Preliminary Estimates of Costs of Substance Abuse in CA and Savings

from Prevention

Ted R Miller, PhDPrincipal Research Scientist

Pacific Institute for Research & Evaluation

240-441-2890 (cell)miller@pire.org

Why Study Costs?Single Compact Metric

• Problem size & risk assessment• Priority setting & resource allocation • Performance comparison• Program evaluation • Advocacy

Risk Assessment: Cost of Violence (All Ages)

ETOH Only28%

ETOH & Drugs14%

Drugs Only5%

None53%

Cost of Youth Crime

None30%

ETOH Only16%

ETOH&Drug40%

DrugOnly14%

These Figures Are Based on Perpetrator Substance Use

40% of Medically Treated Assault Victims Also Are BAC-Positive

Victimization Is 7-10 Times As Likely When Someone Is Alcohol-Positive As When (S)he Is Sober

Priority-setting: BCRs for School-Based Programs (T=tobacco, V=Violence,

C=Cocaine)

PROGRAM Cost/ Kid

MJ redux

Alc redux

BCR

All Stars T $170 6% 7% 37Keepin’ It Real T $160 5% 11% 29LifeSkills TrainingTC $270 3% 1% 25Project Alert C $120 4% 0% 9Project TND C $220 0% 2% 8STARS for Families $150 4% 0% 7

Benefits of Prevention Are Reductions in the Costs of

Substance Abuse & its Associated Harms

$4,393 - $2,769

$2,694 - $2,440

$2,040 - $1,802

$2,437 - $2,112

$1,783 - $679

Performance Comparison: Costs of Underage Drinking per Youth Ages 14-20

Evaluation: 21 Minimum Drinking Age

Reduces % of youth who drink & binge Raises age of initiation which lowers

the risk of alcoholism in adulthood Reduces youth DWI deaths by 19% Reduces alcohol-involved youth

suicides by 27%

Confuses college presidents

21 Minimum Drinking Age Costs $230/Youth in CA & Saves $670

Medical Work & CJ Q(life)

$40

$220

$410

You are the Governor of CA

37 M residents 233K deaths in 2010

Can I convince you to continue my $2 M program to prevent alcohol-related injuries

We did a thorough evaluation. The results are highly significant statistically. Our program reduced deaths and hospital admissions due to alcohol-related injury by

1% !!!!

Our program prevented 50 deaths and 400 hospital admissions last year.

Our $2 M program saved CA taxpayers $70 M in medical payments and work losses last year. That’s $1900 per CA resident.

Those #s Are In Proportion

Underage Drinking: The Industry Profits as the Public Pays

Underage Drinking Is Big Business in CA, Ages 14-18

Lifetime b4 Age 13 Past 30 Days

Binge 30 Days

55%

18%31%

20%

Really Big Business

1,372,000 underage customers in CA in 2009

Annual alcohol sales per kid who drank illegally = $2,445

Legal Drinker Underage

1.6

4.4

Underage Drinkers Are Great CustomersDaily Drinks Per Drinker in CA

Legal Drinker Underage

49%

82%

Booze Consumed When BAC Will Be > .08

The alcohol industry denies it markets to kids

But the signs are everywhere

Are alcopops for the martini crowd or the beer bellies?

What age group do Budweiser frogs & clever dogs target?

Lizards?

“They might as well rename it "Hello, Creepy," because that's exactly how you'll feel purchasing Hello Kitty wine, from the moment you ask the sales clerk where to find it, right through to the cash register ring-up, where they encircle the neck of your bottle with a pendant suitable for a six-year-old. A pleasant cherry-berry scent, carbonation on my tongue, a bit of sweet-ness, a lingering floral aftertaste reminiscent of bubble bath” www.seriouseats.com

17.5% of Alcohol in CA is Consumed by Underage Customers

Under 2117.5%

Legal82.5%

What kind of booze do kids drink?

