatient services to patients whose conditions are consid- 
ered to require immediate care. An ED must be staffed 24 hours a day." 
The operative principle is that the patients arriving are, or may be, 
acutely ill and at risk of severe complications or death if they do not 
receive attention within minutes or hours. 

In 1990, there were 5,472 hospital EDs in the United States, accord- 
ing to the American Hospital Association annual survey (American 
Hospital Association 1991). There were 92,080,647 ED visits in 1990, an 
increase of more than 40 percent from approximately 65,000,000 in 
1973. ED visits amounted to about 25 percent of the 368,183,598 total 
outpatient visits seen by hospitals in 1990. The first examination for 
board certification in emergency medicine (as one of the 23 major 
medical specialties) was given in 1980 (Krentz 1989; Poppy 1990). 

In 1992, there were 10,000 board-certified emergency physicians. 
There were also around 65,000 ED nurses; 21,000 belonged to the 
Emergency Nurses Association. 

Today's ED is the nexus of a sophisticated emergency medical 
services system whose most complex element is the trauma center. 
Trauma centers are specially equipped and staffed emergency depart- 
ments designated by level (from 1 to 3, in descending order of complex- 
ity) to treat patients who have severe burns or injuries. Trauma is the 
leading cause of death in Americans under the age of 45. The rate is 
especially high among young African-American males; trauma causes 
around 140,000 to 160,00 deaths each year (Gibbs 1990; Thai and 
Rochon 1991; U.S. Government Accounting Office [GAO] 1991). It is 
estimated that between 64 and 80 percent of trauma patients can be 
saved and will recover if they are treated promptly (Thai and Rochon 
1991; U.S. GAO 1991). 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



29 



Drug Abuse Warning Network (DAWN) 

The Drug Abuse Warning Network (DAWN) includes: 

• an annual national probability survey of drug-related problems 
treated in hospital emergency departments (EDs); and 

• drug-related death data collected from a nonrandom sample of 
medical examiners and coroners' offices (ME/Cs). 

Since 1972, DAWN has been a source of data on drug-induced or 
drug-related emergency department visits and medical examiner or 
coroner deaths. This surveillance system is managed by the Office of 
Applied Studies, a component of the Substance Abuse and Mental 
Health Services Administration (SAMHSA) and the U.S. Department of 
Health and Human Services. More than 500 EDs provide data for 
DAWN. They are part of a scientifically selected sample of general 
hospitals in the country. The DAWN sample is constructed to produce 
estimates of substance abuse visits to emergency departments across 
the Nation and to 21 metropolitan areas. 

Information on drug-related and drug-induced deaths, involv- 
ing both legal and illegal drugs, is collected from ME/Cs representing 
175 jurisdictions. ED and ME/C data are collected and reported from 
the following metropolitan areas: Atlanta, GA; Boston, MA; Euffalo, NY; 
Chicago, IL; Dallas, TX; Denver, CO; Detroit, MI; Los Angeles, CA; 
Miami, FL; Minneapolis, MN; New Orleans, LA: New York, NY; New- 
ark, NJ; Philadelphia, PA; Phoenix, AZ; San Diego, CA; San Francisco, 
CA; Seattle, WA; and Washington, D.C. ED data also are reported from 
hospitals in Baltimore, MD and ME/C data are reported by ME/Cs in 
Kansas City, KS/MO. 



DAWN reports 
include detailed data 
summaries for each 
metropolitan area . . . 



DAWN excludes cases involving alcohol as the sole substance of 
abuse and excludes cases involving children under age 6. Information 
is presented on the characteristics of the decedents by gender, race/ 
ethnicity, age, and manner of death, along with this information by 
type of drugs mentioned. DAWN information is posted at the follow- 
ing Web site: http://www.samhsa.gov. 

DAWN reports include detailed data summaries for each metropoli- 
tan area and show (1) distribution of drug abuse episodes by demo- 
graphic characteristics, number of episodes, and drug group and (2) 
distribution of drug mentions by reason for emergency department 
contact, classified by drug group. DAWN also reports the number of 
mentions per 100,000 population for certain drugs on a semiannual 
basis by metropolitan area, so it is possible to see if the rates of mentions 
are going up or down and to compare the metropolitan area rates with 
the national rates. Reports are available at http://www.samhsa.gov. 

Data from DAWN can be used to identify substances associated 
with drug abuse episodes reported by DAWN-affiliated facilities; to 
monitor drug abuse patterns and trends and detect new abuse entities 
and new combinations; to assess health hazards associated with drug 
abuse; and to provide data for national, State, and local drug abuse 
policy and program planning. 



30 



Assessing Drug Abuse Within and Across Communities 



DAWN has several advantages in that it is ongoing and, thus, 
continually provides current and consistent information; it identifies 
specific drugs being used and it provides data for selected metropolitan 
areas as well as a composite national picture. 

DAWN collects information on drug abuse-related medical exam- 
iner cases and on all patients treated in an ED because of problems 
induced by or related to drug abuse. In general, drug abuse-related 
cases must meet these criteria to be reported to DAWN: 

• the use of prescription drugs in a manner inconsistent with 
accepted medical practice; 

• the use of over-the-counter (OTC) drugs contrary to approved 
labeling; 

• the use of any other substance (heroin, marijuana, peyote, glue, 
aerosols, etc.) for psychic effect, dependence, or suicide; and 

• the use of alcohol alone is not reported. 

How DAWN Works 

In each facility (hospital ED or medical examiner's office) that 
participates in DAWN, a reporter is assigned to data collection activities. 
Ideally, an ED nurse (or other medical personnel) reviews all ED 
records daily and completes a one-page DAWN form on each drug 
abuse-related case. This report records basic patient demographic data 
and detailed substance abuse information. When ED staff are not 
available, other service departments (such as social services, medical 
records, pharmacy, poison control, volunteer departments) maybe 
recruited to participate in the reporting process. In some cases, the 
hospital may designate an independent reporter (i.e., not a hospital 
staff person) to report DAWN data. The DAWN staff are bound by 
Federal laws protecting patient confidentiality. The data collection 
form does not include any patient identifying information. 

DAWN reporters submit completed forms, along with weekly log 
sheets listing case totals, to SAMHSAs DAWN operations contractor. 
Each participating facility or its designee (e.g., the reporter, nurses' 
fund) receives a small honorarium for submitting data. The DAWN 
operations contractor assumes responsibility for the other costs in- 
curred in reporting, such as mailing reports, training facility personnel, 
telephone communication between facility reporters, and the contrac- 
tor staff who review DAWN reports. 

Contractor staff review, verify, and compile DAWN data. They are 
supported by regional field liaisons who travel to facilities to provide 
training, evaluation, and problem-solving as needed. 

Approximately 13,000 drug abuse episodes are processed monthly 
through DAWN. Data accuracy is ensured through a combination of 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 31 



quality assurance activities. For example, adherence to DAWN report- 
ing guidelines is monitored through periodic record reviews and 
reabstracting studies. Particular emphasis is placed on training and on 
continuing support and followup provided by the field liaisons and 
central office data monitors. 

How DAWN Data Are Disseminated 

On a regular basis, the Office of Applied Studies (OAS) of SAMHSA 
publishes the DAWN semiannual and annual reports. The semiannual 
report presents data on recent trends in mentions of selected drugs, 
while the annual report displays calendar year data according to drugs 
used, patient/decedent characteristics, and drug use patterns. Both 
reports reflect data aggregated at the total DAWN system level and at 
the metropolitan area level. These reports are sent to DAWN facilities 
and are available on request to the general public, drug abuse research- 
ers, public officials, and other regular users of DAWN statistics. 

DAWN reports published by SAMHSA are available at the Web site: 
http://www.samhsa.gov. 

As an example, exhibits C-l and C-2 display San Diego metropoli- 
tan area DAWN mentions for 1992 through 1995. These tables were 
compiled for and presented at the June 1997 national CEWG meeting. 
The data show a relatively high number of methamphetamine/speed 
mentions (n = 679) in 1995. 

Exhibit C-3 shows the Phoenix metropolitan area DAWN emer- 
gency room mentions for the period from 1993 through the 1996. These 
data show a relatively high number of methamphetamine mentions in 
all 4 years, but a slight decrease in such mentions in 1996 (n=690) 
compared with the preceding year (n=761). 

National Hospital Ambulatory Medical Care Survey 

Another potential source of useful information is the National 
Hospital Ambulatory Medical Care Survey (NHAMCS), which was 
initiated in 1991 by the National Center for Health Statistics (NCHS) to 
gather information about the health care provided by hospital emer- 
gency and outpatient departments. This survey has a broader defini- 
tion of substance abuse-related visits, which includes alcohol as a 
primary diagnosis as well as injuries and illnesses sustained because of 
drug and alcohol use (e.g., the driver of a car hit by an intoxicated 
driver or a person caught in the crossfire between drug sellers). NCHS 
does not report which hospitals participate in its survey. 

Hospital Data 

The need for emergency department data is critical to understand- 
ing the usage patterns of drug abusers in a given community Since 
emergency department personnel are often extremely busy, they may 
not normally collect information on drug use practices. Therefore, 



32 Assessing Drug Abuse Within and Across Communities 



Exhibit C-1 : DAWN Data: Estimated Number of Emergency Room Drug Abuse 
Episodes Metions, San Diego — 1992-95 





1992 


1993 


1994 


1995 


Drug episodes 


6,088 


5,310 


5,051 


4,601 


Drug mentions 


10,291 


9,033 


8,701 


8,065 


Alcohol-in-combination 


1,722 


1,515 


1,377 


1,384 


Cocaine 


1,149 


869 


668 


638 


Heroin/morphine 


1,022 


842 


695 


682 


PCP/PCP combinations 


73 


65 


54 


60 


LSD 


58 


48 


47 


53 


Amphetamine 


245 


364 


381 


421 


Methamphetamine/speed 


931 


929 


913 


679 


Marijuana/hashish 


416 


479 


513 


480 



SOURCE: National Institute on Drug Abuse, 1997. 



Exhibit C-2: Biannual Estimated Number of Emergency Room Drug Abuse 
Episodes/Metions, San Diego— 1995-96 





Jan-Jun 


Jul-Dec 


Jan-Jun 




1995 


1995 


1996 


Drug episodes 


2,318 


2,283 


2,429 


Drug mentions 


4,133 


3,932 


4,211 


Alcohol-in-combination 


701 


683 


752 


Cocaine 


319 


319 


336 


Heroin/morphine 


301 


382 


462 


PCP/PCP combinations 


30 


30 


17 


LSD 


25 


28 


47 


Amphetamine 


254 


167 


146 


Methamphetamine/speed 


408 


271 


238 


Marijuana/hashish 


228 


252 


242 



SOURCE: National Institute on Drug Abuse, 1997. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



33 



Exhibit C-3: DAWN Data: Number of Emergency Room Mentions By Drug, 
Phoenix— 1 993-96 



Drug 


Emergency Room Mentions 


1993 


1993 


1994 


1994 


1995 


1995 


1996 


1996 




Jan-Jun 


Jul-Dec 


Jan-Jun 


Jul-Dec 


Jan-Jun 


Jul-Dec 


Jan-Jun 


Jul-Dec 


Drug Episodes 


3,152 


2,778 


3,175 


3,704 


3,935 


3,738 


3,569 


33,614 


Drug Mentions 


5,225 


4,785 


5,325 


6,238 


6,660 


6,211 


6,141 


6,010 


Cocaine 


487 


350 


499 


568 


618 


480 


606 


721 


Heroin 


251 


236 


246 


236 


226 


261 


274 


350 


Alprazolam 


85 


91 


108 


115 


116 


137 


118 


88 


Marijuana 


123 


103 


159 


294 


275 


195 


315 


277 


Diazepam 


149 


113 


75 


151 


172 


171" 


135 


124 


Amitriptyline 


105 


81 


77 


112 


152 


135 


119 


104 


Diphenhydramine 


93 


53 


105 


102 


75 


73 


45 


69 


Methamphetamine 


229 


252 


379 


434 


435 


326 


365 


325 


Lithium-Carbonate 


83 


72 


84 


99 


139 


121 


136 


124 


Clonazepam 


108 


107 


105 


131 


145 


167 


118 


96 


Amphetamine 


37 


62 


153 


249 


286 


162 


133 


163 


Trazodone 


54 


55 


48 


72 


50 


79 


52 


40 


Carisoprodol 


141 


130 


119 


167 


189 


215 


166 


125 



SOURCE: National Institute on Drug Abuse, 1997. 



strategies need to be developed to convince those with the data to 
share it with the network. The purpose of collecting the data needs to 
be made clear to these groups. 

It should be explained to hospital staff that there are three primary 
purposes for collecting local data on emergency department visits. 
First, such data will allow hospitals and the hospital associations to 
identify the extent to which substance abuse treatment in EDs affects 
hospital operations and resources. Second, data will highlight the 
impact of substance abuse on the local community and help the hospi- 
tal and public agency planners identify the appropriate future re- 
sources needed to serve this population. Third, collecting and sharing 
these data will allow community -based providers and hospitals to work 
more closely to provide better case management and aftercare services. 
Exhibit C-4 shows a sample of an ED record layout. 

Undoubtedly, one of the major hurdles in analyzing these data is 
integrating dissimilar data bases. For example, the general hospital data 
and State hospital data could be run on two separate systems, forms, or 
programming languages. Retrieving the information from private 



34 



Assessing Drug Abuse Within and Across Communities 



Exhibit C-4: Suggested Emergency Department Record Layout, Drug- or Alcohol- 
Related Episodes 



Data Set Element 


Description 


Medical Record Number 


Unique Patient Identifier 


Service Date 


Year, Month 


Date of Birth 


Year, Month, Day 


Sex 


Male/Female 


Race 


White, African-American, etc. 


Zip Code 


5-Digit Zip Code 


Hospital Number 


6-Digit Medicare Provider Number 


Primary Diagnosis 


Drug/Alcohol-Related or Not 


Secondary Diagnoses 


Drug/Alcohol-Related or Not 


Disposition of Patient 


Home, Outpatient, Other Hospital 


Source of Payment 


Medicare/Medicaid, Private, HMO, etc. 


Patient Origin 


Jurisdiction of Patients' Residence 


Source of Admission 


Other ER, Institution, Home, etc. 



SOURCE: National Institute on Drug Abuse, 1997. 



Hospital based drug 
use data are difficult 
to collect, aggregate, 
and analyze 



psychiatric hospitals is either too expensive or not possible because of 
the private hospital's claim that information is proprietary or confiden- 
tial. However, if a representative of the private hospital is a member of 
the surveillance network, it may be possible to get aggregate patient 
information from this facility. To integrate these data sources, to the 
extent possible, the network might establish a special work group. 

Given the difficulties associated with accessing and analyzing these 
sources of data, and the limited time and resources of a network, it is 
advisable to identify someone at the State or local level who has the 
knowledge, skills, and time to do the necessary work. Ideally, this 
person would access, prepare, and report these data at the network 
meeting in a simple format so that the data can be used along with 
other data sources to assess drug use patterns and trends. There should 
be periodic independent investigations on a sampling basis of the 
quality and accuracy of the data system(s). 

Hospital-based drug use data are difficult to collect, aggregate, and 
analyze. Most hospitals collect information, maintain records, and 
report on the types of drug-related problems and the specific drugs 
used by patients. However, the lack of uniformity among public, 
private, and not-for-profit hospital data bases makes it increasingly 
difficult to report the extent of substance abuse in any jurisdiction, 
region, or on a statewide basis. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



35 



In attempting to obtain information about hospital patient drug 
use, three problems are usually confronted. Because hospitals tend to 
be complex organizations, it is difficult to identify individuals within 
them who have responsibility for patient data. Second, hospital staff 
who have responsibility for patient data tend to be very busy, difficult 
to reach, and reluctant to share information. Third, the reporting of 
drug-related medical problems (e.g., drug overdoses) often does not 
include specific information about the drugs involved. 

To obtain information, contact should be made with the hospital's 
executive director, the official in charge of planning or marketing, or 
the hospital's epidemiology department. If the hospital is relatively 
small, it should be fairly easy to identify the appropriate hospital 
representative. 

As an illustration, an ethnographer in one site made an effort to 
obtain patient drug use data from three local hospitals, two of which 
were public and one of which was a private hospital, to identify some 
of the difficulties that might be confronted. He started by making 
telephone calls to all three hospitals, explaining that he was associated 
with a local university and was interested in obtaining information 
regarding hospital admissions (e.g., drug overdoses) for the network 
(explaining the purpose and activities of this group). 

The ethnographer's experiences with each of the hospitals was 
different. At the public hospitals, he found a general understanding of 
the information desired and genuine efforts to be helpful. The nurse to 
whom the ethnographer was referred at the University Hospital was 
very cooperative. She had her staff conduct a computer run on emer- 
gency room mentions for poisoning. Within a day of the request, the 
nurse faxed the ethnographer a report. The data included poisoning/ 
overdose admissions, but they were not specifically related to drugs. 
The General Hospital staff also were helpful, but it was difficult to 
identify the potential sources of patient drug use data. Finally, the 
ethnographer was referred to the director of the outpatient drug abuse 
treatment program and was able to obtain some data. 

The private hospital was much more concerned about patient 
confidentiality. The ethnographer was referred to a nurse who re- 
quested a letter explaining the purpose of the inquiry, the identification 
of the organization for which the ethnographer worked, and the 
specific information desired. She explained that the patient drug use 
data collected by the hospital was similar to the data collected by public 
hospitals. The drug overdose cases recorded did not include the names 
of the specific drugs involved. It was learned that it would be necessary 
to go to the doctors' charts for specific drug information. 



36 Assessing Drug Abuse Within and Across Communities 



Hospitals treat a 
broad range of drug 
use-related condi- 
tions . . . 



Hospitals treat a broad range of drug use-related conditions and 
populations presenting those needs. Detoxification and medical 
rehabilitation are two of the primary services provided in a hospital. 
The research shows that about 5 percent of alcoholics and drug abusers 
require hospitalization or a medical setting for detoxification (Whitfield 
1982). However, some drug abusers who do not have health insurance 
use the hospital emergency room as their source for primary and other 
care. Some chronic drug abusers relapse from time to time and "wear 
out their welcome" at one emergency room and then seek care at the 
next closest hospital. Others are admitted to the hospital for a medical 
or psychiatric illness that is a consequence of drug-using behavior. Each 
of these individuals is difficult to track within the addiction continuum 
of care, and each needs differing levels of care and case management to 
avoid future hospitalizations. Generally, alcohol and drug abuse 
patients receive care in three basic types of hospitals: acute general, 
private psychiatric, and State psychiatric hospitals. 



Hospital-based drug 
use data can provide 
a valuable resource 
for local networks 



Purpose of Studying Hospital-Based Drug-Related 
Discharges 

Developing a drug abuse hospital data base is important because 
hospitals are the only treatment facilities open 24 hours a day, 365 days 
a year to provide emergency detoxification and rehabilitative and other 
inpatient treatment. Every hospital is in a position to test patients for 
alcohol and drug abuse treatment. Often, serious complications from 
drugs and alcohol occur at times when the hospital is the provider. 
Also, accidents and illnesses are often complicated by drug or alcohol 
use. Or, there may be a "comorbid" condition, such as affective disorder 
coexisting with drug or alcohol dependence. Hospital-based drug use 
data can provide a valuable resource for local networks. 

Because of the recession in the early 1990s, State governments 
began to reduce their budgets. Some of the first services to be cut were 
drug-related nonhospital detoxification, intermediate care, halfway 
houses, and long-term drug abuse treatment facilities. Other reduc- 
tions in Medicaid attempted to cut eligibility requirements of recipients 
and services reimbursed under each State's Medicaid plan. This in turn 
has continued to have an impact on public agencies, which have long 
waiting lists for treatment in all types of facilities. In the private sector, 
managed care and aggressive utilization review programs severely 
curtailed admissions to and occupancies of hospital-based and free- 
standing substance abuse treatment programs. Some general hospitals 
closed their detoxification units in exchange for more profitable service 
lines. 



Where Can a Network Obtain Hospital Data? 

The first step is to find out who in State or local government collects 
and analyzes hospital data. One can contact the State health planning 
or hospital rate-review agency; State alcohol, drug abuse, and mental 
health administrations; local health departments; or a regional or 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



37 



. . . identify a re- 
searcher who can 
assist the network in 
collecting and 
analyzing the data 



statewide hospital association. Each agency might have some or all 
data for general, private, or State hospitals. It is good practice to collect 
data from more than one resource so that the data can be cross-vali- 
dated. 

Unless there is a network member who has knowledge of and 
expertise in accessing and analyzing hospital data sets, a second step 
might be to identify a researcher who can assist the network in collect- 
ing and analyzing the data. 

If the network is concerned about a relatively small geographic area 
(a region with one or two hospitals), it may be possible to obtain infor- 
mation directly from the local hospital. Initial contact should be made 
with the hospital's chief executive officer, official in charge of planning 
or marketing, or epidemiology department. Because of comorbidity 
(i.e., with mental illness), it is important to inquire whether the hospital 
has a director of psychiatry who might be a potential collaborator to 
collect drug use information. It is useful also to ask directors of other 
hospital divisions about the effect of substance abuse on their patients. 

Remember to make inquiries regarding data bases of private psy- 
chiatric hospitals and State psychiatric hospitals. Both State and private 
psychiatric hospitals sometimes have units dedicated to the dually 
diagnosed patient or dedicated to the addicted patient population. For 
State psychiatric hospital data, one should contact the State mental 
health authority and become familiar with its data system and the 
people who maintain it. If the private psychiatric hospital data are not 
in a State data base, this information will be harder to access; one will 
need to visit each private psychiatric hospital to determine to what 
extent these hospitals serve drug-using populations. One might want 
to see if there is a separate association of private psychiatric providers in 
the area who might be interested in the network data collection project. 

If you need statewide or comprehensive regional data that are not 
supplied by a State agency, the network may consider approaching the 
State's hospital association or major payers (e.g., Medicaid, Medicare, 
Blue Cross/Blue Shield). Remember to perform a comprehensive 
assessment; acute general, private psychiatric, and State psychiatric 
hospital data must be retrieved. Do not be surprised if each of these 
data types is on a separate data base, with one system based on fiscal 
years and others based on calendar years. If there are no centralized 
data bases, be prepared to inquire at each hospital regarding its data 
base. Contacting each hospital is a time-consuming and daunting task. 
However, the knowledge that will be gained during this data collection 
experience will prove invaluable, because network members will be the 
only persons who know how the system fits (or does not fit) together. 

The next question is: What data elements does the network need to 
retrieve? The following section will explain how drug use diagnoses are 
categorized. 



38 



Assessing Drug Abuse Within and Across Communities 



For basic informa- 
tion, it is preferable 
to use DRGs 



Development of the International Classification of 
Diseases 

Diagnostic coding dates back to 17th-century England, where 
statistical information was gathered through a system known as the 
London Bills of Mortality. By 1937, this method of tracking information 
evolved into the International Causes of Death. The World Health 
Organization (WHO) published a statistical listing in 1948 that could be 
used to track both morbidity and mortality. 

The International Classification of Diseases (ICD) led the way for 
the current text in international use today, the International Classifica- 
tion of Diseases, 9th Revision (ICD-9-CM). This version precisely 
delineates the clinical picture of each patient, providing exact informa- 
tion beyond that needed for statistical groupings and analysis of health 
care trends. 

Another classification system is the revised fourth edition of the 
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) 
published by the American Psychiatric Association (APA 1994). In 
DSM-IV, psychoactive substance use means "the persistence of psycho- 
active substance use for at least 1 month or repeatedly over a long 
period of continuing use despite the recurrence or persistence of one or 
more known adverse consequences or taking of recurrent physical risks 
such as driving while intoxicated." Nearly all of the DSM-IV classifica- 
tions are identical to ICD-9-CM codes. 

Drug-Related ICD-9-CM Diagnoses and Diagnostic Related 
Groups 

Since the enactment of the Tax Equity and Fiscal Responsibility Act 
of 1982 (TEFRA), Diagnostic Related Groups (DRGs) have been used to 
set limits on Medicare reimbursement. This patient classification 
scheme can be used to provide surveillance networks with information 
about the types of drugs used by hospital patients. Since it requires 
considerable knowledge and expertise to work with these data, net- 
works should, as noted earlier, identify a researcher who knows how to 
access and analyze the information. This might be someone who is 
associated with a hospital, health department, or university. 

Computer systems can usually use either the ICD-9-CM or DRG 
classification system. For basic information, it is preferable to use DRGs. 
For more complex questions, running the 51 ICD-9-CM codes would be 
more appropriate. 

The ICD-9 classification system provides principal, secondary, and 
tertiary diagnostic codes. It will be useful to look at secondary (and 
perhaps tertiary) codes. For example, drug dependence, psychosis, or 
nondependent abuse are often diagnosed in conjunction with mental 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



39 



and emotional disorders. It is frequently difficult to tell which impair- 
ment came first. Treatment for a drug problem may be necessary before 
effective treatment for mental illness can be initiated. There may be as 
many drug cases that fall into the secondary diagnostic codes as fall into 
the principal diagnostic codes. The majority of cases where the drug 
code is not the principal code may have a mental health code (e.g., 
affective disorder, adjustment reaction) as the principal code. Other 
conditions that may have a secondary code related to drug or alcohol 
dependence, psychosis, or nondependent abuse are pregnancy, acci- 
dental poisoning, and fractures. 

Below are the addiction-related DRG codes matched to ICD-9-CM 
codes. 

