Search

The spread of illegally manufactured opioids, including fentanyl, has brought unprecedented levels of drug overdose deaths in North America. In some markets, illegally manufactured fentanyl (IMF) is essentially displacing heroin, not just being used to adulterate it. It is not possible at this time to provide an accurate point estimate of the amount of IMF consumed in the United States. Yet for various purposes (e.g. assessing changes in production levels and the appropriate role for various supply reduction efforts), it is important to have a sense of scale. This article provides guidance through two thought experiments that provide a hypothetical upper bound on U.S. consumption. The first considers a scenario in which IMF replaces heroin in all illegal opioid markets. The second starts with the number of individuals with an opioid use disorder and considers what total consumption would be if IMF was the only opioid they consumed. Both calculations suggest it is unlikely that the annual consumption of IMF in 2021 could have been more than single digit pure metric tons. For comparison, the most recent best estimates of the amount of cocaine and heroin consumed in the U.S. are 145 and 47 pure metric tons, respectively. The article also raises questions about the limitations of using traditional equianalgesic morphine equivalent dose conversions to estimate the total market consumption of IMF.

Synthetic opioids, mostly illegally manufactured fentanyl (IMF), were mentioned in 60% of United States (US) drug overdose deaths in 2020, with dramatic variation across states that mirrors variation in IMF supply. However, little is known about IMF markets in the United States and how they are changing. Researchers have previously used data from undercover cocaine, heroin, and methamphetamine purchases and seizures to examine how their use and related harms respond to changes in price and availability. This analysis used US Drug Enforcement Administration (DEA) data to address two questions: (i) "To what extent does IMF supply vary over time and geography?" and (ii) "What has happened to the purity-adjusted price of IMF?"We developed descriptive statistics and visualizations using data from 66 713 observations mentioning IMF and/or heroin from the DEA's System to Retrieve Information from Drug Evidence (STRIDE; now STARLIMS) from 2013 to 2021. Price regressions were estimated with city-level fixed effects examining IMF-only powder observations with purity and price information at the low-to-medium wholesale level (1 g to ≤100 g; n = 964).From 2013 to 2021, the share of heroin and/or IMF observations mentioning IMF grew from near zero to more than two-thirds. The share of heroin observations also containing IMF grew from1% to ~40%. There is important geographic variation: in California, most IMF seizures involved counterfeit tablets, whereas New York and Massachusetts largely involved powder formulation. The median price per pure gram of IMF powder sold at the10 to ≤100 g level fell by more than 50% from 2016 to 2021; regression analyses suggested an average annual decline of 17% (P 0.001). However, this price decline appears to have been driven by observations from the Northeast.Since 2013, the illegally manufactured fentanyl problem in the United States has become more deadly and more diverse.

Objective: To determine the prevalence estimate of U.S. adults who knew someone who experienced a fatal drug overdose and how disruptive these were.Methods: Wave 14 (February-March 2023) of the online RAND American Life Panel, a longstanding nationally representative survey of 2,072 U.S. adults aged 18 and older was utilized with the addition of new questions about knowing someone who died of a drug overdose.Results: In weighted analyses, 42.4% of respondents reported knowing at least one person who died by overdose with a mean number of 2.88 for those who knew anyone who had overdosed. More than a third reported the overdose disrupted their lives to some degree.Conclusions: A large proportion of American adults have been exposed to the overdose death of someone with whom they had a personal relationship. The accelerating rate of overdose deaths have likely increased the number of people bereaved. Policy implications: It is necessary to determine intervention and support needs after overdose deaths as may have an impact on future overdoses and mental health concerns in this population.

BACKGROUND AND AIMS: There is little information on consumption patterns across the diverse range of cannabis product types. This paper examines trends in consumption patterns in Canada and the United States (US) between 2018-2020. DESIGN: Repeat cross-sectional surveys were conducted as part of the International Cannabis Policy Study online survey in 2018 (n=27,024), 2019 (n=45,426), and 2020 (n=45,180). SETTING: Respondents were recruited from commercial panels in Canada and US states that had and had not legalized non-medical cannabis (US 'legal' and 'illegal' states, respectively). PARTICIPANTS: Respondents were male and female participants aged 16-65 years. MEASUREMENTS: Data on frequency and consumption amounts were collected for nine types of cannabis products, including dried flower and processed products (e.g., oils and concentrates). Consumers were also asked about mixing cannabis with tobacco. Socio-demographic information was collected. FINDINGS: Dried flower was the most commonly used product, although use in the past 12 months declined between 2018 and 2020 in Canada (81% to 73%), US legal (78% to 72%) and illegal states (81% to 76%; p

Background and objectives To expand on epidemiologic studies examining associations between the legalization of recreational cannabis and use among young adults, we examined the associations between licensed and unlicensed cannabis outlet density and cannabis outcomes. Methods A total of 1097 young adults aged 21 and older living in Los Angeles County were surveyed before licensed recreational cannabis outlets opened (Time 1: July to December 2017) and after (Time 2: July 2018 to June 2019). Using a database of open licensed and unlicensed cannabis retailers to calculate individual-level cannabis outlet density measures, we examined associations between outlet density within a 4-mile radius of participants' residences with Time 2 outcomes of any past-month use, daily use, intentions to use, quantity used, consequences, and cannabis use disorder (CUD) symptoms. Results After controlling for demographic factors and cannabis outcomes at a time point prior to their opening (Time 1), licensed cannabis outlets were associated with young adults' cannabis use, heavy use, and intentions, and unlicensed outlets were associated with young adults' heavy cannabis use and CUD symptoms. Conclusion and scientific significance This study expands beyond studies of outlet prevalence to find that, after controlling for outcomes 1 year prior, licensed and unlicensed outlets were associated with young adults' cannabis outcomes. The current study is among the first to find associations between cannabis use outcomes and density of cannabis outlets among young adults using data from two time points: preopening and postopening of recreational cannabis retailers. Findings can inform policies around the density and placement of cannabis outlets. (Am J Addict 2020;00:00-00).

