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The prohibition of drugs and maximization of utility

The publisher's the prohibition of drugs and maximization of utility edited version of this article is available at Subst Use Misuse Abstract Economic analyses of substance misuse prevention assess the intervention cost necessary to achieve a particular outcome, and thereby provide an additional dimension for evaluating prevention programming.

This paper reviews several types of economic analysis, considers how they can be applied to substance misuse prevention, and discusses challenges to enhancing their international relevance, particularly their usefulness for informing policy decisions.

Important first steps taken to address these challenges are presented, including the disease burden concept and the development of generalized cost-effectiveness, advances that facilitate international policy discussions by providing a common framework for evaluating health care needs and program effects.

Economic analysis, Cost effectiveness, Cost utility, Cost benefit, Prevention, Alcohol, Drugs, Substance misuse, Policy, International Misuse of substances such as alcohol, tobacco, and licit and illicit drugs constitutes a major problem across the world.

As indicated by the criteria associated with positive diagnoses of substance use disorders, substance misuse can lead to a variety of negative outcomes, including an enduring decrease in social and occupational functioning as individuals give undue priority to their substance use American Psychiatric Association, 2000 ; World Health Organization, 1992.

The impaired functioning, greater morbidity, and early mortality experienced by those who misuse substances can collectively be defined as the disease burden of substance misuse, and can be quantified in terms of disability adjusted life years DALYsor the number of years of fully functional life lost e.

In the report of the World Health Organization's 2009 Comparative Risk Assessment update for 2004, alcohol, tobacco, and illicit drugs together accounted for 12. The report also addresses these substances individually, and their differential impact according to global region and country characteristics. For instance, among the 24 risks considered, alcohol use is the third leading contributor to the global burden of disease, whereas tobacco use ranks sixth and illicit drug use ranks eighteenth.

Alcohol places the largest toll on men in Africa, in middle income countries in the Americas, and in some high income countries.

  1. On average, effective interventions will allow individuals to enjoy healthier and longer lives and, hence, more QALYs than would have otherwise been the case. Efficacy studies predominate in initial tests of an intervention.
  2. Illegal Drugs, Economy and Society in the Andes. Mandatory Minimum Drug Sentences.
  3. Assessing the Benefits and Costs of Social Policies.
  4. National Academy Press; 2007. Milbank Memorial Fund Quarterly.

Tobacco use differentially affects countries according to income level, as it is the leading cause of DALYs in high income countries and the third cause in middle income countries, but does not rank in the top ten for low-income countries World Health Organization, 2009. Evidence indicates that substance misuse is increasing most quickly in regions that are experiencing dramatic societal change, as is common in developing countries World Health Organization, 2007.

These statistics are especially troubling in that they are linked to pain and suffering experienced not only by the person engaging in substance misuse, but also by their families and friends. In addition, even persons who are not directly connected to the individual engaged in substance misuse can, nonetheless, be directly affected through criminal activity, motor vehicle accidents, and violence.

Thus, the negative effects of substance misuse extend well beyond the person engaged in the problematic behavior. In addition to these health-focused outcomes, substance misuse entails great financial cost for societies, including both direct and indirect costs associated with hospitalization, treatment, accidents, law enforcement, criminal activity, and lower human productivity. Costs related to substance misuse are similarly large in other parts of the world.

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A review of health care costs by twelve European Union countries in the 1990s indicated a total expenditure of approximately 1.

Overall, regardless of whether the total cost of substance misuse is measured in terms of human suffering, disease burden, or monetary expenditures, substance misuse severely impacts individuals, societies, and economies around the world. The negative outcomes associated with substance misuse naturally encourage efforts to reduce its prevalence, including the strategies of both treatment and prevention. Treatment of substance misuse is hypothetically attractive, because resources are directed specifically at those who require help.

Addiction and Its Sciences: What economics can contribute to the addiction sciences

There exist a number of behavioral and pharmacological treatments effective at reducing the rate or severity of substance misuse National Institute on Drug Abuse, 2009. However, it is often the case that persons who could benefit from treatment are not identified, or they are not willing to participate in treatment.

As a result, taking a treatment approach alone allows the possibility that many of the negative outcomes associated with substance misuse could occur before intervention can address the problematic behavior. That is, over time youth continuously interact and transact with multiple entities e. Moreover, a person who exhibits substance misuse may be physiologically addicted, thereby requiring a treatment outcome of complete abstinence before significant improvement can be realized.

Among others, these limitations of treatment approaches for the reduction of the substance misuse prevalence suggest consideration of supplementing such approaches with those entailing preventive interventions.

Importance of being evidence-based and developmentally well-timed The great costs of substance misuse combined with the limitations of attempting to reduce its prevalence primarily through treatment of individuals already exhibiting the problem behavior encourage consideration of prevention efforts as a means of reducing these costs.

There are numerous interventions designed to prevent substance misuse, and differences exist among them with regard to effectiveness and cost to implement. Comprehensive reviews and intervention outcome comparisons are available e. Such reviews, however, cannot consider interventions that have not yet been tested, and results for those that have been tested may not generalize to different cultures and settings.