DRG 433: Alcohol/Drug Abuse or Dependence, Left Against 
Medical Advice 

DRG 434: Alcohol/Drug Abuse Dependence, Detoxification or Other 
Symptomatic Treatment with Complication Condition 

Principal ICD-9-CM codes: 

291 Psychosis, alcoholic 

292 Psychosis, drug 

303.0 Intoxication, acute alcoholic, or alcoholism 

303.9 Other and unspecified alcohol dependence 

304 Dependence, drug 

304.9 Other and unspecified drug dependence 

305.0 Abuse, alcohol; nondependent 

305.2 Abuse, cannabis; nondependent 

305.3 Abuse, hallucinogen; nondependent 

305.4 Abuse, barbiturate, similarly acting sedative or 
hypnotic; nondependent 

305.5 Abuse, opioid-mixed; nondependent 

305.6 Abuse, cocaine; nondependent 

305.7 Abuse, amphetamine; nondependent 

305.8 Abuse, antidepressant; nondependent 

305.9 Abuse, unspecified drug; nondependent 
790.3 Excessive levels of blood alcohol 

DRG 435: Alcohol/Drug Abuse or Dependence, Detoxification or 
Other Symptomatic Treatment Without Complicating 
Condition 

DRG 436: Alcohol/Drug Dependence with Rehabilitation Therapy 

Principal or secondary ICD-9-CM codes: 

291.0 Delirium, alcohol withdrawal 

291 . 1 Syndrome, amnestic, alcohol 



40 Assessing Drug Abuse Within and Across Communities 



291.2 Dementia, alcoholic, other 

291 .3 Hallucinosis, alcoholic withdrawal 

291 .8 Psychosis, alcoholic, specified 

291.9 Psychosis, alcoholic, unspecified 
292 Drug withdrawal syndrome 

DRG 436: Alcohol/Drug Dependence with Rehabilitation Therapy 
303.0 Intoxication, acute alcoholic, alcoholism 

Secondary ICD-9-CM codes:Non-operating room procedures 
94.61 Rehabilitation, alcohol 

94.64 Rehabilitation, drug 

94.67 Rehabilitation, combination alcohol and drug 

DRG 437: Alcohol/Drug Dependence with Combined Rehabilitation 
and Detoxification Therapy 

Secondary ICD-9-CM codes: 

Non-operating room procedures 

94.63 Rehabilitation/detoxification, alcohol 

94.66 Rehabilitation/detoxification, drug 

94.69 Rehabilitation/detoxification, alcohol and drug 

In addition to these DRG codes and the 24 ICD-9-CM codes corre- 
sponding to them, there are drug-related ICD-9-CM codes that are not 
matched to DRG codes, including the following: 

265.2 Pellagra (alcoholic) 

357.5 Alcoholic polyneuropathy 

357.6 Polyneuropathy due to other toxic agents (specific 
illicit drugs can be found in E codes 850-854) 

425.5 Alcoholic cardiomyopathy 

535.3 Alcoholic gastritis 

571 .0 Alcoholic fatty liver 

571.1 Acute alcoholic hepatitis 

571 .2 Alcoholic cirrhosis of liver 

571 .3 Alcoholic liver damage, unspecified 
572.3 Portal hypertension 

573.3 Hepatitis (unspecified toxic) 

648.3 Complications of pregnancy due to drug dependence 

648.4 Complications of pregnancy due to alcohol and drugs 

655.4 Suspected damage to fetus from alcohol 

655.5 Suspected damage to fetus from drugs 

760.71 Fetus affected by alcohol (fetal alcohol syndrome) 

760.72 Fetus affected by narcotics 

760.73 Fetus affected by hallucinogenic agents 
760.75 Fetus affected by cocaine 

965.00 Poisoning by opium 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 41 



965.01 Poisoning by heroin 

965.09 Poisoning by other drugs 
967.0 Poisoning by barbiturates 

967.4 Poisoning by methaqualone compounds 
967.8 Poisoning by other sedatives and hypnotics 

968.5 Poisoning by topical and infiltration anesthetics (e.g., 
cocaine) 

970.0 Poisoning by central nervous system stimulants 
analeptics 

970.1 Poisoning by central nervous system-opiate 
antagonists 

980.0 Toxic effect of alcohol 

Limitations of Using Hospital Data 

How do hospitals decide which medical conditions are drug re- 
lated? Typically, the association is made because a condition occurs 
with unusually high frequency in patients already diagnosed as ad- 
dicted. Cirrhosis of the liver is one example. However, cirrhosis of the 
liver is an outcome (a scarring of the liver) that is not a specific disease, 
and it has a variety of causes besides alcohol use, including viral and 
other infections and exposure to other drugs and chemicals. Thus, 
without knowledge of a patient's alcohol consumption, it may be 
difficult to make a diagnosis of alcoholic cirrhosis. Another example is 
alcoholic cardiomyopathy (alcohol-related damage to the heart 
muscle). This diagnosis is made by exclusion if every other known 
cause of heart muscle damage is ruled out. 

Limitations of the ICD-9-CM also handicap efforts to assess the true 
nature and magnitude of drug-related health consequences. There is 
no code-specific category for acute alcoholic pancreatitis or drug- 
related HIV transmission. Therefore, it is impossible to separate drugs 
or alcohol from other causes of illness; when presenting the informa- 
tion, one can say the utilization data being prepared present a conser- 
vative estimate, since the data do not include all drug-related condi- 
tions (Dufour and Caces 1993). 

Some complexities involved in using ICD-9-CM codes, and ways 
they are being used, are described in Appendix D by epidemiologists 
and researchers at the Washington State Department of Health. 

Information Netwoks Should Request 

The information the network asks for depends upon the questions 
members are attempting to answer. If a network desires general infor- 
mation from hospitals, one should ask for information by DRGs 433- 
437 for discharges, patient days, and average length of stay for the last 
3-5 years to track trends. Depending upon network needs, one may ask 
that these data be developed either by the jurisdiction of a patient's 
residence (where the individual lives) or by where a patient received 
services (jurisdiction of the hospital provider). For more intricate data 



42 Assessing Drug Abuse Within and Across Communities 



All drug- use data 
can be run for 
primary, secondary, 
and tertiary diag- 
noses . . . 



inquiries, it is suggested that the data be run by the above ICD-9-CM 
codes. Many current data bases can perform data runs by socioeco- 
nomic factors; demographic factors such as gender, race, and age 
(specify age groups by children and adolescents younger than 18, 
adults ages 18-25, 26-34, and 35 and older); ZIP code; principal, second- 
ary, and tertiary diagnosis; source of admission; marital status; payer 
source; and disposition of patient (where the patient was discharged). 

All drug-use data can be run for primary, secondary, and tertiary 
diagnoses in order to describe the full impact of substance abuse upon 
the hospital and community. For comparison purposes, it might be 
interesting to know what percentage of all discharges are drug-use 
related; this requires that a broader set of data be developed. Finally, be 
sure to check the confidentiality laws in the State to ensure that confi- 
dential data are not unknowingly revealed. 

Hospital Data Needs and Issue Development 

The search for data will, hopefully, lead to the hospital data base. 
Below are some examples of why one would want to query the hospital 
data base. Network members do not need to have the programming 
experience to actually run these programs, but must know enough 
about the issue and data base to develop a written request and draw an 
example of the printout being requested. 

One should develop a data request form so that output can be 
produced in the same format. Examples are listed below. 



Example # 1 : Request that the patient identifier number be run for 
drug-related use primary and secondary diagnoses, 
DRGs 433^37. You will probably only retrieve recidi- 
vism data from that particular hospital and cannot track 
whether an individual receives treatment at any other 
hospital(s). 

Example #2: Request that the following ICD-9-CM codes be run by 
patient origin (jurisdiction of residence): 

648.3 Complicated pregnancy due to drug dependence 

648.4 Complicated pregnancy due to alcohol and drugs 

655.4 Suspected damage to fetus from alcohol 

655.5 Suspected damage to fetus from drugs 

760.71 Fetus affected by alcohol (fetal alcohol syndrome) 

760.72 Fetus affected by narcotics 

760.73 Fetus affected by hallucinogenic agents 
760.75 Fetus affected by cocaine 

Example #3: Have the programmer run, by age group, the following 
ICD-9-CM codes: 
305.0 Abuse, alcohol; nondependent 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



43 



305.2 


305.3 


305.4 


305.5 


305.6 


305.7 


305.8 


305.9 


Example #4: 



Abuse, cannabis; nondependent 

Abuse, hallucinogen; nondependent 

Abuse, barbiturate, similarly acting sedative or 

hypnotic; nondependent 

Abuse, opioid-mixed; nondependent 

Abuse, cocaine; nondependent 

Abuse, amphetamine or related sympathomimetic; 

nondependent 

Abuse, antidepressant; nondependent 

Abuse, other, mixed, or unspecified drug; 

nondependent 

Request that each ICD-9-CM code be run by age, resi- 
dence, and ZIP code. 



Explain the purpose 
and potential useful- 
ness of the data to 
the network 



In each of the above examples, have the programmer run at least 3 
years of data so you can make comparisons between previous years' 
data. The data will probably be received in a Lotus spreadsheet format. 
The data should be checked to see if the data answer the question being 
asked, to ensure the data's accuracy, and to see if the data make sense. 
After some experience working with the data base(s), members can 
probably ask better questions and begin to challenge the limits of the 
data base(s). An advanced application of drug use data is geo-coding, a 
computerized mapping application that plots data against a State, 
jurisdictional, or subregional map. 

Finally, appreciate programmers and let them know why you want 
the data. Explain the purpose and potential usefulness of the data to 
the network. Do not overburden the programmer with data requests 
that are too complicated or relatively unimportant. Give the program- 
mer enough lead time to complete the request. Develop your own 
graphs and charts from the data received, and thank the programmers 
each time for their help. If the network wants further data runs, have 
the data funneled through one person instead of having many indi- 
viduals inundating the programmer with requests. 

Outcomes of a Comprehensive Hospital-Based Drug-Use 
Report 

A 1993 study in Maryland compared the use of the DRGs and the 
ICD-9-CM codes to analyze hospital-based drug (ab)use discharges. 
Initially, this report showed that closure of detoxification and rehabilita- 
tion drug abuse programs, changes in State Medicaid policies, and 
increased utilization review and managed care programs decreased the 
number of hospital discharges between 1990 and 1992 DRGs and ICD- 
9-CM codes (Gentile 1993). Using the ICD-9-CM drug codes produced 
10 percent more drug use discharges when compared with DRGs. 
However, using primary and secondary ICD-9-CM drug-related dis- 
charges showed four times as many admissions compared with only 
primary DRG diagnoses (45,000 vs. 13,000 discharges). The data 



44 



Assessing Drug Abuse Within and Across Communities 



A significant finding 
. . . is the importance 
of mental health 
data . . . 



showed that the ICD-9-CM codes will better identify the extent to 
which alcohol and drug abuse is a problem in each jurisdiction and 
hospital. It was estimated conservatively that about 45,000 drug users 
(Maryland residents) are treated in Maryland hospitals annually, or that 
about 1 in every 12 admissions is drug related. 

A significant finding of this and other studies is the importance of 
mental health data and their relationship to drug use data. Five of the 
top 10 primary nondrug diagnoses are mental health diagnoses whose 
secondary diagnosis is drug-related. Recent studies and reports survey- 
ing the mental health population found that 50-80 percent of mentally 
ill individuals also have a drug-use diagnosis. The report points out 
significant data gaps in obtaining secondary drug-use diagnoses from 
State psychiatric hospitals and the lack of a systematic method to collect 
emergency room data. 



Law Enforcement Data 



Police Departments 
generally assign 
someone primary 
responsibility for the 
task of collecting, 
managing, and 
reporting arrest data 



There is considerable variability in the way different law enforce- 
ment departments collect and report arrest data. Police Departments 
generally assign someone primary responsibility for the task of collect- 
ing, managing, and reporting arrest data. If a Police Department is 
relatively large, this responsibility is likely to be delegated to a particu- 
lar division. For example, the Denver, Colorado, Police Department has 
a Research and Development Division that collects and reports arrest 
data. The Division produces annual reports that categorize different 
types of criminal offenses by geographic location, police district, and 
demographic category (the information is presented in table form). 
Unfortunately, there is only one category for drug-related offenses, and 
drug types are not specified. 

Other city Police Departments in Colorado collect arrest data 
differently. For example, the Police Department in Aurora only records 
the most serious offense when an arrest is made. The specific informa- 
tion about a drug-related arrest is not recorded. If a person is arrested 
for driving under the influence (DUI) and drugs are found, the arrest 
report only includes the DUI (the greater of the two offenses). Being 
arrested for possession of an injection device is not considered a major 
arrest and would not be recorded in the data base. Similarly, the Police 
Department in Arvada, another city in Colorado just north of Denver, 
does not report specific information about drug arrests. (The type of 
drug involved in the arrest is not reported.) Crimes are reported as 
specific legal offenses. 

The Police Department in Shreveport, Louisiana, uses a standard 
format to report the number and types of arrests in the city by year. 
Exhibit D-l shows the number of annual drug arrests reported by the 
Shreveport Police Department from 1989 to the first half of 1997. 

The table in exhibit D-2 is an example of how the Shreveport Police 
Department categorizes specific types of drug arrests for adults and 
juveniles. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



45 



Exhibit D-1 : Shreveport Drug Arrests 



Year 


Drug Arrests 


% Change 


from previous year 


1989 


662 




10 


1990 


688 




4 


1991 


667 




-3 


1992 


1,076 




61 


1993 


1,114 




4 


1994 


1,136 




2 


1995 


1,399 




23 


1996 


1,501 




7 


Jan-June 1997 


849 




NA 



SOURCE: Office of Alcohol and Drug Abuse, State of Louisiana, 1997. 



Exhibit D-2: Shreveport Drug Arrests — 1996 





Adults and Juveniles 


Juvenile Arrest Only* 




Sale/ 
manufacture Possession Total 


Sale/ 
manufacture Possession Total 


Schedule II (Cocaine and their derivatives: 
morphine, heroin, codeine) 

Schedule I (Marijuana and other opiates) 
Others 


274 307 581 

109 588 697 

223 223 


12 17 29 
6 50 56 
13 13 


Total 


383 1,118 1,501 


18 80 98 



*Persons arrested under the age of 17. 

SOURCE: Office of Alcohol and Drug Abuse, State of Louisiana, 1997. 



Uniform Crime Reports 

All law enforcement agencies are required to report arrest data to 
State authorities who, in turn, report them to the Federal Bureau of 
Investigation (FBI) for inclusion in the Uniform Crime Reports (UCR), 
which include both national and local data. Only six States (Indiana, 
Michigan, Missouri, New Mexico, Ohio, and Tennessee) and the District 
of Columbia do not send UCR data to the FBI. Caution should be 
exercised when using these data, since comparisons between States 
maybe invalid because of variations in reporting procedures, (e.g., 
what constitutes an "aggravated assault" may differ between Vermont 
and California because of definitions of the crime in State law). 



46 



Assessing Drug Abuse Within and Across Communities 



A few States provide data online. If data are not readily obtainable 
from the State, one can request local data from the FBI. However, one 
should expect this process to take several weeks and be prepared to pay 
a moderate fee. The FBI assists all States in developing State UCRs 
compatible with the national program. A standardized format has been 
developed for this purpose. A listing of these UCR programs is pro- 
vided in Appendix E. These programs report the data that go to the 
FBI. 

The format includes data on arrests for drug trafficking (sale, 
growing, or manufacturing) and unlawful possession. Four different 
drug categories are reported: opium or cocaine or their derivatives, 
including morphine, heroin, and codeine; marijuana; synthetic narcot- 
ics, including demerol and methadone; and other dangerous non- 
narcotic drugs such as barbiturates and benzedrine. Because of the 
groups (such as combining opium and cocaine) and the variation in 
reporting "synthetic narcotics" and "other dangerous non-narcotics" 
(LSD might be included in either category), it is impossible to analyze 
trends except for marijuana as a proportion of all drug arrests. Alcohol 
arrests, including driving under the influence, public drunkenness, and 
liquor law violations, can be very helpful in pointing out at-risk popula- 
tions and juvenile drinking. However, all of these offenses are influ- 
enced by local law enforcement priorities. If there is a campaign 
against drunk driving, arrests will go up, even though the prevalence of 
alcohol use may change little. Likewise, if the police crack down on 
underage drinking during spring break, the arrest rates will go up. In 
addition, some of the alcohol-related arrests are influenced by whether 
or not the reporting county is a "wet" or "dry" area. 

Recorded offenses are maintained by the municipality and county 
in which they occur. Procedures for handling juveniles vary among 
departments more than do procedures for handling adult offenders. 
Juvenile offenders are often handled informally so the records on these 
arrests are incomplete. In addition, some printouts and publications 
from the State Uniform Crime Report program will group youth as 
younger than 18 while other reports from the same agency will group 
them as younger than 17, so use caution when summarizing these 
statistics. 

In addition, the UCR reports provide information on the race and 
ethnicity of persons arrested. The race categories are White, Black, 
American Indian or Alaskan Native, and Asian or Pacific Islander. The 
ethnic categories are Hispanic and Not Hispanic. However, agencies 
differ in the way that these data are compiled. Generating distribution 
tables based on both race and ethnicity may be problematic. Check 
with the UCR agency to see how it gathers information on race and 
ethnicity. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 47 



From the UCR it is 
possible to obtain 
annual data on the 
number of arrests for 
trafficking and 
possession of drugs 
by county . . . 



From the UCR it is possible to obtain annual data on the number of 
arrests for trafficking and possession of drugs by county and by every 
law enforcement agency that reports within the county. The individual 
agency can be very helpful, for example, if the network is looking at 
drug and alcohol arrests by college students and the college police have 
reported such arrests. 

Caution, however, must be exercised because duplicate reporting 
can occur. One should assume that all arrests made by a local law 
enforcement agency have been sent to the UCR, so do not add local 
statistics to the arrests reported by the UCR. Check with the UCR 
agency to see if State police arrests are reported in the UCR or are 
reported separately, and inquire about arrests made by Federal agencies 
and whether or not they are reported in the UCR. 

Examples of the type of arrest data available from the UCR, as 
reported by the Texas Commission on Alcohol and Drug Abuse, are 
shown in exhibits D-3 and D-4. 

Appendix F includes two UCR tables compiled by the State of 
Maryland. One includes demographic variables for arrested persons 
older than 17 years of age. The other includes similar data on adoles- 
cents younger than 18. 



EXHIBIT D-3: Drug Arrests By County, Texas — 1994 



County 


Traffic All Drugs 


Traffic Marijuana 


Possession All Drugs 


Possession Marijuana 


Bexar 


2,651 


99 


5,512 


2,940 


Brazolia 


298 


78 


481 


353 


Dallas 


2,104 


457 


9,621 


3,627 


Fort Bend 


104 


30 


838 


531 


Galveston 


114 


20 


1,245 


492 


Harris 


695 


75 


11,171 


4,283 


Jefferson 


564 


119 


2,506 


1,147 


Midland 


123 


103 


327 


197 


Smith 


145 


26 


289 


191 


Tarrant 


795 


81 


4,743 


2,229 


Traves 


404 


26 


3,115 


1,105 



SOURCE: Texas Commission on Alcohol and Drug Abuse, 1996. Includes counties that have at least 100 arrests in 1994 
for drug trafficking. 



48 



Assessing Drug Abuse Within and Across Communities 



Exhibit D-4: Drug Arrests By Race/Ethnicity, Texas 



Classification of Drug Offenses 


White 


African-American 


Hispanic 


American Indian, 
Native Alaskan, Asian 


Trafficking, Sale, and Manufacturing 










Opium/cocaine or derivatives 


1,384 


4,237 


1,858 


9 


Marijuana 


1,050 


394 


655 


3 


Synthetic narcotics 


320 


256 


307 


1 


Non-narcotic drugs 


170 


128 


54 


1 


Possession 










Opium/cocaine or derivatives 


5,828 


12,478 


6,029 


41 


Marijuana 


13,637 


6,451 


10,605 


33 


Synthetic narcotics 


1,094 


335 


346 


3 


Non-narcotic drugs 


1,363 


1,203 


821 


7 



SOURCE: Texas Commission on Alcohol and Drug Abuse, 1996. 



A substantial amount of criminal justice system data can be accessed 
through the Internet. For example, the Bureau of Justice Statistics (BJS), 
a component of the Office of Justice Programs in the U.S. Department 
of Justice, is the primary national source for criminal justice statistics. 
BJS collects, analyzes, publishes, and disseminates information on 
crime, criminal offenders, victims of crime, and the operation of justice 
systems at all levels of government. 



A substantial amount 
of criminal justice 
system data can be 
accessed through 
the Internet 



The BJS clearinghouse, called the National Criminal Justice Refer- 
ence Service (NCJRS), provides a variety of services to the public 
through a toll-free number. One can request copies of BJS reports and 
mailing list information, criminal justice statistics, custom literature 
searches of the NCJRS Data Base, referrals to other sources of crime 
data, and data assistance from information specialists at the clearing- 
house. Internet users can obtain documents online either by ordering 
them through e-mail or actually reading or downloading them. Such 
documents tend to contain mostly national data, with very little local 
data. The Internet address is http://www.ncjrs.org. 

In 1978, BJS established the National Archive of Criminal Justice 
Data (NACJD) to facilitate and encourage research in the field of 
criminal justice through the sharing of data resources. NACJD seeks to 
provide (1) computer-readable data for the quantitative study of crime 
and the criminal justice system through the development of a central 
data archive that disseminates computer-readable data, as well as (2) 
technical assistance in selecting data collections and the computer 
hardware and software for analyzing data efficiently and effectively. 
NACJD currently holds more than 500 data collections relating to 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



49 



criminal justice. One can obtain the raw data upon which the clearing- 
house reports are based by calling the archive. In addition, NACJD's 
Web site allows browsing and downloading access to most of the 
archive's data and documentation at no charge. A sampling of vari- 
ables one can search under includes year; State and county Federal 
Information Processing Standards (FIPs) codes [numerical codes given 
for States] ; county population; drug abuse violations, drug abuse 
possession, and drug abuse sale/manufacture by opium, cocaine, 
marijuana, synthetics, and other; driving under the influence; liquor 
law violations; and drunkenness. NACJD's internet address is http:// 
www.icpsr.umich.edu/NACJD/home.html. One can ask questions of 
NACJD staff via the internet by writing nacjd@icpsr.umich.edu. The 
mailing address is NACJD/ICPSR, Institute for Social Research, PO. Box 
1248, Ann Arbor, MI, 48106. 



ICPSR provides 
access to the world's 
largest archive of 
computer-readable 
social science data 



The NACJD is but one of many sources of data available through 
the Inter-University Consortium for Political and Social Research 
(ICPSR), located in the Institute for Social Research at the University of 
Michigan. ICPSR provides access to the world's largest archive of 
computer-readable social science data. Numerous discrete files are 
currently on deposit with ICPSR, and detailed descriptions of the data 
holdings are available. ICPSR' s data holdings may be searched online 
by students and researchers at member institutions. (An online list is 
available of the more than 325 member colleges and universities in the 
United States and Canada, as well as the several hundred institutions 
served by members in Europe, Oceania, Asia, and Latin America.) Data 
holdings cover a broad spectrum of academic disciplines, including 
sociology, public health, criminal justice, and the law. A few relevant 
subject headings include Census Enumerations: Historical and Con- 
temporary Population Characteristics, Health Care and Health Facili- 
ties, and Social Institutions and Behavior (including Minorities and 
Race Relations, Crime and the Criminal Justice System, Vital Statistics, 
Family and Gender). A large number of local data sets also can be 
obtained through ICPSR's holdings. 



Data from Crime Laboratories 

In most States, crime laboratories have been established to coordi- 
nate lab results and other sources of information about illicit drugs and 
to report on the quantities, price, and purity of drugs seized and ar- 
restee urinalysis results. These laboratories are generally operated by 
the State police department or police departments in large cities. In a 
large State, obtain the report from the State laboratory that serves the 
network's area and also see if there is a metropolitan laboratory used 
by the city. 

State and county crime laboratories can be identified in each State 
by contacting the State UCR (see Appendix E) or the State Statistical 
Analysis Center (see Appendix C). 



50 



Assessing Drug Abuse Within and Across Communities 



Based on information collected and analyzed, State laboratories 
often report on drug availability, trafficking, and trends. Looking at the 
number of drug analyses by drug type and by year will show changes 
in availability of various drugs. While the formal reports may be by 
general drug types (marijuana, cocaine, stimulants, opiates, etc.), the 
labs are often able to identify new types or combinations of drugs and 
how many samples and dosage units of a specific substance have been 
analyzed. For example, the State crime lab on the Lower Texas border 
with Mexico reported that the number of flunitrazepam (Rohypnol) 
pills examined each year increased from 194 pills in 1992 to 25,966 in 
1995. 

In another example, the Criminal Intelligence Division of the 
Maryland State Police, the State crime laboratory, produces quarterly 
and annual reports based on lab results and data/information collected. 
Exhibits E-l through E-7 provide examples of data tables included in 
the 1995 report. Exhibits E-l through E-4 show data on cocaine hydro- 
chloride (HCL). 



Exhibit E-1 : Maryland State Police Arrests for Cocaine (HCL) 



Race/Ethnicity 


1993 


1994 


Male 




Female 


Male 




Female 


Black 


107 




25 


104 




13 


White 


99 




37 


89 




35 


Hispanic 


1 




— 


3 




— 


Asian 


... 




... 


1 




... 


Total 


207 




62 


197 




48 


Age 


1993 


1994 


17 and under 




7 






4 




18 to 25 




77 






66 




26 to 30 




73 






45 




31 to 35 




48 






54 




36 and over 




57 






72 




Total 




262 






241 





SOURCE: Criminal Intelligence Division of the Maryland State Police (CIDMSP), 1996. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



51 



Exhibit E-2: Maryland State Police Arrests for Crack Cocaine 



Race/Ethnicity 




1993 






1994 




Male 




Female 


Male 




Female 


Black 


115 




18 


127 




14 


White 


45 




16 


43 




19 


Hispanic 


1 




... 