Background and aims Debates regarding lowering the blood alcohol concentration (BAC) limit for drivers are intensifying in the United States and other countries, and the World Health Organization recommends that the limit for adults should be 0.05%. In January 2016, Uruguay implemented a law setting a zero BAC limit for all drivers. This study aimed to assess the effect of this policy on the frequency of moderate/severe injury and fatal traffic crashes. Design A quasi-experimental study in which a synthetic control model was used with controls consisting of local areas in Chile as the counterfactual for outcomes in Uruguay, matched across population counts and pre-intervention period outcomes. Sensitivity analyses were also conducted. Setting Uruguay and Chile. Cases Panel data with crash counts by outcome per locality-month (2013-2017). Intervention and comparator A zero blood alcohol concentration law implemented on 9 January 2016 in Uruguay, alongside a continued 0.03 g/dl BAC threshold in Chile. Measurements Per-capita moderate/severe injury (i.e. moderate or severe), severe injury and fatal crashes (2013-2017). Findings Our base synthetic control model results suggested a reduction in fatal crashes at 12 months [20.9%; P-value = 0.018, 95% confidence interval (CI) = -0.340, -0.061]. Moderate/severe injury crashes did not decrease significantly (10.2%, P = 0.312, 95% CI = -0.282, 0.075). The estimated effect at 24 months was smaller and with larger confidence intervals for fatal crashes (14%; P = 0.048, 95% CI = -0.246, -0.026) and largely unchanged for moderate/severe injury crashes (-9.4%, P = 0.302, 95% CI = -0.248, 0.058). Difference-in-differences analyses yielded similar results. As a sensitivity test, a synthetic control model relying on an inferior treatment-control match pre-intervention (measured by mean squared error) yielded similar-sized differences that were not statistically significant. Conclusions Implementation of a law setting a zero blood alcohol concentration threshold for all drivers in Uruguay appears to have resulted in a reduction in fatal crashes during the following 12 and 24 months.

Background Overdose deaths related to illegal drugs in North American markets are now dominated by potent synthetic opioids such as fentanyl, a circumstance foreshadowed by often-overlooked events in Estonia since the turn of the century. Market transitions generate important and far-reaching implications for drug policy. Argument and analysis The supplier-driven introduction of illegally manufactured synthetic opioids into street opioids is elevating the risk of fatal overdose. Using the most recent overdose mortality and drug seizure data in North America, we find that overdose deaths and seizures involving synthetic opioids are geographically concentrated, but this might be changing. Examination here suggests that in some places fentanyl and its analogues have virtually displaced traditional opioids, such as heroin. The concealing of synthetic opioids in powders sold as heroin or pressed into counterfeit medications substantially increases harms. The nature and scale of the challenge posed by synthetic opioids is unprecedented in recent drug policy history. Conclusions There is urgent need for policy and technological innovation to meet the challenges posed by illegally produced synthetic opioids. Novel interventions worth examining include supervising drug use, proactively deterring on-line distribution and new technologies aimed at improving transparency, such as point-of-use drug content testing. Continuing to approach this problem only with existing policies and available methods, such as naloxone, is unlikely to be enough and will result in many premature deaths.

Evaluates a large-scale effort to significantly increase certainty and celerity of sanction for an offense while keeping severity low.

This study examines the associations of 24/7 sobriety programs with reduced alcohol-involved offenses.

Background: A number of jurisdictions are considering or implementing different options for cannabis law reform, including New Zealand. Multi-Criteria Decision Analysis (MCDA) helps facilitate the resolution of complex policy decisions by breaking them down into key criteria and drawing on the combined knowledge of experts from various backgrounds.Aims: To rank cannabis law reform options by facilitating expert stakeholders to express preferences for projected reform outcomes using MCDA.Methods: A group of cannabis policy experts projected the outcomes of eight cannabis policy options (i.e., prohibition, decriminalization, social clubs, government monopoly, not-for-profit trusts, strict regulation, light regulation, and unrestricted market) based on five criteria (i.e., health and social harm, illegal market size, arrests, tax income, treatment services). A facilitated workshop of 42 key national stakeholders expressed preferences for different reform outcomes and doing so generated relative weights for each criterion and level. The resulting weights were then used to rank the eight policy options.Results: The relative weighting of the criteria were: "reducing health and social harm " (46%), "reducing arrests " (31%), "reducing the illegal market " (13%), "expanding treatment " (8%) and "earning tax " (2%). The top ranked reform options were: "government monopoly " (81%), "not-for-profit " (73%) and "strict market regulation " (65%). These three received higher scores due to their projected lower impact on health and social harm, medium reduction in arrests, and medium reduction in the illegal market. The "lightly regulated market " option scored lower largely due its projected greater increase in health and social harm. "Prohibition " ranked lowest due to its lack of impact on reducing the number of arrests or size of the illegal market.Conclusion: Strictly regulated legal market options were ranked higher than both the current prohibition, and alternatively, more lightly regulated legal market options, as they were projected to minimize health and social harms while substantially reducing arrests and the illegal market.