Bingers grades 6-10, in the past month, drank

Beer Wine Spirits Beer Only

73%66%

80%

6%

47% of Alcopops Are Consumed Illegally by Underage Drinkers

Under 2147%

Legal53%

% of Drinkers Who Drank Alcopops in the Past Month

8th Grade

10th Grade

12th Grade

19-20 21-24 25-30

77%66% 66%

39% 39%30%

Primary Source of ETOH

Bought Shoulder Tap

Given It Stole Home/ Store

Other

8%

25%

41%

10%17%

Primary Source in Indiana by Grade

6 7 8 9 10 11 120%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Bought itGiven by Person >=21From FamilyShoulder TapStole from StoreAnother Kid/Took from Home

Nationally, $23.8 Billion of Booze Was Consumed by Underage Customers in 2009

Underage Booze Starbucks

$23.8B

$9.8B

In CA

Underage Sales

Industry Profits

$ to Combat

$3.35B$1.65B

$???M

A Devastating Tidal Wave of Alcohol-Related Harm Results

408 deaths in CA in 2010 7500 injured in DWI crashes 115 K violent crimes 180 K property crimes 115 K teens having risky sex 2800 teen pregnancies 1100 kids in alcohol treatment

Underage Drinking Harm in CA Cost $6.8 B in 2010

Violence55%

DWI Crashes17%

Property Crime

9%

Risky Sex 8%

Other Inj3%

Poisoning 1%

Treatment4.5%

FAS2%

Underage Drinking Harm in CA

Medical7%

Other Resource7%

Work25%

Quality of Life60%

How can we make $6.8 B comprehensible?

A National Yardstick

Underage drink-ing

US Depts Justice & Education

$64B $70B

Divide by a Sensible Exposure Measure

$4960 Per Underage Customer $1810 Per Youth Ages 14-20 $3.05 Per Illegal Drink in CA

Per Illegal Underage Drink

Tangible costs

A drink Profit

$1.30$1.50

$0.75

Show a Performance ComparisonUnderage Drinking Cost/Youth

OH PA WV KY IN MI

$2,865

$1,759$2,040 $1,918

$2,194 $2,274

The Costs are for Events Caused by Alcohol

90% of alcohol-involved crashes 75% of alcohol-involved violence 54% of alcohol-involved property

crime 50% of alcohol-involved risky sex

(one eighth of all risky sex)

Usage Example: Oregon

Had consumption data by county Paid to get costs by county Worked with coalitions to understand the

problems & plan solutions Press releases: costs by county, how to solve Pushed county & state legislatures re costs Changed laws & enforcement

Treatment

Harm

Reduction

Intervention

Prevention

Selective/ Educational

Universal/Environ-

mental

Indicated/Behavioral

Prevention Typology

BCRs for School-Based Programs (T=tobacco, V=Violence)

PROGRAM Cost/ Child

MJ redux

Alc redux

BCR

All Stars T $230 6% 7% 30Keepin’ It Real T $210 5% 11% 24Life Skills Training T $360 3% 1% 20Project Northland T $640 7% 7% 17Project Star T $640 7% 3% 10Project Alert $190 4% 0% 8Project TND, Hi School

$290 4% 4% 6

BCRs for Youth Development Programs

PROGRAM Cost/ Kid

MJ redux

Alc redux

BCR

Family Matters T $260 ? 7% 13FamilyStrengtheningT $1400 15% 18% 11SocialCompetncPromo $570 ? 11% 8AdolescntTransitionsT $2000 ? 14% 7Child Development Pjt $370 4% 4.5% 6Guiding Good Choices (Prep f/Drug-FreeYrs) V

$1100 9% (0%)

8% 5

Lower Return on Investment

Cost/Child BCRStars for Families $200 4.5Across Ages $2800 1.1SOAR $5100 1.0CASAstart $9800 0.9

Program Selection Criteria

Return on investment Aggregate benefits Affordability Local priorities & problems Appropriateness for the target population Political feasibility Government savings Immediacy of the impacts (weeks versus years) Intervention overlap Unevaluated spillover effects

