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News and Notes   |    
Psychiatric Services 1999; doi:
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Findings from the 1998 National Household Survey on Drug Abuse show that use of illicit drugs declined slightly in the overall U.S. population from 1997 to 1998. However, use of illicit drugs decreased significantly among youths age 12 to 17, primarily due to a reduction in the use of inhalants.

The survey findings were released in August by the Substance Abuse and Mental Health Services Administration. The survey estimates rates of use of a variety of illicit drugs, alcohol, cigarettes, and other forms of tobacco. The results are based on interviews with a nationally representative sample of civilians age 12 and older who live outside of institutions. A sample of 25,500 persons was interviewed for the 1998 survey.

In 1998 an estimated 13.6 million Americans had used an illicit drug in the month before the survey interview. This number represents 6.2 percent of the population age 12 and older and is slightly less than the 13.9 million estimate for 1997. The number of current illicit drug users in 1998 was about half its peak in 1979, when an estimated 25 million Americans were current users.

Marijuana was the most frequently used illicit drug in 1998. About 60 percent of current illicit drug users reported marijuana use only, and another 21 percent reported use of marijuana and other illicit drugs.

The estimated rate of current illicit drug use among youths age 12 to 17 in 1998 was 9.9 percent, significantly lower than the rate of 11.4 percent in 1997. The rate of use of any illicit drug by youths has fluctuated since 1995; it was 10.9 percent in that year and 9 percent in 1996.

Reduced use of inhalants accounted for most of the decrease between 1997 and 1998. In 1998, 1.1 percent of youths reported current use of inhalants, compared with 2 percent in 1997, a significant difference. Nonsignificant decreases also occurred in the percentage of youths reporting current use of other drugs, including marijuana—down to 8.3 percent in 1998 from 9.4 percent in 1997.

The rate of illicit drug use among youths was higher among those who currently used cigarettes or alcohol. In 1998, 3.4 percent of youths who were nonsmokers used illicit drugs, compared with 39.1 percent of youths who used cigarettes. Among youths who were heavy drinkers—those who had five or more drinks on one occasion five or more days in the last month—68.5 percent were also users of illicit drugs. Among nondrinkers, only 2.9 percent were current illicit drug users.

In 1998 the rate of current illicit drug use among blacks (8.2 percent) was somewhat higher than among whites (6.1 percent) and Hispanics (6.1 percent), although the three groups did not differ appreciably in rates of use among youths age 12 to 17.

An estimated 113 million Americans—52 percent of the population age 12 and older—reported current use of alcohol in 1998. The rate of binge drinking in the overall population was 29.2 percent, and the rate of heavy alcohol use was 10.6 percent. The percentages of the population in these groups have not changed since 1988. The rate of alcohol use among young people age 12 to 20 was 9.2 percent, representing an estimated 10.4 million underage drinkers. Of this group, 5.1 million engaged in binge drinking (48.5 percent) and 2.3 million were heavy drinkers (21.9 percent). No statistically significant changes in rates of underage drinking have occurred since 1994.

The 1998 survey report included retrospective data on first-time use of substances in 1997. The rate of first use of marijuana among youths age 12 to 17 declined significantly in 1997 to 64 per thousand potential new users from 79 per thousand potential new users in 1996. An estimated 81,000 persons used heroin for the first time in 1997. The rate of first use of heroin among young people age 12 to 25 during the period from 1994 to 1997 was at the highest level since the early 1970s. The rate of new use of cocaine among youths age 12 to 17 was 10.8 per 1,000 potential new users in 1997, a rate similar to the high initiation rates of the early 1980s. There were an estimated 1.1 million new users of hallucinogens in all age groups in 1997. The rate of new users of hallucinogens among youths age 12 to 17 was 23.9 per 1,000 potential new users.

Of the estimated 23.1 million persons who used an illicit drug during 1998, 1.9 million reported some health problem due to their illicit drug use and 3.5 million reported an emotional or psychological problem due to drug use. An estimated 4.1 million people met diagnostic criteria for dependence on illicit drugs in 1997 and 1998, including 1.1 million youths age 12 to 17. An estimated 963,000 people had received treatment or counseling for their drug use.

The Substance Abuse and Mental Health Services Administration has made major changes in the design of the 1999 National Household Survey on Drug Abuse. Use of computer-assisted interviewing was initiated, and the sample was expanded to 70,000 interviews. The new system will have the capability of providing state-level estimates of the prevalence of substance use. Results of the 1999 survey will be released next summer.