... 




... 


Asian 


— 




... 


... 




— 


Total 


161 




34 


170 




33 


Age 


1993 


1994 


17 and under 




12 






15 




18 to 25 




68 






63 




26 to 30 




33 






43 




31 to 35 




36 






25 




36 and over 




46 






44 




Total 




195 






190 





SOURCE: Criminal Intelligence Division of the Maryland State Police (CIDMSP), 1 996. 



Exhibit E-3: Maryland State Police Statewide Cocaine (HCL) Prices — 1993-94 



User Quantities 


1993 


1994 


1/4 gram 


$27 


$21 


V2 gram 


$48 


$38 


1 gram 


$89 


$72 


Dealer Quantities 


1993 


1994 


1/8 ounce (3.5 grams) 


$240 


$258 


1/4 ounce (7 grams) 


$420 


$409 


Vz ounce 


$775 


$657 


1 ounce 


$1,300 


$1,155 


2 ounces (57 grams) 


$2,445 


$2,150 


4 ounces (113 grams) 


$4,350 


$4,140 



SOURCE: Criminal Intelligence Division of the Maryland State Police (CIDMSP), 1996. 



52 



Assessing Drug Abuse Within and Across Communities 



Exhibit E-4: Maryland State Police Statewide Crack Cocaine Prices — 1993-94 



User Quantities 


1993 


1994 


$10 crack 


.10 grams 


.11 grams 


$20 crack 


.17 grams 


.19 grams 


$40 crack 


.29 grams 


.34 grams 


$50 crack 


.37 grams 


.40 grams 


Dealer Quantities 


1993 


1994 


1 gram 


$105 


$119 


2 grams 


$155 


$172 


1/4 ounce (7 grams) 


$410 


$435 


1 /2 ounce (14 grams) 


$765 


$775 


1 ounces (28 grams) 


$1,295 


$1,125 



SOURCE: Criminal Intelligence Division of the Maryland State Police (CIDMSP), 1996. 

The price of cocaine (HCL) is determined for 2-gram and 1-gram 
amounts. Most users do not buy more than 1 gram of cocaine at a time. 
The average purity is based on all samples seized, regardless of the 
amount seized or how the cocaine was obtained. Contrary to popular 
belief, there is no relationship between the amount seized and purity. 
The dividing line between user and dealer seizures is 2 grams. Larger 
quantities are bought by dealers who repackage the cocaine into 
smaller amounts for resale. 

Maryland's Criminal Intelligence Division concluded that between 
1993 and 1994, drug prices decreased for both user and dealer quanti- 
ties of cocaine (HCL). The only apparent increase was observed in the 
1/8-ounce amount; this "finding" can be explained primarily by the 
small sample size. 

When drug users buy marijuana or cocaine, both the price and the 
amount received can be negotiated. A slightly larger or smaller amount 
has a commensurate change in price. This has not been true for pur- 
chases of crack cocaine. At the street level, the price of crack is fixed, for 
example, at $3-$5 per vial, and the buyer accepts whatever the dealer 
offers. Therefore, changes in availability are measured by the average 
amount paid for purchases of crack. 

The average purity is based on all samples seized. As with cocaine 
(HCL), there is no relationship between amount and purity, which is 
expected because crack is a purified form of cocaine. There is no 
dividing line between user and dealer quantities of crack. Users typi- 
cally smoke the crack immediately after purchase. Therefore, it is 
unusual to find user amounts of crack during routine investigations. 

A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 53 



During 1994, crack users received more crack for their money, 
reflecting a decrease in price. Dealer prices for crack cocaine appear to 
have increased; however, this is more a reflection of the way purchases 
break down by county. In rural counties, midsize purchases of crack are 
generally more expensive than in urban areas, so that rural figures 
inflate the average statewide price for the drug. 

According to Maryland's Criminal Intelligence Division, the price 
for heroin is determined based on a 1-gram purchase of low-purity 
heroin. The price is not determined for street-level purchases of high- 
quality heroin, since they are rare. As a general rule, high-quality 
heroin is four to five times more expensive than a comparable amount 
of low-purity heroin shown in exhibit E-5. Between purchases and 
seizures, there is a sufficient sample each month to determine purity for 
both high and low categories. The vast majority of purchases and 
seizures are for small quantities or are larger amounts repackaged for 
street-level sale, so combining uncut and cut heroin is not an issue. 

Because heroin is typically purchased at the street level in $10 and 
$20 bags, it is more useful to determine how much of the drug is re- 
ceived for the amount paid at each level (exhibit E-6). 



Exhibit E-5: Maryland State Police Statewide Low-Purity Heroin Prices — 1993-94 



Amount 


1993 


1994 


Vz gram 


$43 


$35 


1 gram 


$85 


$67 


2 grams 


$170 


$107 


1/4 ounce 


$340 


$310 


1 /2 ounce 


$655 


$595 


1 ounce 


$1,300 


NA 



SOURCE: Criminal Intelligence Division of the Maryland State Police (CIDMSP), 1996. 



Exhibit E-6: Maryland State Police Price of Heroin and Amount of Purchase 



Price 1993 1994 



$10 0.19 grams 0.17 grams 

$20 0.27 grams 0.31 grams 



SOURCE: Criminal Intelligence Division of the Maryland State Police (CIDMSP), 1996. 



54 Assessing Drug Abuse Within and Across Communities 



It was reported that an oversupply of heroin has enabled dealers to 
sell higher purities at the street level. The higher purities permit 
alternative use methods such as snorting, thus helping to create a new 
population of heroin users. Casual drug users are more likely to take 
drugs by inhalation or smoking rather than by injection. Therefore, 
smokable or snortable heroin can be used by the same methods as 
cocaine. Also, using heroin in smokable or inhalable form eases the 
anxiety of users who want to avoid contracting AIDS and other blood- 
borne diseases through injection. The marketing of heroin is gaining 
ground in Maryland, as evidenced by the increased number of addicts 
appearing in heroin abuse programs from 1990 to 1994 who became 
addicted through smoking or inhaling. 

In 1994, 40 percent of the 15,324 heroin abusers who entered drug 
treatment in Maryland reported that inhalation was the route of 
administration, compared with 28 percent in 1992. 

In Maryland, marijuana price is determined for 1/8- ounce and 1/4- 
ounce purchases; 75 percent of the purchases statewide are made for 
these amounts. The purity, or in the case of marijuana, potency, is not 
included because of insufficient data. The dividing line between user 
and dealer amounts is 16 grams, or slightly more than 2 ounces, because 
a natural break occurs in the data at this point, and intelligence infor- 
mation suggests that this is the dividing line between the user and 
dealer levels (exhibit E-7). 

The Maryland State Crime Laboratory reports data on a variety of 
other drugs. This information can be found in Appendices F-l and F-2. 



Exhibit E-7: Maryland State Police Statewide Marijuana Prices — 1991-94 



Amount 


1991 


1992 


1993 


1994 


1/8 ounce 


$42 


$37 


$38 


$34 


1/4 ounce 


$61 


$63 


$61 


$59 


1/2 ounce 


$101 


$115 


$106 


$108 


1 ounce 


$167 


S205 


$190 


$158 


2 ounces 


NA 


$380 


$355 


$227 


4 ounces 


NA 


$730 


$680 


$515 



SOURCE: Criminal Intelligence Division of the Maryland State Police (CIDMSP), 1996. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 55 



...the DMP pro- 
vides information on 
where the buy was 
made, the brand 
name, the purity, and 
the price per milli- 
gram pure 



Drug Trafficking Reports 

The regional offices of the Drug Enforcement Administration (DEA) 
prepare quarterly intelligence reports that provide information on drug 
trafficking patterns. Some of these reports are available to the public, 
and the intelligence analysts are a good source of information on who 
the wholesalers are as compared with the street traffickers for the 
different drugs. 

Each division office also has a diversion control unit that concen- 
trates on the diversion of legal prescription drugs. This group can 
provide information on which prescription drugs are being diverted 
and the patterns of diversion. In addition, the State Pharmacy Board 
and State Medical Board usually have investigators who can provide 
additional information on the diversion of prescription drugs. 

Appendix G provides a listing of the DEA division offices. 

State drug trafficking reports also can be obtained by contacting 
State and local narcotics officers. These intelligence drug trafficking 
reports can help network members understand when, how, and from 
where illicit drugs are transported into the State. These reports provide 
information about drug availability cost and trends. In many instances, 
the reports can be obtained by contacting the State police or criminal 
justice agency. 

Appendix H provides an example of drug trafficking information 
included in the 1995 Drug Prospectus Report produced by the Criminal 
Intelligence Division of the Maryland State Police Department. 

Domestic Monitor Program 

The Domestic Monitor Program (DMP) of the DEA reports on 
sources, kinds, cost, and purity of retail-level heroin. This information 
is based on actual undercover heroin purchases made by the DEA on 
the streets in selected cities. The buys provide information on whether 
the heroin was Asian, Mexican, Colombian, or undetermined, and what 
adulterants and diluents were present. In addition, the DMP indicates 
where the buy was made, the brand name, the purity, and the price per 
milligram pure. Because the validity of this information is dependent 
on the number of buys made by the DEA, it is important to determine 
the specific number of buys. One or two buys would provide inconclu- 
sive evidence. Information on the DMP can be obtained from the local 
DEA field offices 



Price and Purity Data 

The Domestic Unit of the Strategic Intelligence Section, Drug 
Enforcement Administration, compiles data on the price and purity of 
illicit drugs from DEA field division reports. Data are based on illegal 
drugs confiscated at the local level. These data are used to assess illegal 
drug availability A depressed price and an elevated purity might 



56 



Assessing Drug Abuse Within and Across Communities 



signal an increased availability of a certain drug. Increased price and 
declining purity might indicate decreased availability of that drug. 

Data on price and purity of illegal drugs should be analyzed over a 
long term and in conjunction with other available information on drug 
trafficking and drug abuse patterns. 

Exhbit E-8 shows the average price for marijuana confiscated 
during April-June 1996. Exhibit E-9 includes national price and po- 
tency data for marijuana, from 1993 through the first half of 1996. 

Illegal Drug Price/Purity Reports can be obtained from local DEA 
field officers or from the Intelligence Production Unit (IPU), Intelli- 
gence Division, DEA Headquarters. 



Exhibit E-8: Quarterly Price Data in Dollars for Marijuana— April-June 1996 



Division 


Primary Source 


Pound 
Commercial 


Pound Sinsemilla 


Ounce 
Commercial 


Ounce Sinsemilla 


National Range 


COL/JAM/MEX/- 
THAI/US 


200-4,000 


1,000-8,000 


40-400 


100-600 


Atlanta 


MEX/US 


1,200-1,600 


1 ,800-2,000 


90-180 


230 


Boston 


COL/MEX/US 


300-4,000 


1,000-6,000 


75-160 


100-600 


Chicago 


COL/MEX/US 


850-2,000 


2,500-6,500 


75-160 


420-480 


Dallas 


MEX/US 


500-3,000 


NA 


60-80 


NA 


Denver 


MEX/US 


500-1,800 


1,500-3,500 


NA 


NA 


Detroit 


JAM/MEX/THAI/US 


800-4,000 


1,500-3,000 


80-250 


150-200 


Houston 


MEX/US 


350-900 


NA 


NA 


NA 


Los Angeles 


COL/MEX/THAI/US 


200-1,000 


5,000-6,000 


250 


NA 


Miami 


COL/JAM/US 


700-1,700 


2,000-3,000 


NA 


NA 


Newark 


JAM/MEX/US 


900-4,000 


2,400-3,000 


90-400 


NA 


New Orleans 


MEX/US 


700-1 ,500 


1,600-5000 


100-400 


200-600 


New York 


MEX/US 


300-2,000 


2,400-3,500 


NA 


NA 


Philadelphia 


JAM//MEX/US 


1,500-3,200 


1,400-3,200 


100-250 


NA 


Phoenix 


MEX/US 


650-750 


NA 


75-100 


NA 


San Diego 


COL/MEX/US 


400-800 


2,000-4,000 


50-100 


200-400 


San Francisco 


MEX/THAI/US 


350-1,000 


1,500-6,000 


40-100 


200-600 


San Juan 


JAM/MEX/US 


900-2,500 


1700 


250-400 


NA 


Seattle 


MEX/THAI/US 


600-3,000 


2,000-8,000 


NA 


NA 


St. Louis 


MEX/US 


900-2,000 


1,500-4,000 


NA 


NA 


Washington, DC. 


JAM/MEX/US 


850-2,200 


1,100-5,000 


100-250 


150-500 



SOURCE: Drug Enforcement Administration, 1997. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



57 



Exhibit E-9: Annual Price and Potency Data in Dollars for Marijuana, National Range 



Type 


Quantity 


1993 


1994 


1995 


1996 
(Jan-June) 


Commercial Grade 


Pound 
Ounce 


300-5,000 
24-450 


285-4,000 
40-450 


300-4,000 
40-400 


200-4,000 
40-400 


Potency (THC) 




4.18% 


4.06% 


3.51% 


5.02% 


Sinsemilla 


Pound 
Ounce 


1,000-9,500 
75-100 


900-9,500 
100-1,000 


800-8,000 
100-900 


700-8,000 
60-600 


Potency (THC) 




5.45% 


7.29% 


7.25% 


10.48% 



SOURCE: Drug Enforcement Administraiton, 1997. 



Arrestee Drug Abuse Monitoring Program 

The National Institute of Justice's (NIJ) Arrestee Drug Abuse Moni- 
toring Program (ADAM) is a survey of arrestees in metropolitan areas 
across the United States. It is projected that there will be 75 ADAM sites 
by the year 2000. ADAM is an expansion and enhancement of the Drug 
Use Forecasting (DUF) program, which was established by NIJ in 1987. 

In each site, quarterly interviews and bioassays are obtained from a 
sample of arrestees. Response rates usually reach 90 percent for the 
interviews, with approximately 80 percent of those interviewed agree- 
ing to provide urine samples. All urine specimens are sent to a central 
laboratory for analysis, and they are analyzed for 10 drugs: cocaine, 
opiates, marijuana, phencyclidine (PCP), methadone, benzodiazepines, 
methaqualone, propoxyphene, barbiturates, and amphetamines. All 
positive results for amphetamines are confirmed by gas chromatogra- 
phy to eliminate positives that may have been caused by over-the- 
counter drugs. For most drugs, the urine test can detect use in the 
previous 2-3 days, although marijuana and PCP can sometimes be 
detected several weeks after use. 

In 1996, program sites were located in 23 major metropolitan areas 
and data were collected data from 19,835 adult male booked arrestees. 
Data also were collected from 7,532 adult female booked arrestees at 21 
of these sites, and from 4,145 juvenile male and 645 juvenile female 
detainees at 12 sites and 7 sites, respectively. 

Current ADAM sites include Atlanta, Birmingham, Chicago, Cleve- 
land, Dallas, Denver, Detroit, Ft. Lauderdale, Houston, Indianapolis, 
Kansas City, Los Angeles, Manhattan, New Orleans, Omaha, Philadel- 
phia, Phoenix, Portland, St. Louis, San Antonio, San Diego, San Jose, 
and Washington, D.C. 



58 Assessing Drug Abuse Within and Across Communities 



Data from ADAM is used to examine drug abuse patterns and 
trends in arrestee populations and to compare differences across sites. 
Outreach data collection will provide vital insights into the leading and 
trailing edges of drug epidemics and into the links between drugs and 
crime beyond our central cities. 

To obtain information, contact the ADAM Program, National 
Institute of Justice, 633 Indiana Avenue NW, Room 880, Washington, 
D.C. 20531. 

Some States participating in CSAT's Treatment Needs Assessment 
contract have funded additonal arrestee sites through a series referred 
to as the SANTA program. Contact the State Alcohol and Drug Abuse 
agency for information on local ADAM or SANTA studies. 



Surveys 



Network members 
should be knowl- 
edgeable about 
three ongoing 
national surveys . . 



Surveys are one of the primary sources of epidemiologic data on 
incidence and prevalence, patterns and trends, and correlates and 
consequences of drug use and abuse. Network members should be 
knowledgeable about three ongoing national surveys of drug use and 
the most up-to-date results of these surveys. These surveys provide 
regional and national data on drug use prevalence and trends. The 
data typically show differences in drug use among specific groups, (e.g., 
by gender, age, and race/ethnicity). A comparison of local versus 
national data could, theoretically, yield a number of different but useful 
findings. For example, in a given year, there may be little difference 
between the local and national prevalence rates and patterns of drug 
use. Such a scenario would substantiate the validity of the local data. 

Conversely, a comparison of local and national data may show 
divergent patterns overall or for a particular drug or population group. 
For example, the national data may reflect the emergence of a new 
drug or an increased prevalence of a popular drug, such as marijuana, 
that has not yet become apparent at the local level. Such a divergence 
could serve as an "alert." Has the trend been missed in local data 
gathering, or is it a pattern that may emerge in the future? How should 
local efforts be designed to determine whether the specific drug is or 
will become a substance of abuse in a confined geographic area? 

Knowledge of national surveys can be useful in planning surveys at 
the State and local levels. The methods and questionnaires used in the 
national surveys have been tested for utility and for reliability and 
validity. Sampling strategies, as well as procedures for training data 
collectors, should be accessible and useful. The instruments are in the 
public domain and can be used without cost by any interested party. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



59 



National Surveys 

The National Household Survey on Drug Abuse (NHSDA) pro- 
vides information on prevalence and trends in the use of illicit drugs, 
alcohol, and tobacco among members of the household population 
aged 12 and older in the United States. Information on lifetime ("ever 
used"), past-year, and past-30-day use is collected on the following 
drugs: any illicit drug, marijuana, cocaine hydrochloride, crack cocaine, 
hallucinogens, any psychotherapeutics (nonmedical use of sedatives, 
tranquilizers, stimulants, and/or analgesics), alcohol, cigarettes, smoke- 
less tobacco, phencyclidine hydrochloride (PCP), anabolic steroid use, 
inhalants, and heroin. The survey is based on a multistage area prob- 
ability sample design. 

National Household Survey reports can be obtained by contacting 
SAMHSA, Office of Applied Studies, Rockwall II Building, 5600 Fishers 
Lane, Rockville, Maryland 20857, or from the following Web site: 
http://www.samhsa.gov. 

The Monitoring the Future Study (MTF) reports on the prevalence 
of drug use and related attitudes among secondary school students 
(8th, 10th, and 12th grades). Data have been collected since 1975 from 
125 to 140 public and private schools to provide a representative cross- 
section of students throughout the coterminous United States. A 
followup mail survey is structured to collect data from college students 
1-4 years after high school. Information on lifetime, past-year, and 
past -30-day use is collected on the following drugs: any illicit drug, 
marijuana, stimulants, cocaine, crack cocaine, hallucinogens, lysergic 
acid diethylamide (LSD), hallucinogens other than LSD, inhalants, 
barbiturates, other opiates, tranquilizers, methylenedioxymeth- 
amphetamine (MDMA or "ecstasy"), crystal methamphetamine ("ice"), 
steroids, and heroin. 

The reports describing the results of the MTF can be viewed at Web 
site www.isr.umich.edu/src/mtf. 

The Youth Behavior Risk Survey (YBRS), developed by the Centers 
for Disease Control and Prevention, monitors risk behaviors among 
public school youth in grades 9 through 12. Use of alcohol, tobacco, 
and other drugs, as well as dietary behaviors, physical inactivity, and 
risky sexual behaviors are the priority risk behaviors surveyed. Illicit 
drugs covered include marijuana, cocaine, crack, inhalants, heroin, PCP, 
LSD, MDMA, methamphetamine, crystal methamphetamine, and 
peyote (mushrooms). Use of licit drugs (e.g., steroids) without a 
doctor's prescription also are covered. 

Selected summaries of the YRSB surveys can be viewed at http:// 
www.cdc.gov/nccdphp/dash/problem.htm. 



60 Assessing Drug Abuse Within and Across Communities 



State Surveys 

In recent years, CSAT funded every State to undertake a family of 
surveys to estimate the need for treatment. Every State has conducted 
a telephone survey of adults, which has produced both prevalence and 
abuse/dependence numbers at the sub-State planning level. 

In addition, CSAP funded some States to conduct surveys to esti- 
mated prevention needs. Many of these are surveys of students. Each 
State received enough funds to undertake other surveys and to esti- 
mate the need for services. 

Contact the State Alcohol and Drug Abuse Agency for further 
information about the surveys conducted. 

Some States, as noted, also conduct school surveys. An example is 
the annual surveys conducted by the Texas Commission on Alcohol and 
Drug Abuse, in collaboration with the Public Policy Resources Institute, 
Texas A&M University. Also, a number of States participate in the 
national YBRS. 

Among the States that have conducted household surveys on drug 
use is Louisiana, where the State Office of Alcohol and Drug Abuse 
funded a survey of 5,115 Louisiana adult residents in 1996. The 
NHSDA contractor collaborated with Louisiana State University School 
of Medicine in the effort. 

Louisiana also recently completed an interesting survey that cov- 
ered not only drug use among youth, but also compulsive gambling. 
The survey included 12,066 youth in grades 6-12 in both public and 
nonpublic schools. Included in the questions were lifetime use, past- 
month, and more regular use of alcohol, tobacco, marijuana, and other 
illicit drugs (e.g., cocaine/crack, heroin, other narcotics, tranquilizers, 
hallucinogens, amphetamines, and barbituates), including use of 
someone else's prescribed drug. The survey, funded in 1995 by the 
Louisiana Economic and Development and Gaming Corporation, was 
conducted by Louisiana State University in coordination with school 
superintendents and the Louisiana State Office of Alcohol and Drug 
Abuse. 

Local Surveys 

In many instances, local school districts have used their Safe and 
Drug Free Schools grant funds to determine the prevalence of drug use 
and abuse among their students. In some instances, these surveys are 
in cooperation with statewide efforts, while in other instances, they 
were done by survey firms that specialize in studying students. The 
Parents Research Institute for Drug Education (PRIDE), Parents for a 
Drug Free America, and the American Alcohol and Drug Survey are 
examples of these private survey efforts. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 61 



Local jurisdictions 
sometimes conduct 
household surveys 
on drug abuse 



Local jurisdictions sometimes conduct household surveys on drug 
abuse. For example, Louisiana State University, Baton Rouge, surveyed 
residents in East Baton Rouge Parish using computer-assisted telephone 
interviewing following a random-digit dialing sampling technique. In 
addition, drug and alcohol program administrators, treatment practi- 
tioners, and law enforcement personnel were surveyed to gain insight 
into the nature of the substance abuse problem from those intimately 
involved in its control, to assess treatment services, and to determine 
the characteristics of clientele who are processed by treatment and law 
enforcement agencies. 

Local jurisdictions also may survey arrestees to determine the 
prevalence of drug use in the population. Cities may find support to 
conduct an ADAM-type study, as was done in Bernalillo County, New 
Mexico, or they may be a participating ADAM site. 

At all such local levels, it will be useful to check whether a survey is 
compatible with a national or State survey. Using the questionnaire(s) 
or selected items from the questionnaire(s) will enhance comparability 
between national and State or local findings. It may be possible to get 
the State agency to oversample in the area at a minimal cost (compared 
with running an independent survey). Contact the State Alcohol and 
Drug Abuse Agency for further information. 



HIV/AIDS Data 



CDC distributes scientific publications on all aspects of HIV and 
AIDS, including copies of AIDS-related articles from the Morbidity and 
Mortality Weekly Report (MMWR) series. 

CDC NAC ONLINE, a computerized network, offers a direct link to 
Clearinghouse information and a means for communicating electroni- 
cally with others who are providing HIV services. Data can be accessed 
with a personal computer and modem or by telephone. Some of this 
information is available through http://www.cdc.gov. 

Each State health department should have a HIV/AIDS unit that 
collects much of the information that is subsequently submitted to 
CDC. The State data will be more current and can include additional 
data elements. Available infomation typically includes mode of trans- 
mission, age, race, and sex data. The data are reported cumulatively 
from the date that reporting started and also for the current year. The 
cumulative data include all the data, which will show the full impact of 
AIDS; however, shifts in modes of transmission will be clearer if the 
network compares the noncumulative data for 2 successive years. As 
an example, for modes of transmission in Texas the cumulative percent 
age of homosexual or bisexual men is 65 percent, compared with 54 
percent for 1995. The cumulative percentage of injection drug users is 
12 percent, compared with 16 percent for 1995; the cumulative percent 
age for heterosexual contact is 5 percent compared with 8 percent for 



62 



Assessing Drug Abuse Within and Across Communities 



1995. The percentage of men having sex with men and injecting drugs 
is 9 percent cumulatively and 8 percent for 1995. More importantly, the 
racial/ethnic distribution changed over time. Cumulatively, 59 percent 
are Anglo, 24 percent are African-American, and 17 percent are His- 
panic; for 1995, 47 percent are Anglo, 32 percent are African-American, 
and 20 percent are Hispanic. 

Check the validity of data with State health department personnel. 
In some instances, cases of HIV are underreported, while AIDS data are 
considered more accurate. In addition, to protect the confidentiality of 
some persons, data may not be reported for small rural counties where 
only two or three persons have AIDS. 

Further, the HIV/AIDS unit will be aware of other local research and 
data, and, since it administers the Ryan White planning funds, it can 
direct the network to the local Ryan White Council and the data and 
plans generated at the State and local levels. 

Telephone Hotline Data 

Telephone drug hotlines, which are set up to provide information 
and referral sources, can be a useful source of information about drugs 
and drug abusers. Typically, hotlines are organized to provide informa- 
tion and counseling services to individuals concerned about or experi- 
encing problems after using drugs. In quantifying the information 
collected from callers in a systematic way, it is possible to detect poten- 
tial changes in use of particular drugs and the emergence of new drugs. 
Although one should keep in mind that hotline information is not 
based on a scientifically selected sample and is not catalogued for 
analysis, the counselors can provide valuable insight in explaining new 
trends and "fads." 