Enforce- ment

Policies & Laws

Public Support - Norms

Environmental Prevention

PublicPrivate

Passive

BCRs for Environmental Interventions (costs & benefits computed comparably)

BCRMandatory Server Training 320% Alcohol Tax 830% Alcohol Tax 5Reduce Outlet Density by 10% 7Restrict Alcohol Sales Hours/Days 8TV Alcohol Advertising Ban 821-Minimum Drinking Age 3Enforce Serving Intoxicated Patrons Law 29

BCRs for Environmental Controls (costs & benefits computed comparably)

ENVIRONMENTAL CONTROL BCR20% Alcohol Tax 830% Alcohol Tax 5Mandatory Server Training 3Enforce Serving Intoxicated Patrons Law 55Reduce Outlet Density by 10% 8Restrict Alcohol Sales Hours/Days 8TV Alcohol Advertising Ban 8

BCRs for Environmental Controls & Workplace Programs

ENVIRONMENTAL CONTROLS BCR

Provisional License, 12AM Driving Curfew 7Communities that Care youth SA coalition/pgm 15

WORKPLACE PROGRAMSTeam Awareness, Retail Workers 7Prime Life 18

Program Selection

No one intervention will reduce most problems more than 10%-15%

Need a package of complementary interventions

DWI Deaths

Hardcore12%

Underage 2110%

M/C9%

Other69%

ALL DRIVERS% Redux

DWI Deaths BCR

Enforce SIP Laws 11% 55Admin License Revoc 6.5% 21.08 Max Driver BAC 7% 14Intensive Breath Tests 15% 7Server Training 17% 3.3 YOUTH0-Tolerance LT 21 4% (20%) 24Grad License/Curfew 2% (5%) 821 MLDA 4% (19%) 3.5

RECIDIVISTS% Redux

DWI Deaths BCR/ ROI

Ignition Interlock 7% 7Impoundment 4% 5Intensively Supervised Treatment

4% 4

House Arrest 3% 3 BROADER IMPACTChild Seat Law LT 1% 38M/C Helmet Law 2.5% 3Primary Belt Law 10% 18

BROADER MEASURES % Redux DWI

Deaths

BCR/ ROI

Regional Trauma System 14% 2.7

Brief ETOH Intervention 6% 31

20% Tax on ETOH 4% 830% Tax on ETOH 6% 5

METHODSIncidence-based costs

Savings = Lifetime consequences of the harms prevented

Societal viewpoint: everyone's costs count

Costs are estimated froma perspective Society Government Insurers Employers

How Do We Measure Lost Quality of Life?

METHODS

Quality-Adjusted Life Year (QALY)

QALYs are routinely used to evaluate the outcome of clinical trials & preventive health interventions

A QALY is a health outcome measure that assigns a value of 1 to a year of perfect health and 0 to death

Sum fraction of perfect health lost to a health problem each year

QALY = 1 - DALY

Placing a $ Value on QALY Loss is Optional

Reasons to monetize Compare health sector w/other investments Get a single comprehensive burden measure Victims generally should monetize

Reasons not to monetize Value of quality of life is hard to measure Valuing life is distasteful Avoid explaining how it is calculated

How to Monetize Look at what people pay for safety &

health 10,000 people each spend $500 on airbags

Reduce risk of death by 1 in 10,000 $500 x 10,000 = $5M

Value of statistical life =work loss + QALY loss

Value of a Statistical Life Extra wages for

risky work Highway safety

Speed choice Use of safety

devices (belts, helmets)

● Demand & price Car safety features Smoke alarms Bicycle helmets Cigarettes Houses in dangerous/

polluted areas● Surveys

Crime Instead

Looks at jury awards for pain & suffering

Suits vs 3rd parties

Summary AOD in CA cost $165B in 2010 CA will be releasing costs by county Costs of AOD abuse are useful in risk

assessment, resource allocation, evaluation & advocacy

Costs can sell your programs Costs fairly weigh components of the SA

problem In communicating costs, show a yardstick,

divide by an exposure measure, compare performance