Table Of ContentCost-Benefit/Cost-Effectiveness
Research of Drug Abuse
Prevention: Implications for
Programming and Policy
Editors:
William J. Bukoski, Ph.D.
Richard I. Evans, Ph.D.
NIDA Research Monograph 176
1998
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
National Institute on Drug Abuse
Division of Epidemiology and Prevention Research
5600 Fishers Lane
Rockville, MD 20857
ACKNOWLEDGMENT
This monograph is based on the papers from a technical review on
“Cost-Benefit/Cost-Effectiveness Research of Drug Abuse
Prevention: Implications for Programming and Policy” held on July
28-29, 1994. The review meeting was sponsored by the National
Institute on Drug Abuse.
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Opinions expressed in this volume are those of the authors and do not
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Institute on Drug Abuse or any other part of the U.S. Department of
Health and Human Services.
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names appearing in this publication are used only because they are
considered essential in the context of the studies reported herein.
National Institute on Drug Abuse
NIH Publication No. 98-4021
Printed June 1998
NIDA Research Monographs are indexed in the Index Medicus. They
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ii
Table of Contents
Click on the title or the page number to go to section
Introduction......................................................................................1
William J. Bukoski
The Impact of Substance Abuse on Federal Spending..........................5
Jeffrey Merrill and Kimberley Fox
A Historical Perspective on Effective Prevention...........................37
Richard I. Evans
School-Based Approaches to Drug Abuse Prevention: Evidence
for Effectiveness and Suggestions for Determining
Cost-Effectiveness...........................................................................59
Gilbert J. Botvin, Elizabeth M. Botvin, and Hirsch Ruchlin
Effectiveness of Prevention Interventions With Youth
at High Risk of Drug Abuse..............................................................83
Richard F. Catalano, Kevin P. Haggerty, Randy R. Gainey,
Marilyn J. Hoppe, and Devon D. Brewer
Costs, Benefits, and Cost-Effectiveness of Comprehensive Drug
Abuse Prevention..........................................................................111
Mary Ann Pentz
Overview of Methods: Cost-Effectiveness, Cost-Benefits,
and Cost-Offsets of Prevention.....................................................130
Albert Woodward
Analytic Issues for Estimating the Benefits and Costs of Substance
Abuse Prevention..........................................................................141
Gary A. Zarkin and Robert L. Hubbard
Benefits and Costs of a Family-Focused Methadone Treatment
and Drug Abuse Prevention Program: Preliminary Findings..........161
Robert D. Plotnick, Diane S. Young, Richard F. Catalano,
and Kevin P. Haggerty
iii
Issues and Methods in Evaluating Costs, Benefits, and
Cost-Effectiveness of Drug Abuse Prevention Programs
for High-Risk Youth......................................................................184
Marsha Lillie-Blanton, Lisa Werthamer, Pinka Chatterji,
Claire Fienson, and Christine Caffray
Implications for Prevention Policy: A Commentary....................214
Robert L. DuPont
iv
Introduction
William J. Bukoski
In an era of managed care, downsizing of Government services and
budgets, the advent of a science of drug abuse prevention, and
confronted with increases in adolescent drug abuse, the practice of
drug abuse prevention finds it necessary to address a number of
interrelated critical questions in order to guide future program
development and policy: What scientific evidence supports the
efficacy and effectiveness of drug abuse prevention programs and
policy currently in effect in schools, the workplace, and communities
across the country? What are the costs associated with those
programs and are those programs and policies beneficial to those
receiving them? How can the practice of prevention be improved by
the emerging science of drug abuse prevention? And, what prevention
programs and services have demonstrated their cost-effectiveness or
cost benefit and can be implemented in the evolving healthcare
system under the pressures of managed care?
Agency administrators of drug abuse prevention programs are seeking
science-based answers to these questions in order to plan and
implement drug abuse prevention programs that reach the populations
most at risk of drug abuse with high-quality, proven, and cost-efficient
approaches to counter the increased pressures to use illicit drugs that
youth, young adults, and adults are experiencing in our society.
Health administrators for managed-care, fee-for-service, and public
and private healthcare plans are exploring a wide array of health
benefits to provide in their healthcare plans to include the
introduction of drug abuse prevention services.