Generally, hotline counselors fill out forms to record information 
about each telephone contact, including types of problems the caller 
has experienced, drugs involved, services needed, and assistance/ 
information provided. The information is often recorded on a stan- 
dardized form by trained staff so it can be aggregated and analyzed 
systematically and efficiently. 

An example of this is the Alcohol and Drug 24-hour Helpline in 
Washington State, which established a computer data base to record 
and quantify information collected from callers (Forbes 1991). Through 
this data base, Helpline staff are able to report periodic increases and 
decreases in the number of callers who report use of different drugs 
and the emergence of new substances of abuse. They also are able to 
monitor use patterns by type of callers and by geographic area. For 
example, in 1991, LSD use, which was typically reported in only one 
county, began to be reported in other counties, alerting staff to a poten- 
tial public health concern. Exhibit F shows a summary of calls reported 
by the Helpline in 1990 by type of drug and pregnancy status. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 63 



Exhibit F-1: Reported Alcohol/Drug Helpline Data, Washington State — 1990 



Total Calls 


32,769 


Drugs Mentioned 


4,451 


Alcohol 


140 


Amphetamines 


20 


Barbiturates 


747 


Cannabis 


1,214 


Cocaine 


64 


Narcotics 


398 


Heroin 


45 


Other illicit drugs 


366 


Prescription drugs 


58 


Tranquilizers 


18 


Inhalants 


46 


Nicotine 


322 


Other 


1,013 


Pregnant 


28 


Alcohol 


21 


Cocaine 


10 


Marijuana 


12 


Heroin 


6 



SOURCE: Forbes, 1991. 



Other Useful Data Sources 



A number of other data sources can provide useful information for 
epidemiologic networks. The following are briefly described in this 
section. 

Census Data 

Census data, collected and reported by the U.S. Bureau of the 
Census every 10 years, help characterize populations within particular 
geographic areas and are therefore useful as a planning resource. The 
Bureau of the Census established census tracts as units for the study of 
small metropolitan sections. Census tracts average about 4,000 people. 
Block numbering areas (BNAs) serve a similar purpose for counties that 
do not have census tracts. Block groups (BGs), subdivisions of census 
tracks and BNAs, are the smallest areas for which data are furnished. 
BG data are provided on microfiche, computer tape, and other prod- 
ucts. The Bureau of the Census publishes extensive data for census 
tracts and BNAs in the report series, Population and Housing Characteris- 
tics for Census Tracts and Block Numbering Areas. In addition, the Bureau 
provides 1990 summarized census data for 5-digit ZIP codes through- 
out the country on computer tape and compact disk-read-only 
memory (CD-ROM). 



64 Assessing Drug Abuse Within and Across Communities 



Census statistics can be obtained for many different kinds of geo- 
graphic areas: 

Regions 

Divisions 

States 

Metropolitan statistical areas (MSAs) 

Urbanized areas (UAs) 

Congressional districts 

ZIP codes 

American Indian and Alaskan Native areas 

Counties 

Cities and villages 

Census tracts and block numbering areas 

Block groups 

Blocks 

Census tracts and block numbering areas are the most widely used 
geographic areas as planning resources. 

These data provide the following information about the people 
who live in particular boundaries: 

Demographics 
-gender 
-age 
-race/ethnicity 

Socioeconomic status 

-median family income 

-percentage of families living below the poverty level 

-percentage of families on public assistance 

Crime 

-homicide rate per 100,000 population 

-robbery rate per 100,000 

-breaking and entering rate per 100,000 

-larceny rate per 100,000 

-major crime rate per 100,000 

-percentage of juveniles referred to juvenile court 

-percentage of juvenile offenses per juvenile 



Health 



-death rate per 1,000 

-infant mortality rate per 1,000 



Housing 

-percentage of units without central heating 
-percentage of units with 1.01 or more persons per room 
-percentage of rental units with rent less than $40 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 65 



The U.S. Bureau of 
the Census also 
offers a variety of 
online services to 
Internet users . . . 



. . . faculty members 
may be conducting 
very relevant re- 
search . . . 



Census data have been used in the mental health field to establish 
rough measures of relative need, identify at-risk populations, and 
evaluate patterns of service utilization (Bell et al. 1982). Surveillance 
networks can use census data to learn more about populations in areas 
where particular types of drug use are prevalent or drug use and 
trafficking are high. 

The U.S. Bureau of the Census also offers a variety of online services 
to Internet users, including data access tools, from the agency's Home 
Page. For example, using DataMap, one can view and print profiles of 
States and counties; 1990 Census Lookup allows the user to create 
extract files from the 1990 summaries (and includes detailed examples 
with proper procedures); and the Data Extraction System allows users 
to create custom data extracts from surveys, including the Current 
Population Survey and others. Census CD-ROM products can be 
ordered at the following address: Department of Commerce, P.O. Box 
277943, Atlanta, GA 30384-7943. Credit card orders can be made by 
telephone by calling: (301) 457-4100. 

Under the Search option on the Home Page, one can type in key 
words to access relevant online documents; search for information on 
localities by place names, ZIP codes, and other identifiers; search for 
information by pointing and clicking on areas of interest on a map 
(only available if you have a graphical interface with your Internet 
subscription); or even perform a staff search of Bureau of the Census 
employees. Lastly, under the Ask the Experts option on the home page, 
one can send general questions and comments via e-mail; access phone 
numbers organized by subject for more specific information; get on 
relevant mailing lists; and contact regional offices, Census State Data 
Centers, National Census Information Centers, and other sources of 
information. One can log onto the Bureau of the Census home page 
through http://www.census.gov. 

In addition, the State Census Data Center can provide information 
on updated census estimates by county for the intervening years 
between the census. In some instances, this center makes the estimate, 
while in other instances, another State agency makes the official State 
and county population estimates for these years. 

University Researchers 

Often there are local university faculty, especially in health, social 
science, and science departments, who are interested in alcohol and 
drug abuse issues or have expertise in research methods that can be 
used by epidemiologic networks. The network and these faculty 
members, who may be conducting very relevant research, may be 
unaware of each other's efforts. In addition to the faculty's research 
interests, they often have students looking for projects, and these 
students can be very useful in collecting information and analyzing 
data, especially since they have access to powerful computers and 



66 



Assessing Drug Abuse Within and Across Communities 



. . . calls can be 
made to identify 
potential data 
sources 



statistical software programs that the network members may not have. 
To find these interested faculty, contact academic departments in public 
health, pharmacy, sociology, anthropology, social work, psychology, 
criminal justice, nursing, health sciences, and education. Research 
centers for special ethnic studies also may house researchers who are 
interested in substance abuse issues. 

Community-Level Sources 

It is not easy to identify sources of information at the community 
level, find out what types of information are available from these 
sources, and establish procedures to obtain relevant information 
initially and, perhaps, periodically. It must be kept in mind that infor- 
mation about drug abuse is likely to be confidential. The people re- 
sponsible for collecting and reporting information about drugs are 
usually very busy and are likely to have reservations about sharing 
information. 

If a network does not already have connections with community 
data sources through its members, there are two ways to start the 
process of identifying sources, and both can be done concurrently. The 
first way is to get local telephone numbers of criminal justice, health, 
and treatment agencies so that calls can be made to identify potential 
data sources. The mayor's office, chamber of commerce, or a similar 
source may have a directory of human resource organizations. Or one 
might simply use the local telephone directory. Community or local 
telephone books generally specify, in the front, pages for telephone 
numbers of local police and sheriff departments. The regular telephone 
directories may list police and sheriff departments under Government 
Listings and hospital and treatment programs in yellow pages or the 
business section (by name). Support staff at network-backed agencies 
may be helpful in this task. 

The second way to start identifying potential information sources at 
the community level is to start at the top and work down. In attempt- 
ing to identify sources of arrest data, begin by calling individuals at the 
State Alcohol and Drug Abuse Agency who can identify and provide a 
list of the substance abuse treatment programs that are located within 
or serve particular communities. Also, call the State Police Department 
and the UCR office to find out who their contacts are at the local level. 
In trying to identify individuals and departments within hospitals, 
contact representatives of the State health department to find out what 
and whom they know. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



67 



Establishing and Developing Relationships with Information Sources 

Public Versus Private Information Sources 

It should be kept in mind that most public organizations, including 
police departments, are obligated to release data/information. For 
example, arrest data collected by Police Departments fall under the 
category of public information as long as individuals are not identified. 
Most of these data are collected and reported to another level of author- 
ity; for example, city and county Police Departments report to regional 
Drug Enforcement Administration offices and to State Police Depart- 
ments. Private hospitals, on the other hand, are not obligated to give 
information to outside sources other than those to which they are 
accountable for documenting services provided and costs associated 
with providing services. 



. . . most public 
organizations . . . 
including Police 
Departments, are 
obligated to release 
data/information 



Preparation/Making Contact 

Prior to contacting representatives of agencies and departments 
about the availability of data/information, one must be well prepared. 
First, it is important to specify whom you represent, the reason for 
pursuing the information, and how the information will be used and 
reported. Second, it must be made very clear that this is a public health 
project and that you do not want the names and identities of individu- 
als who used drugs,but rather, data that have been aggregated and 
quantified. It might be appropriate to invite individuals who have 
access to data/information to attend or participate in a network meet- 
ing. It is always a good practice to follow up a telephone contact with a 
letter reiterating whom you represent, confirming your understanding 
about the availability of data and how it might be obtained and, per- 
haps, formally inviting the individual to the meeting. It is also helpful 
to send each individual information about the network and, if avail- 
able, a copy of a network meeting report or summary or outline of the 
project being planned. 



. . . once relation- 
ships are established 
it is relatively easy to 
tap these resources 
on a regular basis 



Developing Relationships 

It is important to maintain good relationships with community 
agency representatives who have access to current and potential data 
sources. As indicated earlier, it is difficult to identify sources of informa- 
tion at the community level, but once relationships are established it is 
relatively easy to tap these resources on a regular basis. 

Several steps can be taken to develop working relationships with 
data sources, including inviting representatives to a network meeting; 
meeting with representatives so they get to know you personally 
(invite them to your office or visit them); and sending them informa- 
tion, including any documents developed by the network. 



68 



Assessing Drug Abuse Within and Across Communities 



Key Informants 



At a particular point in time, scientifically based indicator data may 
not be available on a particular question of interest. The issue may be 
under study or not yet identified, or, indicator data on the issue may be 
outdated. 



. . . informal sources 
. . . can add an in- 
depth understanding 
to indicator data . . . 



. . . some members 
may be in a position 
to find such 
answers . . . 



There are a number of informal sources that epidemiology net- 
works can consider tapping when indicator data are unavailable or 
incomplete. Such informal sources, in fact, can provide useful informa- 
tion even when members have solid, scientifically based indicator data. 
The types of informal sources described here can be used by networks 
to add an in-depth understanding to indicator data and serve as in- 
terim indicators until more scientific findings are available. 

In assessing information from different sources, it is useful to know 
what the different indicators represent. Why do the numbers change 
from one period to another? Are there factors that the indicator data 
are not showing? The answer to this last question is almost always yes, 
given that indicator data are based on a finite population, different time 
frames, and different sets of measures. 

Consider, for example, that 

• Police Departments change their tactics from time to time in the 
kinds of crimes and geographic areas they target; 

• lower income people are more likely than other populations to 
use emergency rooms for general medical care, while higher 
income people tend to use private health care facilities; and 

• the types of clients treated by drug abuse treatment programs 
vary by type of facility, and these patterns may change because 
of changes in health insurance regulations and government 
funding policies. 

It is therefore important to obtain background information on the 
sources of indicator data to understand what the numbers mean. One 
of the first steps is to ask those who represent the sources from which 
the indicator data are produced to explain how the indicators reflect 
certain policies and certain populations. Ideally, a member of the 
network would be in a position to explain what the numbers mean or 
who can provide an explanation. 

If members do not yet know the reasons or possible reasons for 
changes, some members may be in a position to find such answers in 
the days following a network meeting. For example, if the treatment 
data show that there was a significant increase in primary marijuana 
users admitted into drug abuse treatment programs during the prior 6 
months, it might be useful to contact treatment providers to get their 
views. If one or more network members volunteered to get this infor- 
mation, they could prepare a brief supplementary report and commu- 
nicate the information to the other members. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



69 



. . . investigate the 
reason for changes 
like a reporter 
approaches a news 
story 



The question of why indicator data change over time may be 
partially answered when background information about the sources 
such of data are obtained. For example, an increase in heroin arrests 
may reflect special efforts made by the Police Department to "crack 
down" on heroin dealers during a particular period of time. The 
changes also may reflect something that is happening in the world of 
drug users. 

Surveillance networks generally do not have the time or resources 
to conduct studies to answer questions on why patterns of drug use are 
changing. That does not mean that the answers cannot be obtained. 
Members of the work group may already know or suspect some of the 
reasons for the changes. It is often surprising to discover what network 
members already know, especially those who come into direct contact 
with drug abuse clients. Some members, however, may be reluctant to 
talk about what they know because they consider the information 
unscientific. 

Another method is to investigate the reason for changes like a 
reporter approaches a news story. Member(s) could explore the who, 
what, when, where, why, and how. One or more members of the work 
group might assume this role. Still another method would be for a 
member to assume a role similar to that of a CDC field epidemiologist 
who investigates why, how, and where a disease is spreading. If time 
and resources permit, members could go out to the community and talk 
to people close to or directly involved with the drug scene. In gather- 
ing this type of information, it might be possible to identify some of the 
possible causes for the changes and determine whether these changes 
are likely to be part of a trend. 

At a minimum, network members can make phone calls to key 
people in the field who know the drug scene (e.g., directors of treat- 
ment, social service, health clinic, and recreation programs; clinical 
staff; and outreach workers). In many instances, outreach workers may 
be in the best position to know why new drug use patterns and trends 
are emerging. 

Another reason for using informal sources of information is to 
address the question: How can network members broaden their per- 
spective and identify new drug abuse patterns and trends before they 
emerge through indicator data? One approach is for the network to 
establish linkages with people who are knowledgeable about the 
community or particular populations in the community. (This ap- 
proach, of course, is useful even when indicator data are available.) 

Who are These People? 

Network members can never be sure (especially when beginning a 
local group) who might be in a position to contribute new information. 
Therefore, it is useful for a network to establish a list of such people 



70 



Assessing Drug Abuse Within and Across Communities 



The key is to identify 
key informants who 
can be consulted 
regularly . . . 



over time. The people on this list may be referred to as key informants, 
individuals who can be contacted to obtain a better understanding of 
what is going on in a community. This list might include the following 
types of persons: 

• a school counselor who deals with problematic drug cases; 

• a telephone hotline supervisor; 

• an individual who runs a corner convenience store; 

• an outreach worker who operates out of a church basement; 

• a bartender at a bar or restaurant that drug abusers are known 
to frequent; 

• an ex-drug addict who still knows what is going on in the user 
community; and 

• a local newspaper reporter who covers the drug beat. 

The key is to identify key informants who can be consulted regu- 
larly to find out if any new drug patterns are emerging or if any new 
populations of drug users are being seen. Over time, the network 
members will learn who the best sources are for particular types of 
information. 



Short-Term Ethnography Studies 

So far, some specific techniques to obtain information have been 
outlined, techniques that group members might use to provide context 
for the indicator data. At some point, though, a work group might 
decide that more detailed information is needed about some pattern of 
drug use or what seems to be an emerging trend, something more 
systematic than current knowledge, telephone calls, or conversations 
with knowledgeable people can provide. 



. . . ethnographic 
methods can be 
used to address 
questions that arise 
from epidemiologic 
data . . . 



One method that can be used is ethnography. Formerly the prov- 
ince of anthropologists and sociologists, ethnography is now entering 
the mainstream of social research. There are numerous reasons for 
using this methodology. The reason most pertinent to a network is that 
ethnographic methods can be used to address questions that arise from 
epidemiologic data: who, what, when, where, why, and how. In a time 
of dramatic and continual change, when organizations and institutions 
are unsure of the nature of the world and their role in it, ethnography 
has become a useful way to find some answers, because it focuses on 
learning about the behaviors of people. It goes beyond objective 
analytic description to include an analysis of the knowledge and beliefs 
that underlie behaviors. 



At any point during the research, questions are continuously raised 
based on previous findings. Hypotheses are constantly being devel- 
oped and tested. Two considerations guide sampling in ethnographic 
research. First, because of the emphasis on ongoing, high-rapport 
relationships to elicit needed information, purposive sampling is 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



71 



generally selected rather than random sampling. Second, significant 
differences and dimensions within one or more populations are identi- 
fied only after the ethnographic research is under way, so more appro- 
priate samples emerge over time. Samples are constructed as the 
research develops; the choices of study subjects are made as the popu- 
lation variation becomes clear. Ethnographers keep a record of the 
samples as they develop, so that comparison of the ethnographic 
sample with already available population descriptions can be made 
later to assess the representativeness of the sample. 

The two primary methods used by ethnographers are: 

• participant observation (listening and observing behaviors in the 
natural settings of individuals being studied); and 

• formal and informal interviews. 

Ethnographers take time to observe and understand, firsthand, the 
world of the people they are studying. There is often a difference 
between what people say and what they do and the nature of this 
difference is very important. One way ethnographers learn what 
people do is to go out into the community to see how they live, work, 
and play. To learn why people behave in certain ways, it is important to 
learn about their culture, values, and traditions. 

When ethnographers interview, they listen rather than just ask 
questions. They probe, validate previous information, and when 
appropriate, introduce new topics. 

The following routine information is collected by ethnographers in 
their studies of drug abusers: 

drugs used; 

combinations of substances used; 

frequency of use; 

modes of administration; 

social setting in which drugs are used; 

ages and circumstances for initiation to drugs; 

reasons for using drugs; 

drug effects; 

adverse reactions to drugs; and 

consequences of drug use over time. 

Field observations and interviews are generally recorded. The tape 
recordings are transcribed and the data (contained in the transcripts) 
are coded and sorted by topics. Once sorted, data are reviewed and 
analyzed for patterns. Patterns are associated with aggregate statistics on 
age, ethnicity, gender, and particular types of drugs used and behaviors. 



72 Assessing Drug Abuse Within and Across Communities 



. . . ethnographic 
projects can be 
conducted over a 
short period of time 
at relatively little 
expense . . . 



In ethnography, theory emerges out of the data, because the con- 
cepts and relationships are uncovered during ethnographic research. 
The new concepts and relationships are referred to as "grounded 
theory" because the theory grows from the ethnographic data gathered 
during a study. In ethnography, control is vested in the persons and 
situations studied, as the ethnographer learns about the people, their 
culture and lifestyles, and the world within which they live. 

The national CE WG has used ethnography in a number of ways. 
One model that might be of particular interest to surveillance networks 
is based on short-term studies. This type of ethnographic research, while 
not a full-scale ethnography, is designed so that an experienced ethnog- 
rapher in a particular city, who is already working with drug users, can 
address questions and issues of interest to work group members. 
Generally, these ethnographic projects can be conducted over a short 
period of time at relatively little expense and, ideally, should be de- 
signed and supervised by ethnographers who have formal training and 
are already conducting studies in the area. 

Short-term ethnographic studies were conducted in 12 of the 
CEWG cities between 1994 and 1996. Five of these studies are briefly 
described in Appendix I. 

Ethnographers often work as faculty in university anthropology or 
sociology departments, two disciplines with strong traditions of train- 
ing in the area. Ethnographers now work in other disciplines as well. 
For example, the field of speech communication discovered "the 
ethnography of communication" 30 years ago, and now has specialists 
who have trained in ethnography as well. Since the 1950s, ethnogra- 
phy has been part of public health training in some areas. Many 
ethnographers now work outside university settings. 

In selecting an ethnographer, it is important to review the person's 
training, type of degree, publications, professional organization, and 
affiliation. Also, read the individual's recently published ethnographic 
research, especially if it involves the field of drug abuse. 

Spend some time with the ethnographer discussing issues and 
research topics of greatest interest. Give the ethnographer an overview 
of why the network wants to pursue the study. Are there particular 
questions that need to be answered? Spend some time with the eth- 
nographer as the study progresses to see what sorts of information are 
being collected and to see if adjustments need to be made by adding 
additional questions or by refocusing some of the questions. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



73 



When ethnographers interview, they tend to introduce topics and 
then listen rather than ask questions. There is often a difference be- 
tween what people say and what they do, and the nature of these 
differences is important in ethnography. Ethnographers also use 
documents, archives, memoranda, newsletters, and the like. 



Reporting 



. . . following a 
standardized format 
will make it easier to 
summarize data 
across all the 
areas . . . 



Ethnographers can obtain a variety of data from a variety of 
sources, and systematically assess the constant and variable patterns 
that range across the data. In addition to obsevation and interviews, 
archives, memoranda, newsletters and other documents can be used for 
analysis. Short-term ethnographic studies conducted by the national 
CEWG were very successful because they were conducted by experi- 
enced ethnographers already at work in the communities. 



Networks will find it useful to have a somewhat standardized 
format for reporting findings. This will be useful for several reasons. 
First, as the network evolves over time and produces several reports, a 
standardized format will make it easier to review data from each 
reporting period to generate trends across different time periods. 
Second, for networks that will have a series of papers from different 
geographic areas or jurisdictions, following a standardized format will 
make it easier to summarize data across all the areas; it also will aid 
readers in making their own comparisions across reporting sites. Third, 
it is likely your network will distribute its reports to busy policymakers, 
practitioners, and other interested parties. A standard format, together 
with a clear table of contents in the report, will facilitate their review of 
the data, especially as they become accustomed to the format after 
reading several reports over time. 

It is important to recognize that your network is not likely to have 
all the sources of data described in earlier sections as it begins its sur- 
veillance work. Yet, much can be learned in initial efforts. An example 
is the Lousiana State Epidemiology Work Group, which held its third 
meeting in December 1997. The effort involved seven parishes. Parish 
representatives reported treatment data obtained from the State Office 
of Alcohol and Drug Abuse, as well as parish-specific data from a 
statewide adult household survey on drug use and a statewide school 
survey on drug use. Some parishes also obtained drug-related data 
from hospital emergency departments, coroners' offices, law enforce- 
ment agencies, and special surveys. The parish reports were prepared 
in a standard format. Each paper contained an abstract of key findings. 
The Introduction is used to describe the area and sources of data. 
Actual findings are presented in the section on "Drug Abuse Patterns 
and Trends," supplemented by tabular data at the conclusion of the 
reports. An example of the Rapides Parish report is provided in Appen- 
dix J. 



74 



Assessing Drug Abuse Within and Across Communities 



Because Louisiana SEWG parish reports followed a standard 
format, summarizing key findings did not require an exessive amount 
of time. The major finding was that cocaine (both HCL and crack) 
represented the major illicit drug problem in all seven parishes. For 
example, cocaine/crack accounted for one-half to three-fourths of all 
treatment admissions for primary abuse of an illicit drug. 

The Community Epidemiology Work Group has used a similar 
format over the years; however, the CEWG format for reporting drug 
use patterns and trends is more specific and presents findings by drug 
of abuse (see Appendix B). The city reports are included in NIDA's 
report series entitled Epidemiologic Trends in Drug Abuse, Volume II. 
Recent reports can be viewed on the CEWG Home Page or the NIDA 
Home Page cited on page 2. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 75 



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Beck, M; Glick, D.; Joseph N.; and Katel, P State of emergency: Hospitals are seeking radical solu- 
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Bell, R.A.; Goldsmith, H.F.; Lin, E.; Hizel, R.K.; and Sobel, S. Social Indicators for Human Services. 

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Buechner, J.S., and Waters, W.J. Use of hospital emergency departments for routine medical care. 
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Digregorio, G.J. Cocaine update: Abuse and therapy. Clinical Pharmacology, AFP 41 (1): 247-250, 1990. 

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Community Epidemiology Work Group, Rockville, MD: The National Institute on Drug Abuse, Dec. 
1997. 