For this reason, it is useful to detail broad characteristics that will typify those intervention strategies that are most promising for large-scale implementation and achieving a favorable public health impact, thereby providing initial guidance in program selection in the absence of an empirical record.

Evidence-based Preventive interventions are labeled evidence-based to the degree that they are theoretically grounded and empirically supported Flay et al. The ability to propose and test specific relationships enables intervention improvement, as the results indicate what modifications may be necessary.

Thus, theoretical grounding encourages empirical testing, with those strategies and interventions that receive empirical support being those that are most likely to be truly effective and, therefore, most worthy of consideration for further implementation. The importance of being evidence-based is reflected by the degree to which it permeates the Preventive Intervention Research Cycle PIRCa model developed by the Institute of Medicine to guide the design, development, and testing of preventive interventions to increase the likelihood that they will improve public health Institute of Medicine, 1994 ; National Research Council and Institute of Medicine, 2009.


Developmental timing Early, well-timed, and developmentally appropriate preventive interventions among youth can capitalize on the fact that attempts to modify risk factors are most successful when the precursors of risk are nascent — before they evolve and reify into established attitudes and behaviors that may be more difficult to change e. The developmental perspective of prevention views substance misuse as behaviors that emerge out of a trajectory of risk that begins long before the behavior occurs Dodge et al.

Therefore, prevention efforts that favorably impact critical risk factors at opportune points in time can alter the risk trajectory for youth. Consistent with this idea, successful efforts to prevent risk factors for future substance misuse can begin in children less than five years of age, well before substance misuse typically begins Webster-Stratton, 1998.

The particular case of substance misuse prevention illustrates how preventive interventions are likely to be most effective when they are delivered at critical points in development, when youth are old enough to benefit from prevention programming, but prior to the age at which initiation of the problematic behavior becomes common.

With regard to substance misuse, perhaps the most important period for intervention occurs at the threshold of adolescence Dodge et al.

A variety of newly emerging factors make this a critical time for youth, including experiencing a shift in the relative importance of socialization from the family to peers and friends, greater autonomy, a desire to demonstrate independence and react against perceptions of parental control, and an increased exposure to substance use opportunities and offers Masten et al.

Economic potential of universal prevention Breadth of impact and cost of targeted behavior Effective interventions are an obvious and essential component of a successful public health prevention campaign, but they are not themselves sufficient to ensure an economic return.

In particular, the problem behavior to be prevented by intervention will determine the maximum potential savings of universal prevention. Similar to population-level vaccination programs that seek to reduce the prevalence of a biological disease, universal substance misuse preventive interventions are designed to be appropriate for nearly all youth in a population, seeking to include them in prevention efforts regardless of their individual risk or substance misuse behaviors.

Also important is the degree of cost associated with each case. Just as various substances will differ with respect to the severity of the impact their misuse has on functioning, they will also differ with respect to the costs their misuse imposes on individuals, families, governments and societies.

Thus, interventions have a greater potential impact when they target types of substance misuse that have higher prevalence in the populations or that are associated with higher economic costs. The intervention must be effectively disseminated, requiring buy-in from societal institutions and stakeholders, such as local governments, schools, religious groups, employers, and clinics, as well as participating families and individuals. Finally, the preventive intervention must be continuously sustained over the long term.

Sustainability is an ongoing process that entails continuing efforts, assessments, evaluation and modification. Sustainability planning is critical to make certain that society continues to reap the anticipated benefits of prevention programming beyond the initial start up period. Economic challenges facing universal prevention The existence of effective preventive interventions is not sufficient for sustained, universal prevention.

Such an undertaking also requires favorable action on the part of policy makers because any large-scale effort involves the dedication of substantial resources. At any given time there exist a number of effective interventions, and the total costs for supporting all of them would outstrip the finite resources that are available. There is a need, therefore, to be able to evaluate and choose among a variety of potential interventions.

  1. Implications for Programming and Policy.
  2. Consumption responding to price does not imply that users have perfect foresight, successfully maximize utility, or are otherwise rational [ 16 ]. As a result, an intervention's effectiveness may be less in another country, which would directly decrease its economic potential.
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  4. Though these various ventures seek to achieve categorically different outcomes, they nonetheless compete for the same resources, and the decision regarding which to support requires a fair comparison on a common metric. These include not only total costs for implementation, but also the average cost, calculated as the total cost divided by the number of individuals receiving the intervention.
  5. Drug Policy for Results.

This choice might be focused on choosing among programs that address a problem identified as a priority for prevention. For example, if the prevention of alcohol misuse is identified as a priority, the relevant programs may be compared on both how much they cost to implement and how much they tend to decrease rates of misuse.

However, the choice may be more complex, in which programs that address different outcomes need to be compared, or in which a preventive intervention must be compared with initiatives largely unrelated to health, such as investments in education, job training, or construction.