However, to make wise decisions concerning the use of limited
resources, drug abuse prevention program administrators, healthcare
providers, and insurers are asking tough questions concerning the
efficacy, cost, and benefits to be derived for their clients by providing
drug abuse prevention programs and services under the auspices of
their agencies’ healthcare programs and plans. While the adage that
“an ounce of prevention is worth a pound of cure” still has currency
in the current debate, empirical data gathered through rigorous
scientific methods are being demanded by the field so that policy
making can be improved by the adoption and implementation of
1
science-based drug abuse prevention programs that actually work in
the real world.
In response, the emerging science of drug abuse prevention is
beginning to provide practical answers for these types of questions.
For example, over the past 5 years, the science of drug abuse
prevention (Bukoski 1997; Mrazek and Haggerty 1994; Sloboda and
David 1997) has yielded a number of important findings and emerging
prevention principles that indicate adolescent drug abuse prevention
can be prevented by theory-based approaches that focus on social skill
development; drug resistance techniques; family monitoring and
communication skills; strengthening antidrug abuse norms and
perceptions of social disapproval; promoting increased awareness and
salience of the perception of harmful effects resulting from drug use;
creating positive social networks; promulgation of preventive health
policies; and community mobilization for prevention. This research
also suggests the importance of the variety of implementation actions
that are essential to promote high fidelity and quality of program
delivery leading to positive program outcomes. These
implementation techniques include the employment of interactive
teaching methods; staged learning through behavioral analysis to
include coaching, role modeling, practice, reinforcement, and training
for generalization; and use of multiple developmentally appropriate
booster sessions.
However, hard data on the cost-effectiveness or cost-benefit of
specific drug abuse prevention programs have proven to be elusive.
Only a handful of studies have been conducted over the past 20 years,
providing suggestive evidence that exposure to drug abuse prevention
programs could be justified based on data derived from cost-
effectiveness and cost-benefit studies. As a result of this desperate
need for additional research to be focused on this topic, the National
Institute on Drug Abuse (NIDA) convened a group of experts in the
fields of drug abuse prevention research and economic evaluation
studies (cost-effectiveness and cost-benefit) to assess the current
scientific knowledge base of the efficacy of drug abuse prevention
programs, to explore state-of-the-art economic evacuation
methodologies and their application in the future to analysis of the
cost-effectiveness and cost-benefit of drug abuse prevention, and to
identify possible research directions for these types of studies that are
needed by the field of drug abuse prevention. Scientific papers from
this meeting were then reviewed, revised, and assembled to form this
publication.
This NIDA monograph attempts to place in perspective a number of
salient scientific and practical issues by providing a timely and
2
relevant review of scientific evidence that supports drug abuse
prevention programs and policy, by discussing methodological and
analytic developments in conducting cost-benefit and cost-
effectiveness studies in the area of drug abuse prevention, and by
assessing the implications of these research studies for the
development in the future of evidence-based drug abuse prevention
that would meet the highest scientific standards of excellence. This
research could lead to high-quality, accessible, effective, and cost-
efficient drug abuse prevention services offered in a variety of venues
to include schools, communities, the workplace, and the healthcare
system.
In the first chapter, Merrill and Fox discuss in detail the cost impact
of drug abuse on Federal entitlement spending. This chapter provides
a unique perspective on the multimillion-dollar drain annually on the
Federal entitlement budget to pay for the health consequences of drug
abuse in our society. These costs are hidden in the budgetary process,
and this chapter provides interesting data concerning actual dollar
savings that could be realized through more effective drug abuse
prevention services. The next four chapters by Evans; Botvin and
colleagues; Catalano and colleagues; and Pentz provide a solid review
of the scientific literature concerning the efficacy of drug abuse
prevention programs implemented in schools and for high-risk youth.
Scientific evidence presented in these chapters suggests that drug abuse
prevention programs that have been tested under rigorous controlled
conditions have demonstrated impact in reducing the prevalence and
incidence of adolescent drug abuse. Preliminary evidence provided in
these chapters suggests that exploratory analysis of empirical data is
beginning to yield rudimentary scientific evidence of the cost-
effectiveness of drug abuse prevention programming.