National Institute on Drug Abuse. Epidemiologic Trends in Drug Abuse, Volumes I and II: Proceedings, 
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A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 77 



GLOSSARY 



AIDS- 

ARD- 
BG — 
BJS - 



BNA 
CDC 

CDS 



Acquired Immunodeficiency 
Syndrome 

AIDS-Related Diseases 

Block Group 

Bureau of Justice Statistics 

Block Numbering Area 

Centers for Disease Control and 
Prevention 

Client Data System 



CEWG — Community Epidemiology Work 
Group 

CIDMSP- Criminal Intelligence Division of 
Maryland State Police 

CODAP - Client Oriented Data Acquistion 
Process 

CSAP Center for Substance Abuse 

Prevention 

CSAT Center for Substance Abuse 

Treatment 



DAWN 
DEA — 



Drug Abuse Warning Network 

Drug Enforcement Administration 

Department of Health and Human 
Services 

Domestic Monitor Program 

Diagnostic Related Group 



DSM-IV - Diagnostic and Statistical Manual of 
Mental Disorders 



DHHS 

DMP- 
DRG- 



DUI- 
ED- 
FBI - 
FIPS 



Driving Under the Influence 

Emergency Department 

Federal Bureau of Investigation 

Federal Information Processing 
Standards 



GAO General Accounting Office 

HIV Human Immunodeficiency Virus 

ICD International Classification of 

Diseases 

ICD-9-CM International Classification of 
Diseases, 9th Revision 

ICPSR Inter- University Consortium for 

Political and Social Research 

IDU Injection Drug Users 

IEWG International Epidemiology Work 

Group 

IVDA Intravenous Drug Abuse 

ME/C Medical Examiners and Coroners 

MECISP - Medical Examiner and Coroner 
Information Sharing Program 

MMWR - Morbidity and Mortality Weekly 
Report 

MSA Metropolitan Statistical Area 

MTF Monitoring the Future Study 

NACJD — National Archive of Criminal Justice 
Data 

NCHS National Center for Health Statistics 



DUF 



Drug Use Forecasting System 



78 



Assessing Drug Abuse Within and Across Communities 



NCJRS — National Criminal Justice Reference 
Service 

NDATUS National Drug and Alcohol Treatment 
Unit Survey 

NHAMCS National Hospital Ambulatory Medi- 
cal Care Survey 

NIAAA — National Institute on Alcoholism and 
Alcohol Abuse 

NIDA National Institute on Drug Abuse 

OAS - — ■ Office of Applied Studies 

OTC Over the Counter 

PRIDE — Parents Research Institute for Drug 
Education 

SAMHSA Substance Abuse and Mental Health 
Services Administration 

SEWG State Epidemiology Work Group 

SIDS Sudden Infant Death Syndrome 

STD Sexually Transmitted Disease 

TCADA - Texas Commission on Alcohol and 
Drug Abuse 

TEDS Treatment Episode Data Set 

TEFRA — Tax Equity and Fiscal Responsibility 

Act 

UA Urbanized Area 

UCR Uniform Crime Reports 

UFDS — Uniform Facility Data Set 
WHO World Health Organization 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 79 



Appendix A: National CEWG Members 



Mark R. Bencivengo 
Coordinating Office for Drug and 

Alcohol Abuse Programs 
Philadelphia Department of 

Public Health 
1101 Market Street, 8th floor 
Philadelphia, PA 19107 
Phone:(215) 592-5404 
Fax: (21 5) 592-5427 

Richard F. Calkins 
Evaluation and Data Services 
Center for Substance Abuse Services 
Michigan Department of Public Health 
PO. Box 30195 
Lansing, MI 48909 
Phone:(517) 335-8858 
Fax:(517) 335-8837 
E-mail:calkinsr@state.mi.us 

Thomas W. Clark 

Health and Addictions Research, Inc. 

419 Boylston Street, Suite 801 

Boston, MA 02116 

Phone:(617) 266-9219 

Fax:(617) 266-9271 

E-mail:twc@world. std.com 

Ilene L. Dode, Ph.D. 

EMPACT — Suicide Prevention Center, Inc. 

1232 East Broadway, Suite 120 

Tempe,AZ 85282 

Phone:(602) 784-1514 

Fax: (602) 967-3528 

E-mail:idode@aol.com 

Carol L. Falkowski 

Hazelden Foundation 

PO. Box 11-CR9 

Center City, MN 55012-0011 

Phone:(612) 213-4566 

Fax:(612) 213-4496 

E-mail.cfalkowski@hazelden.org 



Blanche Frank, Ph.D. 

Bureau of Applied Studies 

New York State Office of Alcoholism 

and Substance Abuse Services 
55 West 125th Street, 10th floor 
New York, NY 10027 
Phone:(212) 961-8494 
Fax:(212) 961-8490 

John F French 

Research and Information Services 

Data Analysis and Epidemiology 

Division of Addiction Services 

New Jersey Department of Health 

129 East Hanover Street CN 362 

Trenton, NJ 08625-0362 

Phone: (609) 292-8930 

Fax:(609) 292-3816 

E-mail:johnf@netaxs.com 

Michael Ann Haight 
Management Information Services 
County Alcohol and Drug Services 
PO. Box 85222 
San Diego, CA 92186-5222 
Phone:(619) 692-5752 
Fax:(619) 692-5604 
E-mail:mhaight@aol.com 

James N. Hall 

UpFront Drug Information 

and Education Center 
5701 Biscayne Blvd., Suite 9PH 
Miami, FL 33137 

Phone: (305) 757-2566/(305) 375-8032 
Fax: (305)758-4676 
E-mail:uupfrontin@aol.com 

Leigh Henderson 

3001 Guilford Avenue 

Baltimore, MD 21218 

Phone:(410) 235-3096 

Fax: (410) 235-3096 

E-mail:lhenderson@welchlink.elch.jhu.edu 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



A-1 



Lee Hoffer 

Data Analysis and Evaluation 

Colorado Department of Health 

ADAD-DAE-A2 

4300 Cherry Creek Drive South 

Denver, CO 80222-1530 

Phone: (303) 294-5270 

Fax: (303) 295-3441 

E-mail:lee. hoffer@uchsc.edu 

Valerie Hoffman, Ph.D. 

UCLA Drug Abuse Research Center 

University of California, Los Angeles 

1100 Glendon Avenue, Suite 763 

Los Angeles, CA 90024-3511 

Phone:(310) 825-9057 

Fax: (310) 794-2802 

E-mail: vhoffman@ucla.edu 

Heidi Israel 

Division of Infectious Diseases 

St. Louis University School of Medicine 

1200 South Grand 

St. Louis, MO 63104 

Phone: (314) 268-5448 

Fax: (314) 268-5196 

E-mail:israelha@sluava. slu.edu 

T. Ron Jackson 

Evergreen Treatment Services 

1250 First Avenue South 

Seattle, WA 98134 

Phone: (206) 223-3644 

Fax: (206) 223-1482 

E-mail:ronjack@u. washington.edu 

Jane C. Maxwell 

Research Department 

Texas Commission on Alcohol and Drug Abuse 

9001 North IH 35, Suite 105 

Austin, TX 78753-5233 

Phone: (512) 349-6645 

Fax: (512) 349-6802 

E-mail:jane_maxwell@tcada. state. tx.us 



Marcia Meth 

Johnson, Bassin & Shaw, Inc. 

8630 Fenton Street, Suite 1200 

Silver Spring, MD 20910 

Phone:(301) 495-1080 

Fax:(301) 587-4352 

E-mail:mmeth%nidal@ngmsmtp. samhsa.gov 

John A. Newmeyer, Ph.D. 

Haight-Ashbury Free Clinics, Inc. 

612 Clayton Street 

San Francisco, CA 94117 

Phone: (415) 931-5420 

Fax: (415)864-6162 

E-mail:jnewmeyer@aol.com 

Claire Sterk, Ph.D. 
Emory University 
School of Public Health 
Women's and Children's Center 
1518 Clifton Road, NE 
Atlanta, GA 30322 
Phone: (404) 727-9124 
Fax: (404)727-8744 
E-mail:sterk@sph.emory.edu 

Gail Thornton-Collins 

New Orleans Health Department 

517 North Rampart Street, 4th floor 

New Orleans, LA 70112 

Phone: (504) 565-7700 

Fax: (504) 565-7886 

W. Wayne Wiebel, Ph.D. 
School of Public Health 
University of Illinois at Chicago 
2121 West Taylor Street, Room 552 
Chicago, IL 60612 
Phone: (312) 996-4870 
Fax: (312) 996-1450 
E-mail:drugs@uic.edu 

D. William Wood, Ph.D., M.PH. 
School of Public Health 
University of Hawaii at Manoa 
1960 East-West Road, T-102 
Honolulu, HI 96822 
Phone: (808) 956-8066 
Fax: (808) 956-4585 



A-2 



Assessing Drug Abuse Within and Across Communities 



Appendix B: National CEWG Report Format 

PATTERNS AND TRENDS OF DRUG ABUSE IN DRUGFREEVILLE: 
A REPORT THAT FOLLOWS THE CEWG OUTLINE 



Daphne Data, Ph.D. 

Stanley Statistic, Ph.D. 

Alcohol and Drug Abuse Division 

Drugfreeville Department of Health 



Drugfreeville, Drugless State 



The abstracts should be approximately 150 words in length. It should contain a general overall 
statement, followed by about 1 sentence for each drug category and for AIDS. 



INTRODUCTION 



1. Area Description 

This short section describes factors unique to 
your city. It can include demographic, geo- 
graphic, or socioeconomic factors. Include 
any factors that may be related to the drug 
abuse problem in the city. 

2. Data Sources and Time Periods 

This section should contain a series of bulleted 
items: 

• Source — Describe the type of data. 
Explain any limitations and caveats. 
For each source, define two time 
periods: the latest reporting period and 
the comparison reporting period. If 
you use your State's fiscal years, 
please define them. 



Order — If possible, try to sequence 
the data sources so they will conform 
to the following REVISED order: 



1. 

2. 
3. 

4. 

5. 
6. 
7. 
8. 
9. 
10. 



Deaths 

Emergency room mentions 

Treatment admissions/ demo 

graphics 

Drug Use Forecasting data 

(DUF) 

Arrests/arrestee urinalyses 

Availability, price, and purity 

Seizures 

Trafficking/distribution 

Ethnographic information 

Special studies (if available) 



The "Data Sources and Time Periods" section 
might also provide a good opportunity to 
introduce exhibits; thus, exhibit order would 
also follow the outline. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



B-1 



DRUG ABUSE TRENDS 



This introduction section is optional. If you 
choose to use it, please write no more than one 
or two paragraphs. Different authors use this 
section in different ways: some give data for 
overall drug use (combined data); some 
discuss just one major drug category or just 
one indicator; others describe data caveats or 
limitations. 

1. Cocaine 



You can also include paragraphs on special 
studies. 

Don't forget to refer to your exhibits in your 
discussions. 

2. Heroin 

The above guidelines apply to all the drug 
categories in the Drug Abuse Trends section. 



The first paragraph often opens with an over- 
all one-sentence statement about all the indi- 
cators (optional). It then talks about ethno- 
graphic data, if available. 

Subsequently, each paragraph discusses one 
indicator. If a paragraph contains lots of data, 
or more than one source, you may want to 
split it into two paragraphs. 

The order of the paragraphs is as follows: 
deaths; emergency room mentions; treatment 
admissions/demographics; DUF; arrests; 
availability, price, and purity; seizures; traf- 
ficking/distribution; ethnographic information 
special studies (if available). 



3. Other Opiates 

For drug categories with fewer relevant data, 
you can combine several indicator discussions 
into one or two paragraphs. 

4. Marijuana 

5. Stimulants 



6. Depressants 

7. Hallucinogens 



SPECIAL STUDIES 



This section is optional if such data are avail- 
able. Alternatively, you may choose to include 
this information in the 



appropriate drug category discussions in the 
above Drug Abuse Trends section. 



B-2 



Assessing Drug Abuse Within and Across Communities 



ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) 
AMONG INJECTING DRUG USERS (IDUs) 



Please be sure to include the following num- 
bers: Cumulative number of cases (compared 
to the figure from last report); percentage of 
cases that are both IDU and heterosexual; 
percentage of cases that are both IDU and 
homosexual/ bisexual. 



If you give both State and city figures, please 
differentiate between the two for EVERY 
figure. Please be clear about whether or not 
your data include pediatric cases. 



EXHIBITS 



Please make sure each exhibit is numbered 
and titled. 

• Include a SOURCE line on each 
exhibit. 



For graphs, please include a printout of 
your data points. If you are using the 
same graph as for your last report, 
AND IF THE PREVIOUS DATA 
HAVE NOT CHANGED, you can 
include only the data points from the 
most recent time periods. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



B-3 



Appendix C: Statistical Analysis Centers by State 



Alabama 

Alabama Criminal Justice Information Center 
770 Washington Avenue, Suite 350 
Montgomery, AL 36130 
(205) 242-4900 

Alaska 

The Justice Center 
University of Alaska Anchorage 
3211 Providence Drive 
Anchorage, AK 99508 
(907) 786-1810 

Arizona 

Arizona Criminal Justice Commission 
1501 West Washington St. 
Suite 207 

Phoenix, AZ 85007 
(602) 542-1928 

Arkansas 

Special Services Section 

Arkansas Crime Information Center 

One Capitol Mall, 4D200 

Little Rock, AR 72201 

(501) 682-2222 

California 

Office of Management Evaluation and Training 
Law Enforcement Information Center 
RO. Box 903427 
Sacramento, CA 94203-4270 
(916) 227-3531 



Colorado 

Colorado Division of Criminal Justice 
700 Kipling Street, Suite 1000 
Denver, CO 80215 
(303) 239-4453 



Connecticut 

Office of Policy and Management 

Policy Development and Planning Division 

80 Washington Street 

Hartford, CT 06106 

(203) 566-3522 

Delaware 

60 The Plaza 
Dover, DE 19901 
(302) 739-4846 

District of Columbia 

University of the District of Columbia 
Department of Criminal Justice 
4200 Connecticut Avenue NW 
Washington, DC 20008 
(202) 274-5687 

Florida 

Florida Department of Law Enforcement 
PO. Box 1489 
Tallahassee, FL 32302 
(904) 487-4808 

Georgia 

Statistical Analysis Bureau 
Department of Criminal Justice 
Georgia State University 
PO. Box 4018 
Atlanta, GA 30302-4018 
(404) 651-3515 

Hawaii 

Crime Prevention Division 

Department of the Attorney General 

City Center Building 

810 Richards Street, Suite 701 

Honolulu, HI 96813 

(808) 586-1416 



'SOURCE: Bureau of Justice Statistics, U.S. Department of Justice, Washington, DC, September 1995. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



C-1 



Idaho 

Support Services Bureau 
Department of Law Enforcement 
PO. Box 700 

Meridian, ID 83680-0700 
(208) 884-7044 

Illinois 

Illinois Criminal Justice Information Authority 
120 South Riverside Plaza 
Suite 1016 
Chicago, IL 60606 

Indiana 

Indiana Criminal Justice Institute 
302 West Washington Street 
Room E209 

Indianapolis, IN 46204 
(317) 232-1233 

Iowa 

Division of Criminal Justice and Juvenile 

Planning 
Lucas State Office Building 
Des Moines, IA 50319 
(515) 242-5816 

Kansas 

Kansas Criminal Justice Coordinating Council 
Jayhawk Tower, Suite 501 
700 Southwest Jackson 
Topeka,KS 66603 
(913) 296-0923 

Kentucky 

Office of the Attorney General 
State Capitol Building 
Frankfort, KY 40601 
(502) 564-4002 

Louisiana 

Louisiana Commission on Law Enforcement 
1885 Wooddale Boulevard, Suite 708 
Baton Rouge, LA 70806 
(504) 925-4440 



Maine 

Maine Criminal Justice Data Center 
Department of Corrections 
State House Station 111 
Augusta, ME 04333 
(207) 287-4343 

Maryland 

Maryland Justice Analysis Center 
Institute of Criminal Justice and Criminology 
College of Behavioral and Social 
Sciences 
2220 Samuel J. LeFrak Hall 
University of Maryland 
College Park, MD 20742-8235 
(301) 405-4699 

Massachusetts 

Massachusetts Committee on Criminal Justice 
100 Cambridge Street, Room 2100 
Boston, MA 02202 
(617) 727-0237 

Michigan 

Michigan State University 
School of Criminal Justice 
560 Baker Hall 
East Lansing, MI 48824-1118 
(517) 355-2197 

Minnesota 

Minnesota Planning Agency 
Centennial Office Building, Room 300 
658 Cedar Street 
St. Paul, MN 55155 
(612) 296-4852 

Mississippi 

Department of Criminal Justice Planning 
301 West Pearl Street 
Jackson, MS 39203 
(601) 949-2225 

Missouri 

Information Systems Division 
Missouri Highway Patrol 
1510 East Elm 
Jefferson City, MO 65102 
(314) 751-4026 



C-2 



Assessing Drug Abuse Within and Across Communities 



Montana 

Board of Crime Control 
Montana Department of Justice 
303 North Roberts Street 
4th Floor 

Helena, MT 59620 
(406) 444-4298 

Nebraska 

Commission on Law Enforcement & Criminal 

Justice 
RO. Box 94946 
Lincoln, NE 68509-4946 
(402) 471-2194 

Nevada 

Nevada Highway Patrol 

Records and Identification Services 

555 Wright Way 

Carson City, NV 89711-0525 

(702) 687-5713 

New Hampshire 

Office of the Attorney General 

33 Capitol Street 

Concord, NH 03301 

(603) 271-3658 

New Jersey 

Research and Evaluation 

Department of Law and Public Safety 

Hughes Justice Complex, CN-085 

Trenton, NJ 08625 

(609) 984-2737 

New Mexico 

Institute for Social Research 
University of New Mexico 
2808 Central Avenue SE 
Albuquerque, NM 87106 
(505) 277-4257 

New York 

Bureau of Statistical Services 

Division of Criminal Justice Services 

Executive Park Tower, Eighth Floor 

Stuyvesant Plaza 

Albany, NY 12203 

(518) 457-8381 



North Carolina 

Criminal Justice Analysis Center 
Governor's Crime Commission 
3824 Barrett Drive, Suite 100 
Raleigh, NC 27609-7220 
(919) 571-4736 

North Dakota 

Information Services Section 
Bureau of Criminal Investigation 
4205 State Street 
Bismarck, ND 58502-1054 
(701) 221-5514 

Ohio 

Research and Statistics 

Office of Criminal Justice Services 

400 East Town Street, Suite 120 

Columbus, OH 43215 

(614) 466-0310 

Oklahoma 

Oklahoma Criminal Justice Resource Center 
621 North Robinson, Suite 445 
Oklahoma City, OK 73102 
(405) 232-3328 

Oregon 

Criminal Justice Council 
Statistical Analysis Center 
155 Cottage Street NE 
Salem, OR 97310 
(503) 378-4123 

Pennsylvania 

Bureau of Statistics & Policy Research 
Pennsylvania Commission on Crime 

and Delinquency 
PO. Box 1167 
Harrisburg, PA 17108 
(717) 787-5152 

Rhode Island 

Governor's Justice Commission 
222 Quaker Lane, Suite 100 
Warwick, RI 02886 
(401) 277-2620 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



C-3 



South Carolina 

Office of State and Grant Programs 
Department of Public Safety 
1205 Pendleton Street 
Columbia, SC 29201 
(803) 734-0423 

South Dakota 

Office of the Attorney General 
500 East Capitol Avenue 
Pierre, SD 57501 
(605) 773-6310 



Washington 

Office of Financial Management 
PO. Box 43113 
Olympia, WA 98504-3113 
(360) 586-2501 

West Virginia 

Marshall University 

Research & Economic Development Center 

1050 Fourth Avenue 

Huntington, WV 25755-8100 

(304) 696-2718 



Tennessee 

Tennessee Bureau of Investigation 
1148 Foster Avenue 
Nashville, TN 37210-4406 
(615) 726-7970 

Texas 

Criminal Justice Policy Council 
PO. Box 13332 
Austin, TX 78711-3332 
(512) 463-1810 

Utah 

Research Division 

Commission on Criminal & Juvenile Justice 

Room 101, Utah State Capitol 

Salt Lake City, UT 84114 

(801) 538-1059 

Vermont 

Vermont Center for Justice Research 
33 College Street 
Montpelier, VT 05602 

(802) 828-8511 

Virginia 

Department of Criminal Justice Services 
805 East Broad Street 
Richmond, VA 23219 
(804) 786-4000 



Wisconsin 

Office of Justice Assistance 
222 State Street, 2nd Floor 
Madison, WI 53702 
(608) 266-7185 

Wyoming 

Division of Criminal Investigation 
Office of the Attorney General 
316 West 22nd Street 
Cheyenne, WY 82002 
(307) 777-7523 

Northern Mariana Islands 

Criminal Justice Planning Agency 
Commonwealth Northern Mariana Islands 
PO. Box 1133 
Saipan,MP 96950 
(670) 322-9350 

Puerto Rico 

Criminal Justice Information System 

Office of the Attorney General 

PO. Box 192 

San Juan, PR 00902 

(809) 729-2445 

Virgin Islands 

Law Enforcement Planning Commission 
8172 Sub Base, Suite Three 
St. Thomas, VI 00802-5803 
(809) 774-6400 



C-4 



Assessing Drug Abuse Within and Across Communities 



Appendix D: Method for Assessing 

Hospitalizaiton Related to Drug and Alcohol 

Misuse by Youth and Young Adults 

Juliet VanEenwyk, Ph.D., Steven C. Macdonald, Ph.D., and Lillian S. Bensley, Ph.D. 

Office of Epidemiology 
Washington State Department of Health 



Background 

The Washington State Violence Reduction 
Programs Act of 1994 required the Washington 
State Department of Health to compile data on 
behaviors and related risk and protective factors 
which affect youth and their communities. 
These behaviors included violent behavior 
among youth, early pregnancy, dropping out of 
school, drug and alcohol abuse, suicide, child 
abuse, and domestic violence. The original data 
set was compiled in 1995 for defined geographic 
areas called Public Health and Safety Networks 
(Networks), which are roughly equivalent to 
counties or portions of counties. The Networks 
and Local Health Jurisdictions used the data to 
determine where to focus prevention efforts. We 
are currently in the process of updating the data 
to provide communities with information for 
ongoing assessment and program evaluation. 

To assess the extent of alcohol and drug abuse, 
we developed community level data from a 
number of sources, including arrest data for drug 
and liquor law violations and driving under the 
influence of drugs or alcohol, alcohol- and drug- 
related traffic collisions; youth receiving State- 
sponsored alcohol and drug treatment; and 
alcohol- and drug-related hospital admissions. 
For the current update, we plan to use the follow- 
ing methodology to assess hospitalization of 
youth and young adults related to misuse of 
drugs and alcohol. 



Methods 

General considerations 

1 . Assign youth and young adults to the com- 
munity based on zip code of residence, not 
location of hospital. 

2. Count hospital discharges, not people. For 
example, a person who is discharged from 
the hospital for drug- or alcohol-related 
diagnoses twice in one year and three times 
in the following year will be counted twice in 
the first year and three times in the following 
year. While counting people is also a valid 
approach, we have chosen this approach 
partly because we are unable to unduplicate 
data we receive for Washington residents 
hospitalized in Oregon. More importantly, 
each hospitalization represents an adverse 
event which we would like to prevent; thus, 
each hospitalization is an event of public 
health importance. 

3. Count each hospital discharge only once. 
Thus, a person hospitalized for both alco- 
holic psychosis and alcohol dependence 
syndrome will be counted only once for that 
hospitalization. 

4. Count the occurrence of the ICD-9-CM 
codes in any of the diagnosis fields. From 
1994-1996, approximately 37 percent of the 
alcohol- and drug-related codes specified 
below appeared as the first diagnosis. The 
remaining 63 percent appeared in secondary 
diagnosis fields. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



D-1 



An analysis of the first diagnosis for records 
where the drug or alcohol code appeared in the 
2nd-9th diagnosis field revealed that approxi- 
mately 85 percent of the first diagnoses were 
mental disorder codes (51 percent), complica- 
tions of pregnancy (17 percent), or trauma (16 
percent). If a substance abuse code appears with 
the complication of pregnancy or injury code, it 
is probably that the substance abuse is related to 
the hospitalization and, therefore, should be 
counted. We also want to count youth and young 
adults with comorbidities of substance abuse and 
mental disorders, since the substance abuse 
problem must be treated simultaneously with 
treatment for the mental disorder. In persons 
with the dual diagnosis of mental illness and 
substance abuse, it is also difficult to determine 
whether underlying mental disorder contributes 
to substance abuse or vice versa. 

For the remaining 1 5 percent of records where 
the drug or alcohol diagnosis is in the 2nd to 9th 
diagnosis field, no group of diagnoses appears as 
the first diagnosis on more than 2 percent of 
records. For many of these diagnoses, it is 
highly likely that the drug or alcohol use contrib- 
uted to the hospitalization. 

Method of identifying records 

1 . Pull hospitalizations for people age 10 to 24 
years at discharge. 

2. Exclude all records with codes for suicide 
(E950-E959). 

3. We have developed a 2-tiered approach 
which assigns each hospitalization with 
relevant ICD-9-CDM codes to definitely/ 
probably or possibly related to drug and 
alcohol abuse. The ICD-9-CM codes are 3- 
digit numbers followed by up to 2 digits to 
the right of the decimal point. Unless other- 
wise specified, when we list the 3-digit code, 
we include any record with the 3-digit code, 
irrespective of the numbers after the decimal. 



Likewise, when we list the code with 1 digit 
after the decimal, we include those codes 
with the same 4 numbers irrespective of the 
number in the 2nd space after the decimal. It 
is important to pull the records in the 
stepwise manner indicated so that records 
with appropriate codes are not excluded. 

Codes for definite and probable drug 
and alcohol misuse 

Step 1. Include any record meeting the age 
and nonsuicide criteria that has the following 
diagnoses in any of the diagnosis fields: 



265.2 




Alcoholic pellegra 


291 




Alcoholic psychoses 


303 




Alcohol Dependence Syndrome 


304 




Drug Dependence Syndrome 


305.0,. 


2-9 


Non-Dependent Abuse of 
Drugs 


357.5 




Alcoholic polyneuropathy 


425.5 




Alcoholic cardiomyopathy 


535.3 




Alcoholic gastritis 


571.0- 


571.3 


Alcohol-related liver disease 


648.3 




Drug dependence in pregnancy 


790.3 




Excess blood alcohol 


965.00 


,01 


Poisoning by opium or heroin 


969.6 




Poisoning by psychodysleptics 
(hallucinogens) 


980.0 




Toxic effect of ethyl alcohol 



Step 2. Include remaining records with the 
following diagnoses in any of the diagnosis 
fields and no concurrent diagnosis of E930- 
E949, adverse reactions to drugs, medicinal 
and biological substances in therapeutic use, 
properly administered and taken. 

292 Drug psychoses 

357.6 Polyneuropathy due to drugs 

Codes for possible drug and alcohol abuse 

Some codes in the series 960-979 (poisoning 
by drugs, medicinals, and biological sub- 
stances) can include possible cases of drug 



D-2 



Assessing Drug Abuse Within and Across Communities 



and alcohol misuse. According to the ICD-9- 
CM rules, this series specifically excludes 
drug dependence and nondependent abuse. 
However, for the specific codes in the 960- 
979 series listed below, we found that ap- 
proximately 25 percent of the records have a 
concurrent diagnosis of drug dependence or 
nondependent abuse. The remaining 75 
percent of records with these codes may 
represent: 

• cases of dependence or abuse where the 
dependence or abuse is not mentioned on 
the discharge summary and, therefore, 
not coded as such; 

• cases of youth experimenting with drugs, 
but not meeting the technical definition 
of dependence or abuse; or 

• cases of medicines given or taken in error 
which have caused an adverse reaction. 