In Uruguay, residents age 18 and older seeking legal cannabis must register with the government and choose one of three supply mechanisms: self-cultivation, non-profit cannabis clubs or pharmacies. This is the first paper to measure the association between type of legal cannabis supply mechanism and traffic crashes involving injuries.Ecological study using ordinary least squares regression to examine how department-level variation in registrations (overall and by type) is associated with traffic crashes involving injuries.Uruguay.532 department-quarters.Quarterly cannabis registration counts at the department level and incident-level traffic crash data were obtained from government agencies. The analyses controlled for department-level economic and demographic characteristics and, as a robustness check, we included traffic violations involving alcohol for departments reporting this information. Department-level data on crashes, registrations and alcohol violations were denominated by the number of residents ages 18 and older.From 2013 to 2019, the average number of registrations at the department-quarter level per 10 000 residents age 18 and older for self-cultivation, club membership and pharmacy purchasing were 17.7 (SD = 16.8), 3.6 (SD = 8.6), and 25.1 (SD = 50.4), respectively. In our multivariate regression analyses, we did not find a statistically significant association between the total number of registrations and traffic crashes with injuries (β = -0.007; P = 0.398; 95% CI = -0.023, 0.01). Analyses focused on the specific supply mechanisms found a consistent, positive and statistically significant association between the number of individuals registered as self-cultivators and the number of traffic crashes with injuries (β = 0.194; P = 0.008; 95% CI = 0.058, 0.329). Associations for other supply mechanisms were inconsistent across the various model specifications.In Uruguay, the number of people allowed to self-cultivate cannabis is positively associated with traffic crashes involving injuries. Individual-level analyses are needed to assess better the factors underlying this association.

Background and aims Supervised consumption sites (SCS) operate in more than 10 countries. SCS have mostly emerged as a bottom-up response to crises, first to HIV/AIDS and now overdose deaths, in ways that make rigorous evaluation difficult. Opinions vary about how much favorable evidence must accumulate before implementation. Our aim was to assess the nature and quality of evidence on the consequences of implementing SCS. Methods We reviewed the higher-quality SCS literature, focusing on articles evaluating natural experiments and mathematical modeling studies that estimate costs and benefits. We discuss the evidence through the lens of three types of decision-makers and from three intellectual perspectives. Results Millions of drug use episodes have been supervised at SCS with no reported overdose deaths; however, uncertainties remain concerning the magnitude of the population-level effects. The published literature on SCS is large and almost unanimous in its support, but limited in nature and the number of sites evaluated. It can also overlook four key distinctions: (1) between outcomes that occur within the facility and possible spillover effects on behavior outside the SCS; (2) between effects of supervising consumption and the effects of other services offered, such as syringe or naloxone distribution; (3) between association and causation; and (4) between effectiveness and the cost-effectiveness of SCS compared to other interventions. Conclusions The causal evidence for favorable outcomes of supervised consumption sites is minimal, but there appears to be little basis for concern about adverse effects. This raises the question of how context and priors can affect how high the bar is set when deciding whether to endorse supervised consumption sites. The literature also understates distinctions and nuances that need to be appreciated to gain a rich understanding of how a range of stakeholders should interpret and apply that evidence to a variety of decisions.

Police–community relations are strained in the United States, especially along racial lines. This paper assesses community perceptions of crime and the police before and after the implementation of...

Background Cannabis social equity programs intend to redress inequities experienced by low income and Black, Indigenous, and People of Color (BIPOC) during cannabis prohibition in the United States. In Los Angeles County (LA), the approach is to increase cannabis outlet licensure and employment for low income and BIPOC communities. Monitoring locations of both licensed and unlicensed outlets over time is critical to informing how local social equity programs may affect communities. Methods We identified locations of licensed and unlicensed cannabis outlets in LA, from February to April 2019 and again from March to April 2020, and calculated the number and type of outlets by socio-demographic characteristics of census tracts (race/ethnicity, poverty, education, unemployment) using the 2013–2017 American Community Survey 5-year estimates. Results Licensed outlets increased in LA from 162 in 2019 to 195 in 2020; unlicensed outlets decreased from 286 to 137 over the same time period. In 2020, more licensed outlets were in tracts with majority white residents and adults with at least a bachelor’s degree; fewer licensed outlets were in tracts with larger Latinx or Black populations, whereas 71% of unlicensed outlets in 2020 were in low-income tracts, and more unlicensed outlets were in predominately Latinx tracts, high poverty and high unemployment tracts, and tracts with more single female-headed households. Conclusions Neighborhood-level analyses are an important first step, but more data are needed for comprehensive evaluations of social equity programs—from individual businesses to the communities living nearby—to understand the impacts on low income and BIPOC populations.