More information about the results of the 1998 survey, including detailed tables, can be found on the Web site of the Substance Abuse and Mental Health Services Administration at www.samhsa.gov.

Most Illicit Drug Users Are Employed Full Time

Seventy percent of respondents to the 1997 National Household Survey on Drug Abuse who reported that they had used illicit drugs in the past month also reported that they were employed full time. Workers who reported that their workplace did not have a written policy addressing alcohol or drug use were more than twice as likely to say they used illicit drugs as were workers in workplaces with a written policy.

The findings are based on data from 7,957 full-time workers age 18 to 49 who responded to the 1997 survey. About 7.7 percent of those respondents reported current illicit drug use, and 7.6 percent reported heavy alcohol use. Projected to the U.S. population, the figures suggest that about 6.3 million full-time workers currently use illicit drugs, and about 6.2 million are heavy alcohol users.

Rates of illicit drug use and heavy alcohol use were highest among 18- to 25-year-olds, males, whites, and those with less than a high school education. Occupational categories with higher rates of illicit drug use included food preparation workers, waiters, and bartenders (19 percent); construction workers (14 percent); workers in other service occupations (13 percent); and transportation and material moving workers (10 percent). Rates of heavy alcohol use were higher for food preparation workers, waiters, and bartenders (15 percent); handlers, helpers, and laborers (14 percent); and construction workers (12 percent).

Highlights of the survey findings on workers' drug use are available from the Web site of the Substance Abuse and Mental Health Services Administration (www.samhsa.gov).

A review of managed care mental health carve-out plans for Medicaid beneficiaries in four states found that the plans lacked systematic federal oversight but that all states took steps to ensure that services were accessible and to monitor their quality.

The General Accounting Office (GAO), the investigative arm of Congress, conducted the review at the request of Senators Edward M. Kennedy (D.-Mass.) and Paul Wellstone (D.-Minn.), who were concerned about Medicaid beneficiaries' access to appropriate mental health services under managed care.

GAO selected four states for intensive analysis—Colorado, Iowa, Massachusetts, and Washington—out of the 30 states that used Medicaid waivers for managed mental health services when the review began. All four states had implemented their managed care programs before January 1996 and had experienced more than one round of the contracting cycle with public or private managed care organizations.

In all the states the mental health carve-outs limited Medicaid beneficiaries to a single prepaid mental health plan. However, the states generally tried through contractual provisions to ensure that beneficiaries could choose their providers from within the plan's network and sometimes outside the network.

The states also set standards in their contracts for determining appropriate levels of services, using broad definitions of medical necessity, and generally reduced or eliminated requirements for prior authorization for access to outpatient care. The states generally expanded the range of covered community-based mental health services compared with their previous fee-for-service programs and reduced the use of inpatient services. To discourage the underprovision of services, the states also capped the profits, losses, or administrative expenditures of the contracting organizations. Colorado and Iowa required the organizations to invest a portion of the profits (or savings, if they were not-for-profit agencies) in new community-based mental health services.

The states monitored the quality of the carve-out plans using approaches based on federal laws and Health Care Financing Administration (HCFA) regulations, GAO reported. These regulations covered quality assurance systems, grievance and appeals systems, medical audits, independent assessments of waiver programs, and data requirements.

The states supplemented these monitoring activities with other strategies, in part because the HCFA regulations were not focused specifically on mental health programs. GAO described the approach in Colorado and Washington State as generally "hands on." Colorado officials made regular site visits to each plan and also conducted annual programmatic site reviews of participating community mental health centers. In Washington, administrative and clinical teams conducted annual reviews of the state's county-based plans. The plans were required to have an independent team of consumers and family members visit each service location at least once a year to conduct focus groups with consumers, family members, social services staff, and community representatives.

Massachusetts and Iowa relied heavily on performance measures to monitor the contracting organizations, attaching financial incentives and sometimes penalties, GAO reported. Massachusetts established 20 performance measures in its carve-out plan, including medication monitoring after discharge, providing notification of hospitalization to the outpatient primary care physician, aftercare planning, and intensive case management for persons with both a psychiatric and a substance abuse diagnosis.