We believe the first two types of records are 
of interest in assessing drug and alcohol 
misuse among youth, but that cases of medi- 
cines given or taken in error are not drug 
abuse. Since we cannot separate these latter 
cases, records where the only drug- or alco- 
hol-related code is one of those shown below 
will be treated as possible cases of drug and 
alcohol abuse. 

If the following codes appear as the only 
drug- or alcohol-related code, the record is 
counted as a possible case associated with 
misuse of drugs and alcohol. 

Step 1. Include remaining records meeting 
the age and nonsuicide criteria that have the 
following diagnosis in any of the diagnosis 
fields: 



305 



Nondependent abuse of drugs 
when 4th digit is not specified 



Step 2. Include remaining records meeting 



the age and nonsuicide criteria with the 
following diagnoses in any of the diagnosis 
fields and no concurrent diagnosis of E930- 
E949, adverse reactions to drugs, medicinal, 
and biological substances in therapeutic use, 
properly administered and taken. 

965. 02, .09 Poisoning by methadone, other 
opiates and related narcotics 

965.8 Poisoning by other specified 

analgesics and antipyretics 
(e.g., Pentazocine) 

967 Poisoning by sedatives/ 

hypnotics 

968.5 Poisoning by topical anesthet- 

ics (cocaine and related com- 
pounds) 

969 Poisoning by psychotropic 
agents when 4th digit is not 
specified 

969.0-.5,.7-9 Poisoning by psychotropic 
agents (nonhallucinogens) 

970 Poisoning by CNS stimulants 

Use of external cause of poisoning or injury 
codes 

We will not use external causes of poisoning or 
injury codes (E-codes) for selection of cases. E- 
codes described the circumstances under which 
someone is poisoned or injured. Because billing 
tends to be based on the medical condition and 
not the cause of the condition, E-codes are not as 
consistently recorded as other ICD-9-CM codes. 
(This needs to be remembered when interpreting 
the data, if codes have been specified as exclu- 
sion criteria.) 

For most of the E-codes which might capture 
drug and alcohol abuse, we cannot distinguish 
poisonings related to abuse from those related to 
wrong drugs given or taken in error, accidents in 
the use of drugs during medical or surgical 
procedures, or accidental inhalation or ingestion. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



D-3 



E850.0 (accidental poisoning by heroin) and 
E860.0 (accidental poisoning by ethyl alcohol) 
may be exceptions. However, between 1994 and 
1996 in the State of Washington data set, there 
were no records with E850.0 and only one record 
with E860.0 which did not also have one of the 
ICD-9-CM codes specified above. Therefore, 
omitting these E-codes does not substantively 
change hospitalization rates for drug and alcohol 
abuse. Between 1994 and 1996, there were 36 
records with E-codes that might be related to 
drug and alcohol misuse among youth and young 
adults that were not identified using the rules 
specified above. This represents less than one- 
half of 1 percent of all hospitalizations captured 
using those rules. 



D-4 Assessing Drug Abuse Within and Across Communities 



Appendix E: State Contacts for Uniform Crime Reports' 



Alabama 

Alabama Criminal Justice Information 
Center 
Suite 350 

770 Washington Avenue 
Montgomery, Alabama 36130 
(334) 242-4900 

Alaska 

Uniform Crime Reporting Section 
Department of Public Safety Information 
System 
5700 East Tudor Road 
Anchorage, Alaska 99507 
(907) 269-5708 

American Samoa 

Department of Public Safety 

Post Office Box 1086 

Pago Pago 

American Samoa 96799 

(684)633-1111 

Arizona 

Uniform Crime Reporting 

Arizona Department of Public Safety 

Post Office Box 6638 

Phoenix, Arizona 85005 

(602) 223-2263 

Arkansas 

Arkansas Crime Information Center 
One Capitol Mall, 4D-200 
Little Rock, Arkansas 72201 
(501) 682-2222 



California 

Criminal Justice Statistics Center 
Department of Justice 
Post Office Box 903427 
Sacramento, California 94203-4270 
(916) 227-3470 



Colorado 

Uniform Crime Reporting 
Colorado Bureau of Investigation 
690 Kipling Street 
Denver, Colorado 80215 
(303) 239-4300 

Connecticut 

Uniform Crime Reporting Program 
1111 Country Club Road 
Post Office Box 2794 
Middletown, Connecticut 06457-9294 
(203) 685-8030 

Delaware 

State Bureau of Identification 
Post Office Box 430 
Dover, Delaware 19903 

(302) 739-5875 

District of Columbia 

Information Services Division 
Metropolitan Police Department 
Room 5054 

300 Indiana Avenue, Northwest 
Washington, D.C 20001 
(202) 727-4301 

Florida 

Uniform Crime Reports Section 

Florida Crime Information Center Bureau 

Post Office Box 1489 

Tallahassee, Florida 32302-1489 

(904) 487-1179 

Georgia 

Georgia Crime Information Center 
Georgia Bureau of Investigation 
Post Office Box 370748 
Decatur, Georgia 30037 
(404) 244-2840 



'Bureau of justice Statistics, U.S. Department of Justice, Washington, D.C, September 1995. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



E-1 



Guam 

Guam Police Department 

Planning, Research and Development 

Pedro's Plaza 

287 West O'Brien Drive 

Agana, Guam 96910 

(671) 472-8911 x418 

Hawaii 

Chief of Research and Statistics 

Crime Prevention Division 

Department of the Attorney General 

Suite 701 

810 Richards Street 

Honolulu, Hawaii 96813 

(808) 586-1416 

Idaho 

Criminal Identification Bureau 
Department of Law Enforcement 
Post Office Box 700 
Meridian, Idaho 83680 
(208) 884-7156 

Illinois 

Uniform Crime Reporting Program 
Illinois State Police 
100 Hies Park Place 
Post Office Box 3677 
Springfield, Illinois 62704 
(217) 782-5791 

Iowa 

Iowa Department of Public Safety 
Wallace State Office Building 
Des Moines, Iowa 50319 
(515) 281-8494 

Kansas 

Kansas Bureau of Investigation 
1620 Southwest Tyler Street 
Topeka, Kansas 66612 
(913) 296-8200 



Kentucky 

Information Services Branch 
Kentucky State Police 
1250 Louisville Road 
Frankfort, Kentucky 40601 
(502) 227-8783 

Louisiana 

Louisiana Commission on Law Enforcement 

7th Floor 

1885 Wooddale Boulevard 

Baton Rouge, Louisiana 70806 

(504) 925-4847 

(504) 925-7730 

Maine 

Uniform Crime Reporting Division 

Maine State Police 

Station #42 

36 Hospital Street 

Augusta, Maine 04333 

(207) 624-7003 

Maryland 

Central Records Division 
Maryland State Police Department 
1711 Belmont Avenue 
Baltimore, Maryland 21244 
(410) 298-3883 

Massachusetts 

Crime Reporting Unit 
Massachusetts State Police 
470 Worcester Road 
Framingham, Massachusetts 01701 
(508) 820-2110 
(508) 820-2115 

Michigan 

Uniform Crime Reporting Section 
Michigan State Police 
7150 Harris Drive 
Lansing, Michigan 48913 
(517) 322-1150 



E-2 



Assessing Drug Abuse Within and Across Communities 



Minnesota 

Bureau of Criminal Apprehension 

Minnesota Department of Public Safety 

Suite 100-H. Town Square 

1246 University Avenue 

St. Paul, Minnesota 55104 

(612) 642-0670 

(612) 642-0610 

Montana 

Management Analyst 

Montana Board of Crime Control 

303 North Roberts 

Helena, Montana 59620 

(406) 444-2077 

Nebraska 

Uniform Crime Reporting Section 
The Nebraska Commission on Law 
Enforcement and Criminal Justice 
Post Office Box 94946 
Lincoln, Nebraska 68509 
(402) 471-3982 

Nevada 

Criminal Information Services 
Nevada Highway Patrol 
555 Wright Way 
Carson City, Nevada 89711 
(702) 687-5713 

New Hampshire 

Uniform Crime Report 

Division of State Police 

10 Hazen Drive 

Concord, New Hampshire 03305 

(603) 271-2509 

New Jersey 

Uniform Crime Reporting 

Division of State Police 

Post Office Box 7068 

West Trenton, New Jersey 08628-0068 

(609) 882-2000 x2392 



New York 
Statistical Services 

New York State Division of Criminal 
Justice Services 
8th Floor, Mail Room 
Executive Park Tower Building 
Stuyvesant Plaza 
Albany, New York 12203 
(518) 457-8381 

North Carolina 

Crime Reporting and Field Services 
Division of Criminal Information 
State Bureau of Investigation 
407 North Blount Street 
Raleigh, North Carolina 27601 
(919) 733-3171 

North Dakota 

Information Services Section 
Bureau of Criminal Investigation 
Attorney General's Office 
Post Office Box 1054 
Bismarck, North Dakota 58502 
(701) 328-5500 

Oklahoma 

Uniform Crime Reporting Section 

Oklahoma State Bureau of Investigation 

Suite 300 

6600 North Harvey 

Oklahoma City, Oklahoma 73116 

(405) 879-2531 

Oregon 

Law Enforcement Data Systems Division 
Oregon Department of State Police 
400 Public Service Building 
Salem, Oregon 97310 
(503) 378-3057 

Pennsylvania 

Bureau of Research and Development 
Pennsylvania State Police 
1800 Elmerton Avenue 
Harrisburg, Pennsylvania 17110 
(717) 783-5536 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



E-3 



Puerto Rico 

Director of Statistics 
Puerto Rico Police 
Roosevelt Avenue 101 
San Juan, Puerto Rico 00936 
l-(787) 793-1234 ext. 3113 

Rhode Island 

Rhode Island State Police 
311 Danielson Pike Post Office Box 185 
North Scituate, Rhode Island 02857 
(401) 444-1121 

South Carolina 

South Carolina Law Enforcement Division 
Post Office Box 21398 
Columbia, South Carolina 29221-1398 
(803) 896-7022 

South Dakota 

South Dakota Statistical Analysis Center 
500 East Capitol Avenue 
Pierre, South Dakota 57501 
(605) 773-6310 

Texas 

Uniform Crime Reporting Bureau 

Crime Information Bureau 

Texas Department of Public Safety 

Post Office Box 4143 

Austin, Texas 78765-4143 

(512) 424-2091 

Utah 

Uniform Crime Reporting 

Bureau of Criminal Investigation 

Utah Department of Public Safety 

4501 South 2700 West 

Salt Lake City, Utah 84119 

(801) 965-4445 

Vermont 

Vermont Crime Information Center 
Post Office Box 189 
Waterbury, Vermont 05676 

(802) 244-8786 



Virginia 

Records Management Division 
Department of State Police 
Post Office Box 27472 
Richmond, Virginia 23261-7472 
(804) 674-2023 

Virgin Islands 

Records Bureau 

Department of Public Safety 

Post Office Box 210 

Charlotte Amalie 

Saint Thomas, Virgin Islands 00801 

(809) 774-2211 

Washington 

Uniform Crime Reporting Program 
Washington Association of Sheriffs and 

Police Chiefs 
Post Office Box 826 
Olympia, Washington 98507 
(360) 586-3221 

West Virginia 

Uniform Crime Reporting Program 

West Virginia State Police 

725 Jefferson Road 

South Charleston, West Virginia 25309 

(304) 746-2259 



Wisconsin 

Office of Justice Assistance 
2nd Floor 
222 State Street 
Madison, Wisconsin 53703 
(608) 266-3323 

Wyoming 

Uniform Crime Reporting 
Criminal Records Section 
Division of Criminal Investigation 
316 West 22nd Street 
Cheyenne, Wyoming 82002 
(307) 777-7625 



E-4 



Assessing Drug Abuse Within and Across Communities 



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A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



F-1 



Appendix F-2: 1994 Drug-Related Arrests of 

Persons Under Age 18 by Age, Gender, and Race/ 

Ethnicity — State of Maryland 





Gender 


09 and 
under 


10-12 


13-14 


15 


16 


17 


Total 

under 

18 


White 


Black 


Asian 


Drug Abuse Laws 


M 


3 


60 


882 


1,153 


1,566 


2,031 


5,695 


2,051 


4,201 


16 




F 




15 


92 


114 


146 


206 


573 








Drug Sales-Total 


M 


3 


32 


437 


529 


696 


855 


2,552 


337 


2,352 


3 




F 




3 


22 


25 


31 


59 


140 








Opium or Cocaine 


M 


2 


27 


383 


460 


620 


718 


2,210 


140 


2,162 




and Derivatives 


F 




1 


15 


16 


24 


36 


92 








Marijuana 


M 




5 


46 


60 


61 


112 


284 


144 


172 


2 




F 




1 


4 


8 


5 


16 


34 








Synthetic Narcotics 


M 






6 


4 


12 


10 


32 


21 


15 


1 


(Methadone, Demorol) 


F 






1 


1 


2 


1 


5 








Other Dangerous 


M 


1 




2 


5 


3 


15 


26 


32 


3 • 




Non-Narcotic drugs 


F 




1 


2 






6 


9 








Drug Possession-Total 


M 




28 


445 


624 


870 


1,176 


3,143 


1,714 


1,849 


13 




F 




12 


70 


89 


115 


147 


433 








Opium or Cocaine 


M 




11 


180 


227 


293 


367 


1,078 


162 


992 


1 


and Derivatives 


F 




4 


14 


13 


18 


28 


77 








Marijuana 


M 




17 


226 


373 


544 


773 


1,933 


1,410 


831 


12 




F 




8 


48 


66 


88 


110 


320 








Synthetic Narcotics 


M 






4 


7 


7 


4 


22 


35 


2 




(Methadone, Demorol) 


F 






3 


2 


4 


6 


15 








Other Dangerous 


M 






35 


17 


26 


32 


110 


107 


24 




Non-Narcotic drugs 


F 






5 


8 


5 


3 


21 









SOURCE: Maryland State Police, 1996. 



F-2 



Assessing Drug Abuse Within and Across Communities 



Appendix G: DEA Division Offices 



Aviation Operations Center 

2300 Horizon Road 

Ft. Worth, TX 76177-5300 

(817) 837-2000 

DEA Atlanta Division 

75 Spring Street, S.W., Room 740 
Atlanta, GA 30303 
(404) 331-4407 

DEA New England Division 

50 Staniford Street, Suite 200 
Boston, MA 02114 
(617) 557-2100 

DEA Carribbean Division 

2434 Loiza Street 
Santurce, PR 00913 

(809) 253-4200 

DEA Chicago Division 

2300 S. Dearborn Street, Suite 1200 
Chicago, IL 60604 
(312) 353-7875 

DEA Dallas Division 

1880 Regal Row 
Dallas, TX 75235 
(214) 767-7151 

DEA Detroit Division 

431 Howard Street 
Detroit, MI 48226 
(313)234-4000 

EPIC 

11339 SSG Sims Street 
El Paso, TX 79908-2033 
(915) 564-2033 

DEA Houston Division 

333 West Loop North, Suite 300 
Houston, TX 77024 
(700) 527-9000 



DEA Los Angeles Division 

255 East Temple Street, 20th Floor 
Los Angeles, CA 90012 
(213) 894-2650 

DEA Miami Division 

8400 N.W 53rd Street 
Miami, FL 33166 
(305)590-4870 

DEA New Orleans Division 

3 Lakeway Center 

3838 N. Causeway Blvd., Suite 1800 

Metairie, LA 70002 

(504) 840-1100 

DEA New York Division 

99 Tenth Avenue 
New York, NY 10011 
(212) 337-3900 

DEA Newark Division 

970 Broad Street, Room 806 
Newark, NJ 07102 
(201) 645-6060 

DEA Philadelphia Division 

600 Arch Street, Room 10224 
Philadelphia, PA 19106 
(215) 597-9530 

DEA Phoenix Division 

3010 North 2nd Street, Suite 301 
Phoenix, AS 85012 
(602) 64-5600 

DEA Rocky Mountain Division 

115 Inverness Drive, East 
Englewood, CO 80112-5116 
(303) 784-6300 

DEA San Diego Division 

402 West 35th Street 
National City, CA 91950 
(619) 585-4200 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



G-1 



DEA San Francisco Division 

450 Golden Gate Ave. 
San Francisco, CA 94102 
(415) 556-6771 

DEA Seattle Division 

220 West Mercer, Suite 300 
Seattle, WA 98119 
(206) 553-5443 

DEA St. Louis Division 

7911 Forsythe Boulevard, Suite 500 
St. Louis, MO 63105 
(314) 425-3241 

DEA Washington, D.C. 

Division 400 Sixth Street, S.W., Room 2558 
Washington, D.C. 20024 
(202) 401-7834 



G-2 Assessing Drug Abuse Within and Across Communities 



Appendix H-1: Excerpts from 1995 Drug 

Prospectus Report, Criminal Intelligence 

Division, Maryland State Police 



Cocaine 

In the eastern region of the United States, a 
system for cocaine distribution exists, with New 
York City at the center of a "hub and spoke" 
distribution design. Cocaine destined for New 
York City arrives from all directions, including 
shipments moving to New York through Mary- 
land. 

Cocaine dealers from Maryland's larger cities 
travel to New York City to buy multi-ounce or 
pound quantities at the best possible prices. In 
the northern part of the State, lower level drug 
traffickers will obtain smaller quantities of 
cocaine in Philadelphia and Wilmington, Dela- 
ware. Likewise, dealers in the southern part of 
Maryland obtain cocaine from sources in Miami 
and Los Angeles. 

Once back in Maryland, these dealers distribute 
ounce and multi-gram quantities of cocaine to 
smaller municipalities via the major highways: 
Interstate 95 from Baltimore, Route 13 from 
Salisbury, Routes 50 and 301 from Cambridge, 
Interstate 70 from Frederick and Hagerstown, 
and Route 68 from Cumberland. Recent drug 
arrests, however, indicate that traffickers may be 
switching to alternate, less traveled routes to 
avoid heavy law enforcement interdiction 
efforts on the major highways. 

Prospective traffickers from New York also come 
to Maryland to sell cocaine and learn the traf- 
ficking trade. In this way, they can gather fund- 
ing, establish supply contacts, and hone their 
business skills in a less ferocious dealing envi- 
ronment than New York City. If, in time, they 
have the opportunity to become dealers in the 
overcrowded New York drug market as well, 
they can easily extend the range of their already 
established and functioning trafficking networks 
northward. 



The problem of New Yorkers venturing into 
Maryland to sell drugs has been mentioned in 
several law enforcement reports. The Criminal 
Intelligence Section of the Baltimore City Police 
Department noted in a report in fall 1992 that 
the agency first observed New Yorkers in a 1987 
Baltimore cocaine trafficking investigation 
involving the Charles "Chucky" Pierce organiza- 
tion. In December 1991, a questionnaire circu- 
lated to all Baltimore patrol districts showed 
four of the nine districts exhibiting a significant 
influx of New Yorkers. The highest level quoted 
was in the southwestern district, where 45 to 50 
percent of the drug activity at that time could be 
directly attributed to New York dealers. The 
northwestern, southeastern, and southern 
districts also reported the impact of New York- 
ers. Both the northwestern and southeastern 
districts reported that 16 to 20 percent of their 
drug-dealing activity could be ascribed directly 
to New Yorkers, while the southern district 
reported that 6 to 10 percent of drug activity 
came from New Yorkers. It was also noted that, 
while the percentage of drug arrests involving 
New Yorkers stayed constant at about 2 percent 
of the total Baltimore drug arrests from 1986 to 
1991, the actual number of New Yorkers (not 
including locals working for New Yorkers) 
arrested each year during that time span had 
increased nearly 200 percent. At that time, 
cocaine was the primary drug sold by New 
Yorkers, making up 54 percent of the cases, 
while heroin (22 percent of the cases) and 
marijuana (18 percent of the cases) dealing 
trailed. 

In 1992, a report by the Wicomico County 
Narcotics Task Force in Salisbury, Maryland, 
indicated that, since 1988, the county had been 
inundated by New York dealers traveling to 
their area to sell drugs, primarily crack cocaine. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



H-1 



This migration of New York dealers purportedly 
supplanted and displaced the Haitian/Jamaican 
cocaine-dealing organizations that had domi- 
nated the market before that time, reducing 
these Caribbean traffickers to dealing on the 
outskirts of the drug community. 

Finally, in 1992, the Maryland State Police (MSP) 
Criminal Intelligence Division issued a report 
noting the influence of New York drug dealers 
on a number of localities within the State. Data 
emerging from Frederick City were of particular 
interest. Of the 1,096 persons arrested for drug 
violations in 1990 and 1991, 48 gave New York 
residence addresses while another 140 listed 
New York as their place of birth. Of the 188 drug 
arrests with New York references, 124 of the 
arrestees, almost 66 percent of the total, were 30 
years old or less at the time of arrest. 

Much of the information about wholesale prices, 
payments to underlings, and other ancillary 
expenses attached to facilitating cocaine dealing 
is derived from anecdotal data acquired from 
apprehended individuals. Like all underground 
enterprises, the cocaine trafficking trade does 
not freely reveal its profit margins, expenses, 
and methods of operation. Thus, arrestees 
exaggerate their success, inflate their earnings, 
and magnify their images as master hustlers and 
street entrepreneurs. Despite the lack of credibil- 
ity of some of these sources, one can gain some 
insight into the profitability of the drug busi- 
ness. One hears how a 19-year-old ex-street 
dealer made $5,000 in one day selling drugs in 
the Lexington Terrace Housing Project in Balti- 
more. In another example, a kilogram of cocaine 
purchased wholesale in 1991 for $18,000 in New 
York City generated $50,000 in street sales in 
Baltimore. In 1991, 40 percent of the gross sales 
gained from vending that kilogram of cocaine in 
Baltimore went to street salesmen, leaving the 
dealer a profit of about $10,000. Using this store 
of anecdotal information with the most recent 
average user/dealer prices, it is possible to 
surmise costs and profits for present-day cocaine 
dealers and street salesmen in Baltimore as 
trafficking operations expand. 



Heroin 

On the East Coast, New York City is recognized 
as the principal debarkation point for heroin 
into the country. The majority of heroin coming 
to Baltimore appears to be from New York City, 
with Philadelphia as the second most frequent 
point of shipment. Virginia may be an interme- 
diate transshipment point for New York heroin 
destined for Maryland. The Drug Price and 
Purity Reports covering a 2-1/2 year period 
(issued by the MSP Criminal Intelligence Divi- 
sion, Analytical Services Unit) show that the 
Northern Virginia area has had substantially 
higher heroin purity levels compared to Mary- 
land. In addition, heroin purity changes be- 
tween the two areas were found to move in 
concert. Purity increases/decreases in Maryland 
mirrored changes in Northern Virginia. This was 
corroborated by intelligence information reveal- 
ing that traffickers were transporting heroin to 
Virginia by train, then sending it to Baltimore by 
bus. 

Maryland's heroin supply certainly does not 
come from just New York and Philadelphia. In 
April 1993, three Maryland women were ar- 
rested with 13.2 pounds of heroin at the U.S. 
Customs station in Otay Mesa, California. A 
controlled delivery was initiated, and the 
women were allowed to complete the transac- 
tion at a Laurel, Maryland, apartment complex. 
In that incident, the suspects traveled from 
Dallas, Texas, to Amsterdam, Holland, then to 
Lagos, Nigeria, where the original heroin was 
allegedly purchased. Then they traveled to 
Mexico City, Mexico, and finally, journeyed to 
the Otay Mesa, California, checkpoint. 

The following heroin demographic information 
for 1994 was extracted from the MSP Criminal 
Intelligence Division, Analytical Services Unit, 
database: 

In 1994, 82 percent of the people investigated for 
heroin were males. Racial breakdowns revealed 
that 59 percent were African American, 37 
percent were Anglo, 3 percent were Hispanic, 
and 1 percent were described as "other race." By 



H-2 



Assessing Drug Abuse Within and Across Communities 



age category, 25 percent were 18 to 25, 19 per- 
cent were 26 to 30, 17 percent were 31 to 35, and 
39 percent were 36 and over. 

High-purity heroin (inhalation quality heroin 
generally at least 20 percent pure) averaged 
between 50 to 55 percent purity in 1994. This 
represents an increase from 44 percent purity 
found in 1993. In 1994, a 1-gram purchase of 
low-purity heroin averaged around $67, while 
the same 1-gram purchase of high-purity heroin 
commanded about $272. 

High-purity heroin may account for the dra- 
matic rise in the Baltimore metropolitan area 
Drug Abuse Warning Network (DAWN) statis- 
tics for emergency room admissions. In the first 
half of 1990, the estimated rate of heroin-related 
emergency room episodes in Baltimore was 30.1 
per 100,000 population. By the end of 1993 this 
rate had increased to 133.1 per 100,000 popula- 
tion. The problem may be rooted in the mental- 
ity of the user who injects heroin. An addict is 
principally concerned with his or her next fix. If 
only high-purity, snortable quality heroin is 
available, the intravenous drug user will prob- 
ably inject it, regardless of the consequences. 

Street-level dealers may find it less time-con- 
suming and possibly even safer to sell heroin 
versus crack cocaine. Crack is a quick acting 
drug with a high that may last as little as 30 
minutes, while the effects of heroin last for 
hours. This means the crack dealer must be 
available to meet the constant demand for the 
drug while the heroin dealer can sell his prod- 
uct, leave an area, and engage in other activities. 
By limiting the time on the street, the dealer 
lessens his risk of arrest. Since crack addicts are 
typically more violent than heroin addicts, 
dealing heroin offers less physical risk to the 
dealer. The same is true for competing dealers. 
Crack dealers have been associated with the 
rampant violence that has occurred in many 
U.S. cities, while heroin dealing has been less 
violent. 