Cannabis policy is developing faster than empirical evidence about policy effects. With a panel of experts in substance use policy development and research, we identified key cannabis policies and their provisions enacted by U.S. states; rated their theoretical efficacy in a restrictive form for reducing problematic use and impaired driving in the context of a recreational cannabis market as judged by experts; and rated the strength of evidence for each policy.Using a modified Delphi approach, 9 panelists rated the comparative efficacy of 18 state cannabis policies for reducing youth use of cannabis, excessive cannabis use among the general population, and cannabis-impaired driving. Each outcome was rated separately using a Likert scale, and panelists also rated the strength of evidence supporting each efficacy rating. Investigators provided descriptions of each policy so that the nine panelists had similar conceptions of each policy.State monopoly (state owns all production, manufacturing, wholesale, and retail operations) was rated as the most effective policy for all three outcome areas. Restrictions on retail physical availability, taxes, retail price restrictions, and retail operations restrictions were also highly rated for all three outcomes. Policies regulating cannabis businesses and products were judged more effective than policies targeting consumer use and behavior. Panelists reported there was little or no direct evidence from the cannabis policy literature for most of the included policies.These ratings can facilitate research as well as policy-making decisions. A relatively small number of policies were judged to be highly effective across all three domains, indicating that for the most part adult excessive use, youth use, and impaired driving can all be reduced with the same set of policies; these policies tended to target the behaviors of businesses rather than consumers. The low levels of direct evidence available to inform policy ratings, as reported by the policy panelists, makes clear the need for ongoing and sustained cannabis policy research.

Background Illegally manufactured potent synthetic opioids (IMPSO) like fentanyl have contributed to rises in overdose deaths in parts of North America and Europe. While many of these substances are produced in Asia, there is little evidence they have entered markets there. We consider the susceptibility to IMPSO’s encroachment in markets in the Asia-Pacific region. Methods Our analysis focuses on Australia, China, India, and Myanmar. Using a mixed-methods approach comprising interviews, literature review, and secondary data analyses, we examine factors facilitating or impeding incursion of IMPSO. Finally, we illustrate the potential for IMPSO fatalities in Australia. Results Australia reports some signs of three facilitating factors to IMPSO’s emergence: 1) existing illicit opioid markets, 2) disruption of opioid supply, and 3) user preferences. The other three countries report only existing illicit opioid markets. While diverted pharmaceutical opioids are a noted problem in Australia and India, heroin is the dominant opioid in all four countries. There are divergent trends in heroin use, with use declining in China, increasing in India, and stable in Australia and Myanmar. If IMPSO diffused in Australia as in North America from 2014 to 2018, and our assumptions generally hold, deaths from IMPSO could range from 1500–5700 over a five-year period. Conclusions This analysis and illustrative calculations serve as an early indication for policymakers. With the exception of Australia, many countries in the region fail to properly record overdose deaths or monitor changes in local drug markets. Early assessment and monitoring can give officials a better understanding of these changing threats.

Reducing substance use among individuals subject to community supervision is an important goal for many judges and community corrections officers. Some jurisdictions have had success by ordering justice-involved individuals to frequent substance use testing with swift, certain, and fair (SCF) sanctions for non-compliance. South Dakota’s 24/7 Sobriety program is one example of a SCF program that has also been adopted statewide in Montana, North Dakota, and other jurisdictions. As other entities outside the Great Plains attempt to adopt the 24/7 approach, there is a need to examine how the program is implemented. This paper examines a 24/7-inspired pilot program that was implemented in a southwestern county in the US in 2018. Data on participation rates and testing results for the 6-month pilot program were examined. Using a semi-structured interview protocol with questions that were adapted from the Consolidated Framework for Implementation Research (CFIR) interview guide, we interviewed nine individuals from six stakeholder groups: 1) Court, 2) District Attorney, 3) Public Defender, 4) Probation, 5) Sheriff, and 6) the non-profit organization that administered the testing. There were important differences in how the program was implemented in the county versus South Dakota’s 24/7 program—namely, there was a different target population, participation was voluntary, and testing was conducted in a different setting which increased costs. While county stakeholders decided to discontinue the program after the pilot period, it was able to implement a SCF program and overcome many of the challenges it confronted. There is some interest in exploring implementation of the SCF with those arrested for driving under the influence of alcohol in the county. For jurisdictions considering the implementation of an SCF program, it makes sense to start with a pilot program with pre-determined objectives and timeline for consistency. It is also crucial to hold regular meetings with all relevant stakeholders before and during the pilot to address context-specific challenges. Conducting an implementation analysis of this process based on the CFIR guide can be useful for understanding why the pilot was a success or failure, and how it may be improved.

Evaluate the deterrent effect of a program that increases the certainty and celerity of sanction for arrestees ordered to abstain from alcohol and other drugs on substance-impaired driving arrests. We examine participant compliance with orders to abstain from alcohol and other drug use via breathalyzer, body-worn continuous alcohol monitoring devices, transdermal drug patches, and urinalyses. We then evaluate the impact of the 24/7 Sobriety program on substance-impaired driving arrests. Using variation across counties in the timing of program implementation in North Dakota as a natural experiment, we use difference-in-differences fixed effects Poisson regressions to measure the program’s effect on county-level arrests for substance-impaired driving. Over half of participants ordered to abstain from substance use complete 24/7 Sobriety without a detected substance use event. At the county level, the program is associated with a 9% reduction in substance-impaired driving arrests after accounting for the impact of oil exploration in the Bakken region, law enforcement intensity, alcohol availability, whether the state’s large universities were in session, and socio-demographic characteristics. We find that the Bakken oil boom is associated with a 22% increase in substance-impaired driving arrests. The results suggest frequent monitoring combined with increased sanction celerity deters substance use-involved crime. While the results are generally consistent with an earlier study of 24/7 Sobriety in another state, differences in the study outcome measures implementation choices across states make direct comparisons difficult. More can be learned by conducting randomized controlled trials that vary time on program, testing technology, and/or level of sanction.