Though these various ventures seek to achieve categorically different outcomes, they nonetheless compete for the same resources, and the decision regarding which to support requires a fair comparison on a common metric.

Economic analysis provides a systematic means for making such comparisons, thereby enabling more informed decisions. Types of economic analysis There are several forms of economic analysis that can be useful for the evaluation of preventive intervention programs. All types of analysis entail the calculation of program costs, but thereafter differ in regard to the specific outcome by which the program effects are assessed.

The following sections provide descriptive overviews of several major categories of economic analysis, and include broad discussion of some pertinent issues. The presentation is necessarily general, and does not attempt to exhaustively consider the manifold details the prohibition of drugs and maximization of utility attend all economic analyses. A number of excellent sources exist in which the interested reader may find technically detailed presentations of economic analyses e.

Analytic perspective One issue that affects all economic analyses and therefore merits discussion is the perspective of the analysis, which defines the types of costs and benefits that will be considered.

Perhaps most commonly encouraged are analyses that take a societal perspective e. However, it can also be of practical importance to perform an analysis from the perspective of a particular stakeholder, such as government, taxpayers, or employers e.

In the hypothetical situation described above, from the perspective of the school district, the use of volunteers as opposed to hiring personnel would represent real cost savings.

Although a non-societal perspective may yield less comprehensive estimates, they can be useful for budgetary planning and the prohibition of drugs and maximization of utility the potential good to influential stakeholders, thereby gaining the support necessary for passing new policy initiatives. In any case, a fair comparison of alternative preventive interventions, or of a prevention effort with any other use of the same money, requires that their economic analyses be conducted from the same perspective.

Cost analysis As the most basic form of economic evaluation, cost analysis entails an assessment of program costs. In short, cost analysis quantifies the resources required to implement the program. Some of these costs will be readily available to evaluators, insomuch as they are likely to be direct and explicit, including training costs, salaries, supplies, and participation incentives.

Less apparent and more challenging to quantify will be overhead costs, and costs borne by others, such as volunteer labor, donations of facilities used, participant transportation costs, and participant time. As noted by Drummond, Stoddart and Torrance 1987if the cost analysis is for the purpose of comparing interventions that utilize similar quantities of a resource — such as two prevention programs that both consume 25 hours use of a donated facility — these costs need not be estimated as they will offset each other.

However, this limits the analysis because results cannot be immediately compared to other programs with dissimilar sources of costs, and the total cost will be underestimated. In addition, given the importance of monitoring implementation quality and program effectiveness for the purpose of sustainability, as well as continuously evaluating and revising the program, the associated assessment costs should be considered in budgeting for long-term and widespread dissemination efforts Pentz, 1998.

Ultimately, cost analyses can yield several bases for program evaluation. These include not only total costs for implementation, but also the average cost, calculated as the total cost divided by the number of individuals receiving the intervention. Particularly germane for comparing programs intended for continuous implementation is the marginal cost, which is the incremental cost incurred by intervening with one additional participant Drummond et al.

Marginal costs tend to decrease as intervention efforts are scaled up, interventions are continuously implemented in a sustained fashion, and costs associated with intervention start up have ended. However, it might be desirable to include start-up costs, as when evaluating the possibility of beginning implementation of a new program.

In such cases it is advised to assess costs across a time horizon, such as 10 years, over which the intervention will have been actively implemented, and after which start up costs would have been incurred. The start up costs can then be accounted for by annualizing them across the time horizon of the analysis Baltussen et al. As previously noted, cost analysis is required for each of the other varieties of economic evaluations of interventions, insomuch as each entails calculating the intervention cost associated with achieving a particular outcome.

Cost-effectiveness Though programs may be compared on cost alone, it makes little sense to consider programs that do not achieve the ends for which they were designed.

Any funds spent on even the least expensive prevention program would be wasted if the program did not successfully reduce the occurrence of the targeted condition among the treated population. Accordingly, in the PIRC model for development of preventive interventions, empirical study focuses in large part on tests of efficacy and effectiveness. In particular, efficacy corresponds to how well an intervention performs under ideal conditions, such as those characteristically associated with clinical trials.

By contrast, intervention effectiveness refers to how well an intervention prevents an outcome under real-world conditions Flay et al. Efficacy studies predominate in initial tests of an intervention.

By contrast, effectiveness studies are typically conducted after efficacy is shown, when an intervention has developed to the point that it is manualized and ready for implementation by third parties, and when the focus is establishing the generalizability of an intervention's effect on a practical outcome.

Cost-effectiveness analyses quantify the ratio of the intervention cost to intervention outcomes, thus estimating the cost required to produce each unit of prevention.

Cost effectiveness may be used to compare alternative courses of action, such as implementation of a substance use prevention program versus doing nothing, or implementation of one prevention program versus another.

Cost-effectiveness can provide comparisons between alternatives when the same outcome is assessed for both alternatives. For example, two substance use prevention programs can be compared on the cost to prevent initiation of alcohol use if both assess that outcome.