Anecdotal information indicates that some 
cocaine dealers require a heroin purchase with a 



cocaine purchase. It has not yet been established 
whether this marketing method is being used to 
hook new heroin users, or if it is related to the 
user population that "speedballs" (injects cocaine 
and heroin mixed together). One trend that 
appears to be on the rise is that of the drug user 
who smokes crack and then snorts heroin to 
lessen the crash resulting from the cocaine high. 

It is also important to understand the nature of 
heroin addiction. While cocaine abuse causes 
user burn out in a relatively short period of time, 
heroin addiction can span years or even de- 
cades, thus ensuring long-term customers. 

Marijuana 

Marijuana cultivation is a lucrative enterprise, 
and Maryland's geographic location and climate 
are conducive to growing the illicit crop. Indoor 
and outdoor grows can be found throughout the 
State. To counter this problem, the State with the 
support of the Bureau of Justice Assistance and 
DEA, has established a Marijuana Eradication 
Program that involves the combined efforts of 
State, county, and local police agencies and the 
Maryland National Guard. These eradication 
efforts are conducted through aerial and ground 
operations and result in a sizeable number of 
arrests and large marijuana seizures. The 1991 
Marijuana Eradication Program set a record for 
marijuana plant seizures, a total of 11,210 plants. 
Plant seizures in subsequent years have shown a 
decline; however, this downturn may be accen- 
tuated because of the extremely successful 1991 
eradication campaign. 

In 1994, outdoor plant seizures declined because 
of several factors. First, a 20 percent decrease in 
helicopter flight time resulted in fewer plants 
being located by air. Secondly, a heat wave in 
early spring and a lack of rain killed many 
seedlings; consequently, eradication team 
members encountered many empty gardens. In 
addition to the plant seizures, 23.2 pounds of 
bulk processed marijuana were seized at out- 
door grows in 1994, a significant decrease from 
1993, when 75 pounds of processed marijuana 
were seized. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



H-3 



Although relatively small in number, seizures 
from indoor marijuana grows in Maryland have 
increased steadily since 1990. Seizures of bulk 
processed marijuana at these indoor growing 
operations have also increased significantly. In 
1994, 88.3 pounds of processed marijuana were 
seized, versus 24.5 pounds in 1993. Officers 
making these indoor seizures frequently en- 
counter sophisticated equipment used to raise 
the delta-9-tetrahydro- cannabinol (THC) levels 
in the plants and increase the volume of mari- 
juana produced per plant. 

Occasionally, officers discover an indoor mari- 
juana grow that is so small that it is deemed for 
personal use. However, the vast majority of 
indoor grows found in Maryland are large 
enough to supply high-grade marijuana for 
commercial sale. Statistics for indoor seizures in 
Maryland revealed an average of 39 marijuana 
plants per grow. The wholesale price of commer- 
cial-grade marijuana averages approximately 
$1,800 per pound, while high- quality sinsemilla 
can sell for almost twice that amount. Currently, 
yield studies indicate that each marijuana plant 
is capable of producing 1 pound of marketable 
marijuana, so a modest 10-plant grow could 
generate at least $18,000 in sales. Thus, an 
indoor grow as small as 10 plants still affords the 
opportunity to make substantial profits when 
production yield and quality are optimized. 

Although an extended decline in marijuana use 
has been evident, marijuana has never vanished 
from the drug scene. Other more exotic or 
currently newsworthy drugs have simply 
overshadowed it. Now the negative social image 
of cocaine may be contributing to a resurgence 
in the popularity of marijuana. The constant 
publicity, education, and exposure regarding the 
dangers of cocaine addiction may have influ- 
enced some users to seek a "softer" alternative. 
Moreover, the much stiffer legal penalties at- 
tached to crack and cocaine trafficking may well 
be an impetus for some drug traffickers/dealers 
to switch to marijuana sales. 

According to information extracted from the 
MSP Criminal Intelligence Division, Analytical 



Services Unit data base, casual use of mari- 
juana appears to be on the rise. In Maryland 
between 1993 and 1994, there was a 27 percent 
increase in persons arrested for user quantities 
of marijuana (1,553 in 1993 and 1,969 in 1994). 
Males comprised 85 percent of these arrests. By 
race, 74 percent of these individuals were 
Anglo, 25 percent were African American, and 
1 percent were of another race. By age cat- 
egory, 14 percent of these marijuana users 
were under 18, 43 percent were between 18 
and 25, 16 percent were between 26 and 30, 13 
percent were between 31 and 35, and 14 
percent were 36 or older. 

Young people are becoming more inclined to 
view marijuana as harmless. Contributing to 
this perception is the overt promotion of the 
drug by rock, hip-hop, and heavy metal musi- 
cal groups. These groups advocate marijuana 
use through their music and frequently use 
their popularity and media exposure to express 
pro-use/legalization views. Organizations 
advocating marijuana legalization use music 
concerts as a venue to solicit support, setting 
up booths and distributing propaganda on the 
benefits of the drug and the rights of the user. 
For example, promoters for a New Year's Eve 
"rave party" in Baltimore County used an 
advertisement with Uncle Sam displaying a 
marijuana leaf in his lapel. 

Contributing to the resurgence of marijuana in 
the Baltimore-Washington area is the use of 
"blunts." A blunt is an inexpensive cigar, typi- 
cally a "Philly Blunts" brand cigar, that has been 
split open and emptied of tobacco. Marijuana 
is substituted for the removed tobacco, and the 
exterior tobacco leaf of each cigar is used to 
rewrap the new contents. Use of blunts began 
in New York or Philadelphia and spread south, 
first to the Washington metropolitan area and 
then to Baltimore City. Reflections of this trend 
can be noted on clothing such as hats, T-shirts, 
and sweatshirts with characters who wear 
dreadlock hairstyles and declare their prefer- 
ence for blunts. In 1992, a feature article in 
High Times magazine described the assembly 
of blunts; an article in 1993 highlighted the 
history of the trend. 



H-4 



Assessing Drug Abuse Within and Across Communities 



Drug use is cyclical in nature, and marijuana use 
appears to have reached the bottom of its most 
recent ebb in usage. Statistics and anecdotal 
information suggest that fads and marijuana use 
as an alternative to other drugs may be refueling 
a resurgence. Although law enforcement wins 
frequent battles against marijuana organizations, 
the massive number of smugglers involved and 
the diversified systems used to manufacture and 
distribute marijuana overwhelm law 
enforcement's efforts. With no foreseeable major 
interruption in supply and a predicted rise in 
the number of users, the status of marijuana as 
the most abused drug will probably rise. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse H-5 



Appendix H-2: Additional Drugs of Abuse 

Reported by Criminal Intelligence Division, 

Maryland Department of State Police 



PCP 

The availability and use of phencyclidine (PCP) 
appears to be stable. The bulk of PCP arrests are 
made in southern Maryland. Highway interdic- 
tions involving PCP in 1994 were common in 
Prince George's, Anne Arundel, and Charles 
Counties. Historically, Prince George's County is 
known as a vending site for PCP, with most of 
the drug entering the county from Washington, 
DC. 

U.S. Drug Enforcement Agency (DEA) intelli- 
gence reports that PCP is generally transported 
from southern California to the Washington, DC, 
area in gallon and 3-gallon quantities in luggage 
via bus or airplane. 

Average PCP prices in Maryland have fluctuated 
over the past 3 years. In 1992, an ounce of liquid 
PCP sold for about $365 and declined to $320 in 
1993. In 1994, an ounce of liquid PCP sold for 
between $350 and $400. The decrease in price 
for PCP may have been the result of larger 
amounts of this drug reaching the streets. 

One liquid ounce of PCP can produce 4 street 
ounces of treated parsley flakes. Each street 
ounce of parsley can be divided into 8 film 
canisters. A single film canister is the usual user 
purchase amount and sells for $50 on the street. 
Therefore, after an initial investment of $300, the 
dealer can realize up to $1,300 profit from sales 
of PCP-treated parsley. 

Dealers in Washington, DC, predominately 
African American males, continue to control the 
wholesale market for PCP. However, over 80 



percent of individuals encountered in Maryland 
highway interdictions and investigations involv- 
ing PCP in 1994 were Anglo. Anglo Maryland- 
ers travel to Washington, DC, to purchase liquid 
PCP from African American wholesalers, and 
return to Maryland to resell the drug locally in 
street-level quantities. 

PCP is usually marketed in two ways. The drug 
is sprayed on parsley flakes ("greens") or mari- 
juana ("love boat") and is sold in film canisters 
containing roughly 2.5 grams each. The treated 
parsley or marijuana is then smoked. In another 
use method, liquid ounces of PCP are sold in 
vanilla extract bottles, and tobacco or marijuana 
cigarettes are dipped into the liquid. These 
treated cigarettes, called "dippers," "sherman 
sticks," or "illies," can be purchased for approxi- 
mately $20 each. 

No other new sales trends for PCP have been 
reported in Maryland. However, reports from 
Washington, DC, indicate that, in street jargon, 
PCP is known as "water." Another trend is PCP 
laced with gasoline. Called "octane," this variety 
of PCP is also being used for "dippers" and for 
treating parsley. 

LSD 

Lysergic acid diethylamide (LSD) continues to 
be a popular drug among high school and col- 
lege-aged individuals. Circulated in high 
schools, on college campuses, at nightclubs, or 
teen and young adult parties, this hallucinogen 
appeals to the younger market because it is easy 
to obtain, cheap to purchase, and produces a high 
lasting up to 12 hours. 



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H-7 



According to DEA intelligence information, 
LSD, or "acid," can be found in virtually every 
State in the nation. LSD is sold in a variety of 
forms at the retail level, including blotter paper, 
gelatin squares ("windowpanes"), sugar cubes, 
and small pills ("microdots"). In Maryland, 
blotter paper is the most common form of LSD. 

Both retail and wholesale LSD prices have 
increased minimally over the past few years. 
State and local undercover agents usually pur- 
chase LSD at retail levels in quantities of 100 
dosage units or less. 

Maryland State Police Statewide LSD Prices 

LSD prices have increased for street-level dealer 
quantities of 50 to 100 dosage units. However, 
prices for user quantities (1 to 5 dosage units) 
have remained stable over the past 3 years. 

In January 1993, a new form of LSD was pur- 
chased during an undercover operation by the 
Maryland State Police (MSP), Drug Enforcement 
Division, in southern Maryland. This LSD was 
in the most common form for LSD in Maryland, 
blotter paper. However, the perforated doses, or 
"hits," measured twice the normal size, approxi- 
mately 1/4 inch square. A picture of a cartoon 
pig dressed in overalls was imprinted on each 
hit. This was the first appearance of this type of 
LSD in Maryland. 

Recently, another type of blotter acid has become 
popular in central Maryland. The blotter paper 
containing the LSD is orange in color and is 
imprinted with a picture of a sun with a human 
face covering each four square blocks of paper. 
The street name of this LSD is "orange sunshine" 
(not to be confused with the microdot form of 
"orange sunshine" LSD popular in the 1960s). In 
October 1993, the MSP Metropolitan Area Drug 
Task Force seized over 1 ,400 dosage units of 
"orange sunshine" in College Park, Maryland. 
"Orange sunshine" has also been sold in Balti- 
more County and Baltimore City. 



Methamphetamine 

Methamphetamine, known as "meth," "speed," 
and "crank" on the street, is a synthetic stimu- 
lant. Methamphetamine powder, often packaged 
in capsules or zip lock baggies, can be swal- 
lowed, snorted, or dissolved in water and in- 
jected. A very pure and potent form of metham- 
phetamine, known as "ice," can be smoked. 

Historically, methamphetamine has been associ- 
ated with outlaw motorcycle gangs. Meth has not 
been prevalent in Maryland because of a decline 
in the activity of this major trafficking group in 
the State. However, recent information suggests 
that methamphetamine may be gaining in popu- 
larity among new and younger users in Mary- 
land. Reportedly, the crystalline powder form of 
methamphetamine is readily available at rave 
parties and all-night dance parties frequented by 
juveniles and young adults, and can be purchased 
for $20 a hit. 

Several national indicators are also showing that 
methamphetamine use is on the rise. The DEA 
reports that, during the early part of 1995, the 
number of methamphetamine seizures as a result 
of highway interdictions has increased signifi- 
cantly around the country. Law enforcement 
agencies indicate that California is usually the 
source of methamphetamine being shipped to 
distribution/user markets throughout the United 
States. 

According to Drug Abuse Warning Network 
(DAWN) Emergency Room data, between 1988 
and 1991 the number of methamphetamine- 
related emergency room episodes decreased 
nationally. However, between 1991 and 1993, 
methamphetamine episodes increased 106 
percent (from 4,900 to 10,100). 

Methcathinone 

Methcathinone, or "cat," first appeared on the 
illicit drug market near Marquette, Michigan, in 
January 1991. Since then, "cat" has spread 



H-8 



Assessing Drug Abuse Within and Across Communities 



throughout the upper peninsula of Michigan and 
to other parts of Michigan and Wisconsin. 
Isolated reports of cat in Florida, Virginia, and 
Washington have been noted. In Maryland, there 
have been reports that persons have attempted to 
manufacture and market "cat" in Frederick. 
County, but confirmation is lacking. 

Methcathinone, a strong amphetamine-like 
substance, is known to be more potent than 
methamphetamine. "Cat" is easy to make and its 
precursor chemicals are readily available. As 
such, the manufacture of "cat" could become 
attractive to drug entrepreneurs. The DEA 
permanently listed methcathinone as a Schedule 
I Controlled Dangerous Substance (CDS) on 
October 15, 1993. 

Maryland does not have a strong existing user 
population for methamphetamine or similar 
drugs, so "cat" may be slow to find a market 
here. However, law enforcement and legislators 
should be aware of this drug and the threat it 
poses if it starts to appear with any regularity in 
Maryland. 

MDMA 

MDMA (3, 4-methylenedioxymethamphetamine) 
is a hallucinogenic amphetamine. Also known as 
"ecstasy," "XTC," "X," and "Adam," it is not a 
prominent drug in Maryland. Popular among 
rave party attendees, it is sold in pill, capsule, or 
powder form and can be taken orally or snorted. 
One hit of the drug sells for between $25 to $45. 
MDMA seizures or undercover purchases have 
been made in Frederick County, Howard County, 
and Baltimore City. In two instances the drug 
was in tablet form and concealed inside Tic-Tac 
and Tylenol containers. Anecdotal information 
suggests that MDMA is finding its way to 
different areas of the State. It is believed that 
teenagers and young adults purchase small 
quantities of the drug at rave parties and return to 
their homes to sell the MDMA to friends and 
associates. 



Sources in nearby Fairfax County, Virginia, 
reveal that MDMA is available and has been 
purchased from an Asian male. The MDMA was 
sold in capsule form at $35 per capsule. The 
source of the MDMA has not been determined. 

The Clarksburg, West Virginia, DEA office was 
involved in the arrest of four individuals con- 
nected with an MDMA clandestine lab opera- 
tion. When seized, the lab contained about 4,000 
ml of MDMA solution. Reportedly, the "cooker" 
of this solution has a bachelor's degree in chem- 
istry. 

Ketamine 

Ketamine, or ketamine hydrochloride, is a legal 
tranquilizer used in veterinary medicine. Chemi- 
cally related to phencyclidine (PCP), it is sold as 
an injectable under the brand names Ketacet and 
Ketajet. For human consumption, ketamine is 
marketed under the name Ketalar. Ketalar is a 
rapid-acting general anesthetic that is mostly 
used for diagnostic and short surgical proce- 
dures. 

Ketamine has been diverted into the illicit 
market from veterinary sources and is called 
"Special K" or "cat Valium" on the street. Nor- 
mally found in injectable form, it is converted 
into a powder and repackaged in small zip-lock 
baggies or capsules. Sold for $20 a dosage unit 
or "hit," ketamine is generally snorted. While 
ketamine acts as a tranquilizer in animals, it has 
hallucinogenic effects on humans. Ketamine can 
cause convulsions, especially when taken in 
large dosages. Some users experience vomiting 
when mixing it with alcohol. The drug can cause 
a depressed person to become suicidal or an 
agitated person to become violent. 

Ketamine has been common in the New York 
night club scene for many years. In the Baltimore 
metropolitan area "Special K" is readily available 
at rave parties. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



H-9 



According to the American Veterinary Medical 
Association, ketamine can only be obtained by 
licensed veterinary clinics and research insti- 
tutes. Last summer, the Virginia Veterinary 
Medical Association reported a scam to obtain 
ketamine. A person would call a veterinary 
hospital or clinic, saying they were from another 
doctor's office. They then stated that they had run 
out of ketamine and wanted to borrow a bottle 
until their order came in. This scheme was 
reported in Virginia, Maryland, and North Caro- 
lina. Heightened awareness among veterinary 
clinics has resulted in tighter controls on 
ketamine supplies and, as a result, traffickers are 
resorting to more drastic measures to obtain the 
substance. In February 1995, three subjects 
committed an armed robbery at a Carroll County 
veterinary hospital and stole bottles of ketamine. 
In June 1995, a veterinary clinic in St. Mary's 
County was broken into and 33 bottles of 
ketamine were stolen. 

In some States, ketamine is controlled, but in 
most States it is only restricted. Because of the 
drug's high potential for abuse, it is under con- 
sideration for an official controlled substance 
classification, based on police and medical 
information. 



Most rave party goers are high school and col- 
lege students ranging in age from their late teens 
to early twenties. Ravers in the Baltimore- 
Washington area are predominantly Anglo; 
however, some rave parties are described as 
melting pots for young people from different 
economic and racial backgrounds. The clothing 
styles are mostly retro 60s and 70s psychedelic 
colors, bell-bottoms, platform shoes, and bizarre 
hats but loose-fitting shirts, shorts and pants, and 
baseball hats worn backwards are also popular. 
Raves are a forum for the "X" generation, a place 
to release frustrations and be rebellious. 

The promoters of rave parties advertise via flyers 
(usually index card sized with psychedelic 
designs), private mailing lists, e-mail, and by 
word of mouth. There is security at all rave 
parties, and the clubs that hold parties check 
identification at the door. A person must be 18 or 
over to attend a rave, but it is easy enough for 
high school students to acquire false identifica- 
tion to gain admittance. Some rave parties claim 
to be alcohol-free, others serve alcohol, and still 
others let participants bring their own. All sell 
non-alcohol drinks, especially sodas and "smart 
drinks," fruit juice drinks with vitamins, amino 
acids, and caffeine. 



Drugs Used at Raves 

Rave parties, also known as underground or 
after-hour parties, are all-night dance parties held 
at night clubs, warehouses, and parks. Disc 
jockeys from New York, Philadelphia, Balti- 
more, and Washington, DC, travel up and down 
the eastern seaboard to play the "techno music" 
heard at these gatherings. The music, accompa- 
nied by laser and strobe light shows, is loud and 
characterized by a fast, pulsating beat. Large rave 
parties are considered to be special events and 
are very popular and well-attended by young 
people. It is not uncommon for people to travel 4 
or 5 hours to attend one of these parties. 



There are also smaller, private rave parties held 
at a variety of different locations. Alcohol is 
generally not served at these functions, and 
consequently, identification is not checked. 
Admission is by invitation only. 

The most prevalent drugs at rave parties are 
LSD, MDMA ("ecstasy"), marijuana, cocaine, 
methamphetamine, ketamine ("Special K"), and 
nitrous oxide. It is difficult for law enforcement 
to mingle with the drug-users at rave parties 
because they generally hang out in cliques or 
tight-knit groups and are suspicious of outsiders. 

Rave parties are distinguished from "house 
parties," which have a predominately African 



H-10 



Assessing Drug Abuse Within and Across Communities 



American crowd. The popular drug at these club 
and social gatherings is marijuana "reefer" joints 
and "blunts," inexpensive cigars, especially 
"Philly Blunts," that are split open, emptied of 
tobacco, and filled with marijuana. 

Prescription Drugs 

Drug diversion is the act of obtaining legal 
prescription drugs for illicit purposes. Such 
drugs are diverted into the illicit market by 
prescription forgery and phone-in prescription 
fraud, by falsifying symptoms in order to obtain 
prescriptions ("doctor shopping"), and by unscru- 
pulous practices of professionals such as doctors, 
nurses, dentists, and pharmacists. Hospitals and 
pharmacies are also the target of thefts by bur- 
glars and by employees themselves. 

Diverted pharmaceutical drugs are popular for a 
variety of reasons. First and foremost, quality 
control is employed during drug manufacture 
and the user knows that each dose will be consis- 
tent and the effects will be the same. Easily 
recognizable, prescription drugs are usually 
imprinted with a drug name or a drug company 
symbol. These drugs are also relatively cheap 
and easy to obtain. Unlike illicit drugs, they can 
be purchased through prescription plans, Medi- 
care, or medical assistance. Finally, the abuse of 
prescription drugs generally goes undetected 
because police either have few resources to 
tackle the problem or are not well informed 
about drug diversion. Prescription drugs in 
Maryland continue to be trafficked primarily by 
Anglos in their early 20s to late 40s. The follow- 
ing are the commonly diverted drugs: 

Dilaudid (hydromorphone, Schedule II), a 
narcotic analgesic 

Percocet/Percodan (oxycodone, Schedule II), 
a narcotic analgesic 

Xanax (alprazolam, Schedule IV), a 
tranquilizer 

Valium (diazepam, Schedule IV), a tranquil- 
izer 



Vicodin, Lorcet, Lortab, Anexsia 

(hydrocodone, Schedule III), narcotic 

analgesics and antitussives 
Doriden (glutethimide, Schedule II), a 

depressant 
Tylenol with Codeine Tylenol 3 or 4 (codeine 

phosphate, Schedule III), an analgesic. 

DEA drug diversion units in the Baltimore- 
Washington area also report that clonidine (brand 
name Catapres), a non-controlled drug used to 
manage hypertension, is being used as a booster 
with narcotics, narcotic analgesics, and sedatives 
such as heroin, methadone, Darvocet, Valium, 
and Xanax. 

A DEA system that tracks the wholesale move- 
ment of pharmaceuticals shows that, in 1993, 
Maryland ranked number one per capita in the 
nation in shipments of oxycodone. In 1992 
Maryland ranked third. An increase was also 
seen with Doriden, a depressant, which ranked 
eighth in 1992 and rose to second in 1993. 
Although there is a large heroin population in 
Baltimore, Maryland, dropped from seventh 
place in 1992 to thirteenth in 1993 for 
hydromorphone (Dilaudid), a narcotic analgesic. 
These three drugs are readily available on the 
street in Maryland. 

The DAWN emergency room sample for the 
Baltimore metropolitan area showed significant 
decreases between the first two quarters of 1992 
and the first two quarters of 1993 for the follow- 
ing prescription drugs reported by participating 
hospitals: alprazolam (Xanax, a tranquilizer), 
diazepam (Valium, a tranquilizer), d- 
propoxphene (Darvon, a narcotic analgesic), 
fluoxetine (Prozac, an antidepressant), 
cyclobenzaprine (Flexeril, muscle relaxant), and 
naproxen (Naprosyn, an analgesic). 

Approximately 5 percent of admissions to 
Maryland treatment facilities in FY 94 reported a 
prescription drug or an over-the-counter drug as 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



H-11 



a substance of abuse. Among those admitted, 
pharmaceutical drugs (non-prescription metha- 
done, barbiturates, sedatives, amphetamines, 
tranquilizers, and over-the-counter drugs) in- 
creased slightly from 2,843 in FY 93 to 3,01 1 in 
FY 94. Because treatment centers report only the 
top three substances cited as substances of abuse 
by each client, it is possible that prescription 
drug abuse by Maryland residents is underesti- 
mated in persons using multiple illicit drugs. 

Inhalants 

The term "inhalants" refers to a wide array of 
chemicals, including solvents, aerosols, gases, 
and volatile nitrites, which, when drawn into the 
lungs, induce a temporary euphoric state. The 
majority of these chemicals are legal to purchase 
and possess. In fact, many are contained in 
common household items such as cleaning 
fluids, glue, nail polish remover, spray paint, 
lighter fluid, and gasoline. 

Inhalants are inhaled, or "huffed." Some of the 
more common ways to huff are directly from the 
container, from a soaked rag, or after the sub- 
stance has been transferred into another con- 
tainer such as a soda can or plastic bag. Many are 
not aware of the potential dangers of this form of 
abuse. Inhalants can cause physical changes such 
as double vision, dizziness, loss of coordination, 
and blackouts. These effects are usually tempo- 
rary; however the misuse of these substances can 
damage the heart, lungs, brain, liver, and kid- 
neys. High concentrations of these substances 
can also cause death by suffocation or cardiac 
collapse from shock. 

Inhalant abuse has been popular among school- 
aged children for many years, and recent reports 
indicate that the frequency of abuse is on the 
rise. The 1993 Monitoring the Future Survey 
reported that, after alcohol and tobacco, inhalants 
are the most abused substances among eighth- 
graders. According to the survey, almost one in 



five eighth graders has used inhalants. The 1992 
National Household Survey on Drug Abuse 
indicates that, for lifetime use, gasoline and glue 
are the most abused inhalants among 12- to 17- 
year-olds, while amyl nitrites (poppers or snap- 
pers) and nitrous oxide are most frequently used 
by adults age 1 8 or over. 

Law enforcement can offer little deterrence 
because most of these products are readily 
available and can be purchased by anyone. 
Moreover, the charge for illegally selling inhal- 
ants is usually a misdemeanor. It is not surpris- 
ing, then, that incidents of inhalant abuse are 
becoming more common. 