Crime is an important outcome in many social policy evaluations. Benefits to society from preventing crime are based on avoiding victimization and freeing criminal justice system resources. For the latter, analysts need information about the marginal cost of policing for different types of crime across jurisdictions; however, this information is not readily available. This paper details key economic concepts relevant to law enforcement services, and then combines publicly available police expenditure data with insights from observational and time-diary studies to generate state-level, crime-specific, average variable cost estimates for crime-response services conducted by police by crime type. Since there is considerable uncertainty concerning various parameters underpinning these calculations, we use Monte Carlo simulation methods to incorporate the uncertainty into our estimates. This study finds that the U.S. population-weighted average variable cost of law enforcement response per police-reported Part 1 violent crime is $10,900, ranging from $6900 to $15,400 at the 10th and 90th percentiles, respectively. For a Part 1 property crime, the equivalent figure is $1300, with a range from $700 to $1700.

Introduction Voters in eight U.S. states have passed initiatives to legalize large-scale commercial production of cannabis for non-medical use. All plan or require some form of “seed-to-sale” tracking systems, which provide a view of cannabis market activity at a heretofore unimagined level of detail. Legal markets also create a range of new matters for policy makers to address. Data Publicly available data were obtained on approximately 45 million individually priced items purchased in the 35 million retail transactions that took place during the first two and a half years of Washington State’s legal cannabis market. Records include product type (flower, extract, lotion, liquid edible, etc.), product name, price, and potency with respect to multiple cannabinoids, notably THC and CBD. Items sold can be traced back up the supply chain through the store to the processor and producer, to the level of identifying the specific production batch and mother plant, the firm that tested the product, and test results. Method Data visualization methods are employed to describe spatial-temporal patterns of multiple correlated attributes (e.g., price and potency) broken down by product. Text-analytic methods are used to subdivide the broad category of “extracts for inhalation” into more homogeneous sub-categories. To understand the competitiveness of the legal cannabis market in Washington we calculate the Herfindahl-Hirschman index (HHI) for processors and retailers. Results Cannabis prices fell steadily and proportionally at the processor and retailer levels. Retail and wholesale price maintained a roughly 3:1 ratio for multiple product types after some initial fluctuations. Although a wide range of edibles are sold, they account for a modest share of consumer spending; extracts for inhalation are a larger and heterogeneous market segment. The HHI indicates the cannabis market is highly competitive at the processor level, but less so for retail markets at the county level. Conclusions Washington’s state-legal cannabis market is diverse and rapidly evolving in terms of pricing, products, and organization. Post-legalization, researchers and policy makers may need to think in terms of a family of cannabis products, akin to how we think of new psychoactive substances and amphetamine-type stimulants, not a single drug “cannabis.”

Background To address the overdose crisis in the United States, expert groups have been nearly unanimous in calls for increasing access to evidence-based treatment and overdose reversal drugs. In some places there have also been calls for implementing supervised consumption sites (SCSs). Some cities—primarily in coastal urban areas—have explored the feasibility and acceptability of introducing them. However, the perspectives of community stakeholders from more inland and rural areas that have also been hard hit by opioids are largely missing from the literature. Methods To examine community attitudes about implementing SCSs for people who use opioids (PWUO) in areas with acute opioid problems, the research team conducted in-depth interviews and focus groups in four counties: Ashtabula and Cuyahoga Counties in Ohio, and Carroll and Hillsborough Counties in New Hampshire, two states with high rates of opioid overdose. Participants were policy, treatment, and criminal justice professionals, frontline harm reduction and service providers, and PWUO. Results Key informants noted benefits to SCSs, but also perceived potential drawbacks such as that they may enable opioid use, and potential practical barriers, including lack of desire among PWUO to travel to an SCS after purchasing opioids and fear of arrest. Key informants generally believed their communities likely would not currently accept SCSs due to cultural, resource, and practical barriers. They viewed publication of evidence on SCSs and community education as essential for fostering acceptance. Conclusions Despite cultural and other barriers, implementation of SCSs may be more feasible in urban communities with existing (and perhaps more long-standing) harm reduction programs, greater treatment resources, and adequate transportation, particularly if there is strong evidence to support them.

Background: There is significant interest in comparing countries on many different indicators of social problems and policies. Cross-national comparisons of drug prevalence and policies are often hampered by differences in the approach used to reach respondents and the methods used to obtain information in national surveys. The paper explores how much these differences could affect cross-country comparisons. Methods: This study reports prevalence of drug use according to the most recent national household survey and then adjusts estimates as if all national surveys used the same methodology. It includes in the analysis European countries for which the European Monitoring Centre for Drugs and Drug Addiction provides the data, the United States, Canada, and Australia. Adjustment factors are based on US data. Findings: Adjusting for modality differences appears likely to modestly affect the rankings of countries by prevalence, but to an extent that could be important for comparisons. For example, general population surveys suggest that the US had some of the highest cannabis and cocaine prevalence rates circa 2012, but this is partially driven by the use of a modality known to produce higher prevalence estimates. This analysis shows that country rankings are partly an artifact of the mode of interview used in national general population surveys. Conclusions: Our preliminary efforts suggest that cross-national prevalence comparisons, policy analyses and other projects such as estimating the global burden of disease could be improved by adjusting estimates from drug use surveys for differences in modality. Research is needed to create more authoritative adjustment factors.