Both HCFA and state officials told GAO investigators that HCFA had minimal criteria for evaluating and overseeing Medicaid mental health carve-outs, and that HCFA regional staff had limited expertise or experience in mental health and managed care issues. Recognizing this problem, HCFA now routinely asks the staff of the Substance Abuse and Mental Health Services Administration to review and comment on all Medicaid waiver applications involving mental health. In addition, HCFA is developing a rule requiring carve-out organizations to have annual external quality reviews and is preparing a draft report to Congress on safeguards needed for individuals with special health care needs who are enrolled in managed care.

The report, entitled Medicaid Managed Care: Four States' Experiences With Mental Health Carve-Out Programs, is available on the Internet at www.gao.gov.



Free clozapine: Zenith Goldline Pharmaceuticals is offering free clozapine for indigent patents who are either unable to pay for the medication or who are awaiting financial assistance such as Medicaid. Psychiatrists, nurses, case managers, and pharmacists can enroll patients in the program by calling the Zenith Goldline Clozapine ALERT Program registry at 800-507-8334 and requesting a telephone transfer to the Clozapine Patient Assistance Program administrator. The administrator will record the patient's initials, Social Security number, the physician's Drug Enforcement Administration number, and the patient's average daily dosage and will arrange for an eight-week supply of clozapine to be sent to a registered pharmacy, at no charge. Patients can receive the free drug without submitting to means testing, filling out forms, or completing an application. As of late September, more than 23,000 patients and 7,500 physicians had registered in the program.

Parity in California: A new law that ensures parity in insurance coverage for mental illness has been signed by California Governor Gray Davis, bringing to 28 the number of states that have enacted parity laws. Fifty-four percent of Americans live in states with parity laws, and 120 million are covered by parity. The California law requires health plans to cover adults and children with the most severe mental illnesses, including schizophrenia, bipolar disorder, major depression, schizoaffective disorder, panic disorder, obsessive-compulsive disorder, autism, anorexia nervosa, and bulimia nervosa. Beginning in July 2000, health maintenance organizations and insurers must provide equitable copayments, deductibles, and maximum lifetime benefits.

Minority research training: The American Psychiatric Association's Program for Minority Research Training in Psychiatry (PMRTP) supports training of minority medical students, psychiatric residents, and fellows who are interested in research by providing advice, placement assistance, tuition, stipends, financial support for travel, and funds for other expenses. The program, funded by the National Institute of Mental Health, is directed by James Thompson, M.D., APA deputy medical director. For more information, contact Ernesto Guerra, Project Manager, PMRTP, APA, 1400 K Street, N.W., Washington, D.C. 20005; phone, 800-852-1390; e-mail, eguerra@psych.org.



Appointment:Joseph Autry III, M.D., has been appointed deputy administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA) in Rockville, Maryland. He joined the staff of SAMHSA's Center for Substance Abuse Prevention in 1990 and was acting deputy administrator at SAMHSA at the time of his appointment.

Awards:E. Fuller Torrey, M.D., of Bethesda, Maryland, is the recipient of the 1999 Humanitarian Award from the National Alliance for Research on Schizophrenia and Depression (NARSAD). The award was presented October 15 in New York City. Dr. Torrey is a founder of the National Alliance for the Mentally Ill and the author or editor of more than a dozen books dealing with schizophrenia. His research on schizophrenia in identical twins demonstrated a strong genetic link in the development of the disorder.

Other NARSAD award recipients were Salomon Z. Langer, Ph.D., of Paris, France, and Richard J. Wyatt, M.D., of Bethesda, Maryland, who shared the Lieber Prize for outstanding research achievements in schizophrenia. Frederick K. Goodwin, M.D., of Washington, D.C., and Husseini K. Manji, M.D., of Detroit shared the Nola Maddox Falcone Prize for outstanding achievements in research on affective disorders.

Dr. Langer is a researcher with Synthelabo Recherche whose work, in partnership with the Pasteur Institute in Paris, has led to the development of more finely tuned medication for schizophrenia. Dr. Wyatt, chief of the neuropsychiatry branch of the National Institute of Mental Health, is a leading researcher on the clinical and epidemiological aspects of schizophrenia. Dr. Goodwin, professor of psychiatry at George Washington University Medical Center, is a former director of the National Institute of Mental Health and an authority on depressive disorders. Dr. Manji, a 1997 recipient of a NARSAD Independent Investigator Award, directs Wayne State University's clinical research division on schizophrenia and mood disorders.




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