In Maryland and elsewhere, there is a growing 
problem in the sale and abuse of nitrous oxide 
gas. Nitrous oxide is a colorless, sweet-smelling 
gas that has a variety of uses. In the medical 
profession, nitrous oxide, known as "laughing 
gas," is most commonly used for minor oral 
surgery and dental work. This gas also has a 
number of industrial uses. It is used as a propel- 
lant in aerosol food cans and is sold commer- 
cially in small canisters or cartridges called 
"whip-its," which are marketed under various 
brand names such as Whippets and EZ Whip and 
used to make whipped cream. Nitrous oxide is 
also sold in cylinders or tanks for medical and 
dental use. Nitrous oxide with hydrogen sulphide 
or another gas added is used as a fuel enhance- 
ment in race cars. 

There has been a growing concern by many in 
the medical profession, government, and industry 
about an increase in the abuse of nitrous oxide. 
Theft of cylinders from suppliers and medical 
sources and the deliberate purchase of tanks 
from distributors who are oblivious to its misuse 
has made nitrous oxide available to many per- 
sons. Some are entrepreneurs who seek to profit 
from its misuse while others are juveniles or 
young adults looking for a cheap high. At con- 
certs, people will openly sell a dose of nitrous 



H-12 



Assessing Drug Abuse Within and Across Communities 



oxide, known as "hippie crack" or simply "ni- 
trous," for approximately $2 to $5. The gas is 
generally dispensed from a large nitrous oxide 
tank into a balloon. The captured gas is then 
sucked through the mouth in the same manner as 
some draw in helium to make their voices 
change. 

Concert goers, however, are not the only ones 
lured into taking part in this activity. In the 
summer of 1992, police officers from the 
Wilkens precinct of the Baltimore County Police 
Department arrested two young men on separate 
occasions for allegedly selling balloons of 
nitrous oxide for $2 to $3 each to kids on the 
street. 



anesthesiological mask is used that stays at- 
tached to the face even if the user passes out, or 
explosion of the tank. 

Many who abuse nitrous oxide believe that it is a 
"safe" (harmless, nonaddictive and undetectable) 
drug. However, taken in combination with 
prescription or over-the-counter medicines or 
any street drugs, anesthetics such as nitrous 
oxide can have serious side effects or can be 
fatal. In addition, the doses or "hits" of nitrous 
oxide purchased on the street may not be medical 
grade laughing gas, but rather an industrial grade 
of the gas used in race cars, with many harmful 
impurities such as sulphuric acid, ammonia and 
nitric oxide. 



Not just a local phenomenon, there are numerous 
news accounts of nitrous oxide- related incidents 
across the country. Some news reports describe 
motor vehicle accidents where not only drivers 
under the influence of nitrous oxide were injured 
or killed, but also pedestrians. Other articles 
recount the deaths of juveniles that were not 
aware of the hazards of inhaling this potentially 
lethal substance. Special dangers include using 
the gas in a closed environment, such as a car, 
where all the oxygen is expelled, or where an 



According to law enforcement, there is a huge 
profit motive for selling nitrous oxide. One large 
compressed gas cylinder contains between 
14,000 to 16,000 liters of nitrous oxide. A 
typical street sale involves a 2- to 3-liter balloon 
of nitrous oxide, which sells for anywhere 
between $2 and $5. One 14,000 liter tank could 
inflate approximately 4,700 balloons. Even at the 
more conservative price of $3 per balloon, the 
profit potential from one large cylinder is 
$14,100. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



H-13 



Appendix I: Ethnographic Studies 



Atlanta 

An ethnographer in Atlanta developed a short- 
term ethnographic project to determine why 
female crack users were increasingly being 
arrested but were not being treated in hospital 
emergency rooms or admitted to drug abuse 
treatment programs. This was an important 
question because the indicator data from all 
three sources (police, hospitals, and drug abuse 
treatment programs) were being used to assess 
the nature and extent of drug abuse problems. 

The ethnographic team in Atlanta already had 
substantial experience in the city. In addition to 
interviews, they did participant observation in 
neighborhoods in which they had previously 
worked. They quickly learned about women in 
the crack scene. 

Female crack users had previously been por- 
trayed primarily as women who offer sexual 
services in return for small amounts of the drug. 
The ethnographers learned that most of the 
female crack users in Atlanta were not happy 
with this arrangement, and looked for other 
ways to support their habits in a more indepen- 
dent, less demeaning way. The solution for 
many of these users was to become crack deal- 
ers. In fact, some had moved into higher level 
positions in the crack distribution network. 

As women entered the crack-dealing business, 
they became more visible to law enforcement 
which, in turn, resulted in an increase in arrests. 
Once they were arrested and known as dealers, 
their arrests tended to repeat. This shift in 
positions in the crack scene thus resulted in 
increase of women in the arrest statistics. 

But why were these women not being seen in 
drug abuse treatment programs and hospital 
emergency rooms? First, they criticized local 
drug treatment programs for their "male" orien- 
tation. One issue was the lack of child care. 



Many refused to consider drug abuse treatment 
because they would have to leave their children 
for extended periods of time. A more diffuse 
issue had to do with what they called "male" 
treatment styles. 

The crack-using females talked about why they 
avoided the emergency room as well. The issue 
of child care came up here, but more impor- 
tantly, women felt that if they went to an emer- 
gency room, they would be labeled as "drug 
addicts" and the label would increase their 
chances of being arrested once they were back 
on the streets. They wanted to avoid this label, 
especially since the police were increasing 
efforts to arrest crack users and dealers. 

Conducting a short-term ethnography, the 
Atlanta researchers were only able to tap the 
surface of this issue, but they did obtain some 
useful information to help understand the 
differences that were being seen in the indicator 
data. The epidemiologic indicators turned out 
not to be a puzzle at all. Instead, the indicators 
reflected a shift in behaviors. More and more, 
the women were turning to drug dealing and 
feeling negatively about treatment facilities. 

Philadelphia 

With the support and interest of the city health 
services, an ethnographer in Philadelphia 
conducted a study of the city's Puerto Rican 
community. The question was, "Why don't more 
Puerto Rican heroin addicts use treatment 
services?" Arrest data showed that a relatively 
high percentage of Hispanic arrestees had used 
illicit drugs. 

The Philadelphia ethnographer, who was al- 
ready well known for her work with needle 
exchange, went into the community to interview 
and observe. In a relatively short period of time, 
she learned why Puerto Rican heroin addicts 
were less likely than addicts in other racial/ 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



1-1 



ethnic groups to use treatment services. First, an 
obvious language problem existed. Many of the 
interviewees could speak English well, but 
experienced difficulty expressing emotional 
problems and needs. In a fast-paced therapeutic 
environment, many felt that there was no point 
in seeking treatment where communication was 
so difficult. 

A second issue had to do with the boundary 
between the streets and treatment. It was 
learned that entering and leaving treatment was 
more of a social than an individual act. Among 
interviewees, the ethnographers found greater 
treatment success when an addict had family 
support in physically entering a treatment 
program and then when leaving it and return- 
ing to the community. In the Anglo-American 
model, the individual shows up, and once 
treatment is finished returns to the community 
and starts a new life. This lack of social support 
in the transitions was often mentioned by 
Puerto Ricans as problematic. 

A third issue related to sources of information 
about different programs. The city used a variety 
of methods to market treatment services, but the 
most important source of information from the 
addicts' point of view was what they learned 
within their drug-using networks and in places 
where drug addicts congregate, like shooting 
galleries. 

Many other issues were identified by the eth- 
nographer, but these three language, social 
support during transition into and out of treat- 
ment, and source of program information 
exemplify the reasons Puerto Rican addicts were 
not taking advantage of treatment resources and 
not well represented in the treatment data set. 

San Francisco 

An ethnographer in San Francisco assessed risk 
factors for HIV transmission among needle- 
using addicts. The ethnographic team observed 
and interviewed a group of homeless men who 
lived under a freeway overpass in the city. One 
of their first conclusions was how often and how 
routinely users put themselves at risk for HIV. It 



was quickly learned that there was one simple 
economic reason. The average cost for a street 
unit of heroin in that city is $20. Seldom does an 
individual have that much money, so typically 
two to three addicts pool their resources. The 
primary type of heroin in San Francisco is 
Mexican Black Tar, which has to be dissolved 
before it can be divided. This means that, at the 
time of use, shares must be apportioned, and the 
measuring out process involves common imple- 
ments or shared water and cotton. The econom- 
ics of heroin, then, established conditions of HIV 
risk most of the time that the men used. 

San Antonio 

In San Antonio, an ethnographic team assessed 
the transmission and prevention of drug-use 
patterns in the family context among the Mexi- 
can-Americans in that city. Chicano addicts often 
explain use and relapse with the Spanish phrase 
la presion, the "pressure" in English. La presion 
is so taken for granted that community members 
have difficulty explaining what it means. In- 
deed, some ethnography consists of making 
such taken-for- granted aspects of life explicit in 
all their complexity. La presion signals a host of 
external events that can occur, often unpredict- 
ably, usually out of the person's control, that 
impact them and their lives in a negative way. 
Many of the problems that result are a function 
of poverty, since the Chicano addicts usually 
lead lives with no margin for such mistakes to 
occur. 

Baltimore 

In Baltimore, there was an interest in determin- 
ing the relationship between (un)employment 
and drug abuse. An ethnographer in Baltimore 
conducted ethnographic interviews and spent 
time in the neighborhood around a homeless 
shelter. He found that some men, who had 
histories of casual and controlled drug use, had 
found work difficult to locate in Baltimore 
because of economic decline. The loss of em- 
ployment had a deteriorating effect on family 
life, and drug use increased. 

For most of the sample, the story was more 
complicated. Most of the men "juggled" different 



1-2 



Assessing Drug Abuse Within and Across Communities 



identities and had done so for years. They 
worked, had families, and used drugs and 
alcohol in more or less serious ways. They had 
lived for years like this, pushing different work, 
family, and drug identities to the edge, then 
coming back to maintain the balance. For these 
men, employment mattered in a different way. 
With the economic downturn in Baltimore, it 
was not easy to find jobs anymore. Once an 
addict pushed a little too far over the edge in 
one job and lost it, others were difficult to find. 
But the problem was also the structure of the 



Baltimore drug markets. With vertical integra- 
tion and a shift to crack cocaine, the old neigh- 
borhood-based markets for heroin disappeared. 
The men lost their sources of supply and the 
new sources were more violent and impersonal 
than what they had known before. With the loss 
of jobs and the shift in the market, they found 
themselves in a world that no longer allowed 
them to use their experience to manage two 
kinds of identities work and drugs. They be- 
came homeless and turned up in the shelter. 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



1-3 



Appendix J: Sample Format for State Reports 

DRUG ABUSE PATTERNS AND TRENDS IN 
ALEXANDRIA/RAPIDES PARISH 

Regional Office 
State Office of Alcohol and Drug Abuse 

Alexandria, Rapides Parish 

Cocaine/crack and marijuana are the most serious illicit drug abuse problems in Rapides 
Parish and the City of Alexandria. In the period from January 1, 1996 through August 31, 
1997, 59 percent (n=783) of the clients admitted to treatment programs for illicit drug use in 
Rapides Parish were primary cocaine/crack abusers; almost 63 percent were African- American 
(compared with 36 percent whites), 67 percent were male, and almost three- quarters (73.7 
percent) were 30 years of age or over. Primary marijuana abusers accounted for almost 27 
percent of the illicit drug abusers admitted to treatment. More than half (59 percent) were 
white (40 percent were African- American), 62 percent were male, and 73 percent were under 30 
years of age. Twenty-nine people were admitted for primary methamphetamine abuse and only 
9 for primary heroin abuse. Most of the methamphetamine abusers were white (55 percent) and 
male (62 percent). The 1996 Alexandria City Police Arrest Report provides further evidence of 
the cocaine/crack and marijuana problems. Of the 398 adult arrests for drug possession, 57 
percent involved marijuana and 41 percent involved cocaine (including crack). Most of the 
adult marijuana (83 percent) and cocaine (83 percent) possession arrests were African-American. 
There also were 31 adult arrests for the sale or manufacturing of illicit drugs; 58 percent 
involved marijuana and 35 percent involved cocaine and 81 percent of those arrested were 
African- American. In addition, 82 juveniles were arrested for drug-related violations by the 
Alexandria police: 73 for drug possession and 9 for selling or manufacturing drugs. Most (93 
percent) were African-American. Over two-thirds of possession arrests of juveniles involved 
marijuana; 27 percent involved cocaine. 



INTRODUCTION 



1. Area Description 



2. Sources of Data 



Alexandria is located in central Louisiana. 
The population of the city is approximately 
50,000 residents. About half the population is 
African-American and half is white. Accord- 
ing to the 1990 census, 54 percent of the 
population are females. Because the city is 
located in the center of the State, treatment 
programs draw people from other areas of the 
State. 



Treatment Data — Rapides Parish 
Drug Abuse Treatment Admissions 
Data were provided by the State Office 
of Alcohol and Drug Abuse for the 
period from January 1 , 1996 through 
August 31, 1997. 

Rapides Parish Coroner's Office — 

Coroner's reports provided information 



A Guide for Community Epidemiology Survel'leice Networks on Drug Abuse 



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on deaths with positive tests for alco- 
hol and/or drugs. 

Rapides Regional Medical Center — 

This facility reported emergency 
department drug-related incidents but 
could not provide information about 
the specific drugs used. 

Marshal's Office, City of 
Alexandria — The Marshal's Office 
provided data on substance-abuse 
related arrests and convictions for 
motivation (disturbing the peace), 
possession of drug paraphernalia, and 
possession of marijuana. 

Metro Narcotics Task Force — This 
task force provides data on drug- 
related arrests by race/ethnicity. 



Alexandria City Police (FBI Arrest 
Report) — This report covers arrests 
for drug violations including the 
manufact uring/sale and possession of 
different drugs by ethnicity. 

Louisiana Adult Household 
Survey — Alexandria was included 
with Shreveport in this Statewide 
survey. 

1996-1997 Adolescent Survey on 
Pathological Gambling and 
Substance Abuse — Data from this 
survey represent 417 youth in Rapides 
Parish. (Sample sizes for different 
questions vary because of branching 
patterns in the questionnaire.) 



DRUG ABUSE PATTERNS AND TRENDS 



1. Treatment Data 

Cocaine/crack accounted for 3 1 . 1 percent of 
all treatment admissions in Rapides Parish 
during the period from January 1, 1996— 
August 31, 1997, and for 59.3 percent of 
admissions for primary abuse of an illicit drug. 
Almost two-thirds of the primary cocaine/ 
crack admissions were men, 62.8 percent were 
African- American, and 73.7 percent were age 
30 or older (exhibit 1). 

Marijuana accounted for 14 percent of all 
admissions, and for 26.6 percent of admis- 
sions for primary abuse of an illicit drug. 
Nearly three-fourths of the (primary) mari- 
juana abusers were male, 59.4 percent were 
white, and 73.5 percent were age 29 or 



younger, with 38.9 percent being under 20 
years of age. 

Nine admissions were for primary abuse of 
heroin; the majority were male, white, and age 
30 or older. There also were 29 admissions 
for primary abuse of meth amphetamine; the 
majority were male, white, and age 30 or 
older, althougn 12 (41.4 percent) were under 
age 30. 

2. Drug-Related Emergency 
Department Admissions 

The Rapides Regional Medical Center re- 
ported 150 drug-related emergency department 
admissions in 1996. Data on the specific 
drugs were not available. 



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Assessing Drug Abuse Within and Across Communities 



3. Drug-Related Deaths 

The Rapides Parish Coroner's Office reported 
1 1 alcohol-related and 2 drug abuse-related 
deaths in 1997. The types of drugs used were 
reported as "unknown." One drug-related 
death involved an accident, the other a homi- 
cide. 

4. Drug-Related Arrests 

• Marshal's Office, City of Alexandria 

The Marshal's Office reported 157 arrests and 
140 convictions for the possession of drug 
paraphernalia in 1996. In addition, there were 
221 arrests and 205 convictions for marijuana 
possession (exhibit 2). 

• Metro Narcotics Task Force 

In 1996, the Narcotics Task Force reported 
229 drug-related arrests (exhibit 3). Of those 
arrested, 77.3 percent were African- Ameri- 
can, and 21.4 percent were white (1.3 percent 
were of other ethnic backgrounds). Of the 
African-Americans, 83 percent were males. 
Of the white arrestees, 59 percent were male 
and 41 percent female. 

• Alexandria City Police 

The Alexandria Police Department reported 
429 arrests of adults for drug-related viola- 
tions in 1996. The vast majority were male 
(89.3 percent) and African-American (82.7 
percent). There were 163 arrests for posses- 
sion of cocaine and 1 1 for the manufacture/ 
sale of cocaine, as well as 227 arrests for 
marijuana possession and 1 8 for the manufac- 
ture/sale of marijuana. Relatively few of the 
1996 arrests involved other drugs. There were 
five arrests for the possession of synthetic 
narcotics and one for the manufacture/sale of 



synthetic narcotics. There were three arrests 
for the possession of other non-narcotic drugs 
and one arrest for the sale/manufacturing of 
these drugs (exhibit 4). 

Partial data reported for the January 1 through 
August 31 period showed that marijuana and 
cocaine continued to be the most serious drug 
problems among adult arrestees. There were 
95 arrests for marijuana possession and 23 for 
cocaine possession (exhibit 4). 

In 1996, 82 juveniles were arrested for drug 
violations; most of the juveniles (92.7 percent) 
were African- American. Fifty youngsters (48 
boys and 2 girls) were arrested for marijuana 
possession; two boys were arrested for the 
manufacture/sale of marijuana. In addition, 20 
(18 boys and 2 girls) were arrested for cocaine 
possession, and 7 (African-American males) 
for the manufacture/sale of cocaine (exhibit 
5). 

The data for the first 10 months of 1997 
showed similar arrest patterns. There were 19 
arrests of juveniles for marijuana possession 
and 3 marijuana manufacture/sale arrests; all 
were male. There were eight arrests for 
cocaine possession (7 were male and 7 were 
African- American; see exhibit 5). 

5. 1996 Louisiana Adult Household 
Survey 

As noted earlier, Alexandria and Shreveport 
were included together in a region in this 
survey. This area had the highest rate of heavy 
alcohol use (10.2 percent of the respondents) 
and the lowest rate of core illicit drug use (4.7 
percent) during the year prior to the survey. 
("Core" drugs are marijuana/ hashish, halluci- 
nogens, cocaine/crack, and heroin/opiates.) 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



J-3 



6. 1996-1997 Statewide Adolescent 
Survey 

A total of 4 1 7 adolescents from Rapides 
Parish were included in the survey. Almost 66 
percent were female, 69 percent white; the 
mean age of the youth was 14.30. Most (61 
percent) had consumed a full drink of alcohol 
and 47 percent had, reportedly, been drunk. 
Almost 25 percent had been drunk monthly, 
weekly, or daily in the last 12 months. The 
drugs reported as ever used by the youth 
included marijuana (26.9 percent), narcotics 
other than heroin (1 1.5 percent), inhalants 



(12.9 percent), hallucinogens (8.6 percent), 
amphetamines (6 percent), cocaine/crack (4.8 
percent), and heroin (3.1 percent; see exhibit 
6). 

7. Field Data 

There is some evidence that youngsters are 
injecting crack. Intravenous crack use has 
been reported, each week, by two to three 
people entering detoxification in Alexandria. 
A few years ago, field reports indicated that 
youngsters were mixing crack with lemon 
juice to melt the crack) and injecting it. 



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Assessing Drug Abuse Within and Across Communities 



EXHIBIT 1 

TREATMENT ADMISSIONS BY PRIMARY DRUG OF ABUSE, AGE AT 
ADMISSION, RACE/ETHNICITY AND PERCENTAGE— RAPIDES PARISH 



Drug Variable 


Cocaine/ 
Crack 


Heroin 


Marijuana/ 
Hashish 


Methamphetamine 


Alcohol 


Other Drugs/ 
No Data* 


Number 


(783) 


(9) 


(352) 


(29) 


(1,199) 


(148) 


Primary Drug 


31.1 


0.3 


14.0 


1.1 


47.6 


5.9 


Age at Admission 
<20 
20-29 
30-39 
40+ 


2.7 
23.7 
50.7 
23.0 


0.0 
12.5 
50.0 

37.5 


38.9 
34.6 

21.7 
4.9 


20.7 
20.7 
34.5 
24.1 


6.7 
23.2 
37.4 
32.6 


12.8 
37.9 
33.1 
16.2 


Race/Ethnicity 
Caucasian 
African-American 
Other 


36.4 
62.8 

0.8 


66.7 

33.3 

0.0 


59.4 

40.3 

0.3 


55.2 

44.8 

0.0 


61.9 

37.6 
0.5 


90.0 

9.4 
0.6 


Gender 
Male 
Female 


66.7 
33.3 


66.7 
33.3 


75.3 
24.7 


62.1 
37.9 


74.1 
25.9 


47.3 
52.7 



N=2,520 

* No Data=33 

SOURCE: Louisiana State Office of Alcohol and Drug Abuse, January 1, 1996-August 31,1997 



EXHIBIT 2 

NUMBER OF DRUG-RELATED ARRESTS AND CONVICTIONS- 
CITY OF ALEXANDRIA, MARSHAL'S OFFICE, 1996 



Charge 


Arrested 


Convicted 


Disturbing the peace by intoxication 


347 


331 


Possession of drug paraphernalia 


157 


140 


Possession of marijuana 


221 


205 


Total Number 


725 


676 



SOURCE: City of Alexandria, Marshal's Office 



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EXHIBIT 3 

GENDER AND RACE/ETHNICITY OF PERSONS ARRESTED 

FOR DRUG-RELATED OFFENSES BY THE METRO 

NARCOTICS TASK FORCE, 1996 



Gender 


Race/Ethnicity 


African-American 


Caucasian 


Other 


Total 


(Number) 


(177) 


(49) 


(3) 


(229) 


Male 


64.2 


12.7 


0.9 


77.7 


Female 


13.1 


8.7 


0.4 


22.3 



SOURCE: Metro Narcotics Task Force 



EXHIBIT 4 

DRUG-RELATED* ADULT ARRESTS BY TYPE OF ARREST, GENDER, AND RACE/ETHNICITY— 

ALEXANDRIA CITY, 1996-1997** 



Type of Arrest 


Males 


Females 


African-American 


White/Other 


1996 


1997 


1996 


1997 


1996 


1997 


1996 


1997 


(Total Violations) 


(383) 


(108) 


(46) 


(16) 


(355) 


(81) 


(74) 


(43) 


Sale/Manufacture 
Cocaine 
Marijuana 
Synthetic Narcotics 
Other Non-Narcotics 


11 

17 
1 










1 


1 








10 
15 










1 

3 
1 
1 








Possession 
Cocaine 
Marijuana 
Synthetic Narcotics 
Other Non-Narcotics 


142 

205 

5 

2 


18 
85 

3 
2 


21 

22 

1 


5 

10 

1 


135 
188 

5 
2 


15 

62 
3 
1 


28 
39 



1 


8 

33 

2 



*Excludes alcohol-related arrests: 320 in 1996, 185 in 1997; 97 percent were DWI in 1996. All were DWI in 1997 

**January 1-August31, 1997 

***"Other" includes only 2 persons charged with possession (1 cocaine, 1 marijuana) in 1996 

SOURCE: Alexandria City Police FBI Arrest Report 



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Assessing Drug Abuse Within and Across Communities 



EXHIBIT 5 

NUMBER OF DRUG-RELATED* JUVENILE ARRESTS BY TYPE OF 
ARREST, GENDER, AND RACE/ETHNICITY— ALEXANDRIA CITY, 1996-1997** 



Type of Arrest 


Males 


Females 


African-American 


White 


1996 


1997 


1996 


1997 


1996 


1997 


1996 


1997 


(Total Violations) 


(78) 


(31) 


(4) 


(1) 


(76) 


(27) 


(6) 


(5) 


Sale/Manufacture 
Cocaine 
Marijuana 


7 

2 



3 











7 
2 




3 










Possession 
Cocaine 
Marijuana 
Synthetic Narcotics 
Other Non-Narcotics 


18 
48 

3 


7 
19 
1 

1 


2 
2 




1 






19 
46 

2 


7 
17 




1 

4 


1 


1 

2 

1 
1 



*Excludes 8 alcohol-related arrests in 1996; 7 were DWI arrests 
**January 1-August31, 1997 

SOURCE: Alexandria City Police FBI Arrest Report 



EXHIBIT 6 



SUBSTANCE USE AMONG ADOLESCENTS AURVEYED— RAPIDES PARISH 



"Ever Tried" 


Percent "Yes" (Rounded) 


Marijuana 

(Drugs other than marijuana) 
Cocaine/Crack 
Heroin 

Other Narcotics 
Tranquilizers 
Hallucinogens 
Amphetamines 
Barbiturates 
Over-the counter drugs 
Someone else=s prescribed drug 
Alcohol (a "full drink") 
Tobacco products 
"Huffing'' (sniffing drugs) 


26.9 

(29.5) 

4.8 

3.1 

11.5 

5.8 

8.6 

6.0 

2.9 

21.6 

12.7 

61.4 

57.3 

12.9 


Ever Been Drunk 

Drunk in last 12 months 
Monthly or more often 


47.0 
24.9 


Mean 


Age first tried marijuana 


1 3 55 


Age at first drink (alcohol I 


10.93 


Age first drunk 


12.50 



N=147 full sample; 398-41 1 on substance abuse questions 

SOURCE: Statewide Adolescent Survey on Pathological Gambling and Substance Abuse (6th through 1 2th grades) School Year 1 996-97 



A Guide for Community Epidemiology Surveillance Networks on Drug Abuse 



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