Aims To (1) assess trends and variation in the market share of product types and potency sold in a legal cannabis retail market, and (2) estimate how potency and purchase quantity influence price variation for cannabis flower. Design Secondary analysis of publicly available data from Washington State's cannabis straceability system spanning July 7, 2014 to September 30, 2016. Descriptive statistics and linear regressions assessed variation and trends in cannabis product variety and potency. Hedonic regressions estimated how purchase quantity and potency influence cannabis flower price variation. Setting Washington State, USA. Participants (1) 44,482,176 million cannabis purchases, including (2) 31,052,123 cannabis flower purchases after trimming price and quantity outliers. Measurements Primary outcome measures were (1) monthly expenditures on cannabis, total delta-9-tetrahydrocannabinol (THC) concentration, and cannabidiol (CBD) concentration by product type; and (2) excise-tax-inclusive price per gram of cannabis flower. Key covariates for the hedonic price regressions included quantity purchased, THC, and CBD. Findings Traditional cannabis flowers still account for the majority of spending (66.6%), but the market share of extracts for inhalation increased by 145.8% between October 2014 and September 2016, now composing 21.2% of sales. The average THC-level for cannabis extracts is more than triple that for cannabis flowers (68.7% compared to 20.6%). For flower products, there is a statistically significant relationship between price per gram and both THC [coefficient = 0.012; 95% confidence interval (CI) = 0.011 to 0.013] and CBD [coefficient = 0.017; CI = 0.015 to 0.019]. The estimated discount elasticity is -0.06 [CI = –0.07 to –0.05]. Conclusions In the state of Washington, USA, the legal cannabis market is currently dominated by high-THC cannabis flower, and features growing expenditures on extracts. For cannabis flower, both THC and CBD are associated with higher per-gram prices, and there are small but significant quantity discounts.

Combined with other studies of “swift-certain-fair”-style interventions, the HOPE replication further strengthens the conclusion that these methods reduce substance use among people under criminal justice supervision.

The synthetic control method is an increasingly popular tool for analysis of program efficacy. Here, it is applied to a neighborhood-specific crime intervention in Roanoke, VA, and several novel contributions are made to the synthetic control toolkit. We examine high-dimensional data at a granular level (the treated area has several cases, a large number of untreated comparison cases, and multiple outcome measures). Calibration is used to develop weights that exactly match the synthetic control to the treated region across several outcomes and time periods. Further, we illustrate the importance of adjusting the estimated effect of treatment for the design effect implicit within the weights. A permutation procedure is proposed wherein countless placebo areas can be constructed, enabling estimation of p-values under a robust set of assumptions. An omnibus statistic is introduced that is used to jointly test for the presence of an intervention effect across multiple outcomes and post-intervention time periods. Analyses indicate that the Roanoke crime intervention did decrease crime levels, but the estimated effect of the intervention is not as statistically significant as it would have been had less rigorous approaches been used. Supplementary materials for this article are available online.

This survey study examines changes in the use of marijuana by adolescents since legalization of recreational use in Washington State.

Introduction Cigarette excise taxes are a well-established policy lever for reducing tobacco use. However, estimating the effect of taxes on smoking behavior can be confounded by endogeneity concerns such as selection. This study leverages a unique natural experiment –compulsory relocation of U.S. military service members to installations – to estimate the relationship between state cigarette taxes and smoking behavior without concerns about selection into environments. Methods The current study uses data from the Department of Defense’s 2011 Health-Related Behaviors Survey and 2011 state cigarette excise taxes from the CDC STATE System. Logistic and Poisson regression analyses estimate the cross-sectional associations between state cigarette excise taxes and the following smoking behaviors: current cigarette smoking, frequency of smoking, heaviness of consumption, and cigarette cessation among individuals who smoked while at the current installation. Results Higher taxes are associated with lower odds of current cigarette smoking (AOR = 0.94; 95 % CI: 0.89−0.98), fewer smoking days per month among current cigarette smokers (IRR = 0.98, 95 % CI 0.97−0.996), and higher likelihood of quitting smoking among individuals who had smoked at their current installation (AOR = 1.14, 95 % CI 1.05–1.25). Taxes are not associated with the number of cigarettes smoked per day among current smokers. Conclusions Exogenous assignment to installations in states with higher cigarette taxes is associated with lower likelihood of smoking and greater likelihood of quitting. Findings provide novel evidence in support of a causal impact of cigarette taxes on lower smoking levels among adults.

Despite overall declines in cigarette smoking prevalence in the United States (U.S.) in the past several decades, smoking rates remain highly variable across geographic areas. Past work suggests that smoking norms and exposure to other smokers in one's social environment may correlate with smoking risk and cessation, but little is known about how exposure to other smokers in one's community is causally linked to smoking behavior – in part due to endogeneity and inability to randomly assign individuals to different ‘smoking environments.’ The goal of this study was to evaluate how exposure to localities with high population-level smoking prevalence affects individual-level cigarette smoking behaviors, including quitting. The study addresses key limitations in the literature by leveraging a unique natural experiment: the plausibly exogenous compulsory assignment of military personnel to installations. Logistic and multivariate regressions estimated cross-sectional associations between smoking/quitting behaviors and our proxy for social environments for smoking, county-level smoking prevalence (CSP). Across 563 U.S. counties, CSP ranged from 3.8 to 37.9%. Among the full sample, a 10 percentage point increase in CSP was associated with an 11% greater likelihood of smoking. In subgroup analyses, young adults, women, those without children in the household, and risk/sensation-seekers were more likely to smoke and less likely to quit when exposed to counties with higher CSP. Relocation to areas with high population-level smoking prevalence may increase likelihood of smoking and impede quitting, and may disparately affect some population subgroups. Findings provide novel evidence that community smoking environments affect adult smoking risk and underscore a need for sustained, targeted efforts to reduce smoking in areas where prevalence remains high.

Background and aims Prohibitions on producing, distributing and selling cannabis are loosening in various jurisdictions around the world. This paper describes the diversification of cannabis supply laws and discusses the challenges to and opportunities for learning from these changes. Methods We document changes in cannabis supply laws that de jure legalized cannabis production for medical and/or non-medical purposes (excluding industrial hemp) in Australasia, Europe, North America and South America. We also highlight challenges to evaluating these legal changes based on our experiences studying cannabis laws and policies in the United States. Findings As of August 2016, two countries have passed laws to legalize large-scale cannabis production for non-medical purposes at the national (Uruguay) or subnational level (four US states). At least nine other countries legally allow (or will soon allow) cannabis to be supplied for medicinal purposes. Most of the changes in cannabis supply laws have occurred since 2010. The data available in most countries are inadequate for rigorously evaluating the changes in cannabis supply laws. Conclusion The evidence base for assessing changes in cannabis supply laws remains weak. Efforts should focus upon collecting information about quantities consumed and market transactions as well as validating self-report surveys.

Background Studies of opioid prescribing patterns have shown that a small percentage of prescribers are responsible for a large portion of total prescriptions. There is some evidence that prescription opioid use may be similarly concentrated, but patterns may differ by population and choice of opioid utilization measure. The objective of this study is to determine what proportion of prescription opioid utilization was attributable to the top utilizers among Medicaid beneficiaries and how this proportion varies by the measure used. Methods We analyzed 2008–2009 Medicaid claims data from 14 states and created three claims-based measures of aggregate opioid utilization: total number of annual prescriptions, total annual milligrams morphine equivalent, and total days supply. We tested two versions of the total days supply measure: one assuming consecutive use and the other assuming concurrent use of prescriptions. Results The top 20 % of prescription opioid users accounted for 66 % of prescriptions, 82–85 % of days supply depending on assumption, and 90 % of morphine milligram equivalents (MME). The degree to which prescription opioid utilization was concentrated among the top 20 % of users varied minimally across states. Conclusions A small percentage of prescription opioid users account for a large share of prescription opioid use. Policy efforts should use metrics pertaining to days supply and total MME, not numbers of prescriptions, to more efficiently target heavy utilization. Policies targeting high-dose prescribing should consider the different ways that overlapping prescriptions may be taken.

Drug use is often measured in terms of prevalence, meaning the number of people who used any amount in the last month or year, but measuring the quantity consumed is critical for making informed regulatory decisions and estimating the effects of policy changes. Quantity is the product of frequency (e.g., number of use days in the last month) and intensity (amount consumed per use day). Presently, there is imperfect understanding of the extent to which more frequent users also consume more intensively.We examine cannabis flower consumption reported in three similar online surveys fielded in times and places where cannabis was and was not legal. These convenience samples returned enough valid responses (n = 2,618) to examine consumption across different frequencies of use via analyses of measures of central tendency, data visualizations, and multivariate regressions. Additional calculations incorporate data from the National Survey on Drug Use and Health.Respondents who reported using daily (i.e., 30 days in the past month) consumed almost twice as much per day of use on average as did those reporting less than daily. We find only modest increases in intensity among those using less than daily, but then a substantial increase (p0.001) for those who use daily. Most respondents report that on heavy or light use days their consumption differs from a typical day of use by a factor of 2 or more, but only about 25% of days were described as heavy or light. We estimate those using cannabis 21+ days a month account for 80% of consumption vs. 71% of the days of use.Daily cannabis users consume more intensively than others, including near-daily users. When possible, survey questions should move beyond the presence or absence of use and number of days used.

This brief describes the results of a study about the surge in synthetic opioids in the United States. The authors found that limiting policy responses to existing approaches will likely be insufficient and may condemn many people to early deaths.

This report provides detailed information about state-legal cannabis production and sales in Washington, as well as insights about the total amount of tetrahydrocannabinol (THC) obtained from legal and illegal sources by Washington residents. In the third year after implementing a regulatory system for cannabis, between 40 percent and 60 percent of THC obtained by state residents was likely purchased in Washington's state-licensed stores.

Jurisdictions considering or implementing alternatives to cannabis supply prohibition will confront several decisions that will influence health, safety, and social equity outcomes. This essay highlights 14 of these design considerations, which all conveniently begin with the letter P: 1) Production, 2) Profit motive, 3) Power to regulate, 4) Promotion, 5) Prevention and treatment, 6) Policing and enforcement, 7) Penalties, 8) Prior criminal records, 9) Product types, 10) Potency, 11) Purity, 12) Price, 13) Preferences for licenses, and 14) Permanency. For each factor, the paper explains why it is important, describes the various approaches, and highlights how some of the jurisdictions that have legalized have addressed these choices. The primary audiences are decision makers considering alternatives to prohibiting cannabis supply and analysts making projections or conducting evaluations of these changes.

The synthetic opioid surge in the United States is a public health emergency. The authors analyze drug overdose mortality and seizure data to better understand the evolution and concentration of the synthetic opioid problem. They find that overdose deaths involving synthetic opioids have increased but remain concentrated in certain states. Drug policy needs to account for how rapidly these potent opioids are upending the old order.

Background This paper combines complementary attributes of web and general population surveys to estimate cannabis consumption and spending in Washington State. It compares those estimates to legal sales recorded by the state’s seed-to-sale tracking system, and thus exploits a rare opportunity to contrast two independent estimates for the same cannabis market. This sheds light on the question of whether nontrivial amounts of black market sales continue even after a state allows licensed production and sale. Methods Prevalence of past-month use is estimated from the 2015/16 U.S. National Survey on Drug Use and Health, adjusted for under-reporting. Estimates of consumption and spending per user broken down by age, gender, and frequency of use are developed from RAND’s 2013 survey of cannabis users in Washington State. Supply side estimates come from the Washington State Liquor and Cannabis Board’s seed-to-sale tracking system. They are expressed in terms of spending, equivalent-weight of flowers, and THC, with THC for edibles imputed using a machine learning technique called random forests. Results For the period July 1, 2016 to June 30, 2017, Washington’s seed-to-sale data record sales from licensed cannabis stores of $1.17B and across all products an amount of THC that is equivalent to roughly 120–150 MT of flower. Survey responses suggest that amounts spent and quantities consumed are larger than that, perhaps on the order of $1.66B and over 200 MT, respectively. Conclusion A perfect match is not expected because of sales to tourists, residual black market activity, production for medical purposes, and diversion across state lines. Nonetheless, the results suggest that three years after state-licensed stores opened, there remained considerable consumption of cannabis supplied outside of the licensed system.

Background Some countries allow physicians to prescribe pharmaceutical-grade diamorphine to dependent users who have previously undergone treatment but are still using street-sourced heroin; this is not allowed in the US. This study provides the first nationally representative US data concerning public support for prescribing diamorphine to dependent users. We also test the hypothesis that calling it “diamorphine” instead of “heroin” increases support for this approach. Methods The RAND American Life Panel is a nationally representative, probability-based survey of US adults. Of the 3345 panel members invited to take the survey, 2530 (75.6%) provided a valid response to our question module. Respondents were randomly assigned to have the question refer to the prescribed drug as either “heroin” or “diamorphine.” The groups did not significantly differ on sex, age, race/ethnicity, or education. We compare the distribution of responses for the two groups and conduct Pearson’s chi-squared test with the Rao–Scott correction. Results For those asked whether the US should try prescribing pharmaceutical-grade “heroin,” the share answering “Yes” (20.8%) was 15 percentage points lower than those responding “No” (35.8%). When the question asked about “diamorphine,” the results were nearly reversed: the share answering “Yes” (30.6%) was almost 12 percentage points higher than those responding “No” (18.9%). The distributions of responses were significantly different (p Conclusions Support for prescribing diamorphine to dependent users is low in the US. While the results are consistent with the hypothesis that referring to heroin as diamorphine may reduce stigma associated with the substance and increase support for prescribing it, opinions may change as individuals learn they are different names for the same substance.

Background and aims During the past three decades an expansive literature has emerged that is dedicated to analysing the processes of policy transfer. One neglected pathway involves subnational agents emulating crime control innovations that have emerged in subnational jurisdictions of other nations. This paper presents the case of the London Mayor's Office for Policing and Crime's (MOPAC) Alcohol Abstinence Monitoring Requirement (AAMR) Pilot to examine the multi‐level factors that facilitate and/or constrain international–subnational crime and justice policy transfer. Methods A qualitative case study design reconstructed the (in)formal events that led to components of the South Dakota 24/7 Sobriety Project (USA) being either abandoned or integrated into MOPAC's AAMR Pilot. Evidence is drawn from elite interviews and documentary materials. Results A series of inter/transnational‐, macro‐domestic‐, meso‐ and micro‐level factors enabled and/or obstructed processes of complete international–subnational policy transfer. Exclusion of domestic violence perpetrators from the London Pilot was fuelled by interest‐group hostility and mobilization. Use of alcohol tags rather than breathalysers to monitor compliance was a result of political–economic constraints, concern surrounding intrusion, technological innovation and policy‐orientated learning. The decision to omit an ‘offender pays’ funding mechanism was a consequence of legal incompatibility and civil service reluctance, while ‘flash incarceration’ for breach was not implemented due to European policy harmonization. Conclusions The London Alcohol Abstinence Monitoring Requirement Pilot was a policy ‘synthesis’ that combined ideas, goals, vocabulary, principles, technology and practices from the South Dakota model with the existing English and Welsh criminal justice framework. Structural factors and the actions of particular agents limited the extent to which policy transfer occurred.