In the remaining chapters, a technical discussion of the quality and
applicability of cost evaluation methodologies for the analysis of drug
abuse prevention is presented. For example, Woodward provides a
definitional overview of the methods of cost-effectiveness, cost-
benefit, and cost-offset methodologies. Zarkin and Hubbard provide
an insightful and technically sound econometric cost evaluation
methodology and framework for assessing the cost-effectiveness and
cost-benefit of drug abuse prevention programs. In their chapter,
Plotnick and colleagues report on applying cost-effectiveness and
cost-benefit methods to the assessment of a family-focused drug abuse
prevention and treatment program for high-risk youth and families
involved in methadone maintenance therapy. Then, Lillie-Blanton
and colleagues discuss salient issues for applying cost-evaluation
techniques to drug abuse prevention programs, citing advantages of
3
various approaches and methodological barriers that still exist
hindering program development and cost evaluations. Finally,
DuPont provides a concluding chapter that begins to assess the
implications of cost-effectiveness and cost-benefit analyses for drug
abuse prevention policy.
Obviously, this NIDA monograph only begins the scientific
conversation on the relevance, appropriateness, and practical value of
conducting scientifically valid economic evaluations of drug abuse
prevention programs that are implemented in schools, communities,
places of work, and healthcare settings across the country. This
monograph suggests that science has an important role in the
discussion currently enjoined by drug prevention practitioners,
policymakers, and health funding entities across the country and that
the scientific community stands as a ready partner with prevention
practitioners in the development of scientifically sound economic
evaluation data to guide future drug abuse prevention programs and
policy.
REFERENCES
Bukoski, W., ed. Meta-analysis of Drug Abuse Prevention Programs.
National Institute on Drug Abuse Research Monograph
170. NIH Pub. No. 97-4146. Washington, DC: Supt. of
Docs., U.S. Govt. Print. Off., 1997.
Mrazek, P., and Haggerty, R. Reducing Risks for Mental Disorders.
Institute of Medicine. Washington, DC: National
Academy Press, 1994.
Sloboda, Z., and David, S. Preventing Drug Use Among Children and
Adolescents: A Research-Based Guide. NIH Pub. No. 97-
4212. Washington, DC: Supt. of Docs., U.S. Govt. Print.
Off., 1997.
AUTHOR
William J. Bukoski, Ph.D.
Associate Director for Prevention
Research Coordination
National Institute on Drug Abuse
National Institutes of Health
Parklawn Building, Room 9A53
5600 Fishers Lane
Rockville, MD 20857
4
The Impact of Substance Abuse on
Federal Spending
Jeffrey Merrill and Kimberley Fox
THE USE OF EPIDEMIOLOGY IN PUBLIC POLICY
FORMULATION
The purpose of this chapter is to demonstrate how epidemiologic
research can be a powerful tool in estimating the costs of substance
abuse to society.
Traditionally, epidemiologic studies have provided information on
how to develop and target interventions aimed at preventing and
curtailing the spread of a specific disease. But epidemiology may be
used to examine a risk factor in terms of more than simply the
etiology of a disease. For example, by studying the effects of a single
risk factor on multiple diseases, the impact of that factor on overall
healthcare costs or government spending may also be quantified.
This notion is extremely applicable with respect to estimating the full
impact of substance abuse on society. Much epidemiologic evidence
already exists on the relationship between smoking, drinking, the use
of drugs, and adverse health outcomes. Already, this research has
led to changes in public policy, from bans on smoking in public
places due to mounting evidence of the impact of passive smoke, to
greater enforcement of drunk driving laws resulting from the
evidence linking drinking to traffic accidents.
By combining studies looking at each of these substances as risk
factors for a variety of diseases, a more complete picture of the
heavy toll that substance abuse takes on society can be seen. Doing
this will help provide evidence of why, ironically, greater investment
in substance abuse prevention and treatment is even more necessary
as efforts are intensified in other areas to cut government spending.
5
PAST RESEARCH HAS LAID THE FOUNDATION
Considerable research already exists, particularly as it relates to the
impact of cigarette and alcohol use on the cost of healthcare.
Costs of Smoking
Quantifying the costs of smoking has been a major public health
issue since the 1960s. Annually, the Surgeon General issues a report
on smoking and health that summarizes all current epidemiologic
evidence on the relationship between smoking, disease, and death.
The most noteworthy of these was Reducing Health Consequences
of Smoking: 25 Years of Progress (U.S. Department of Health and
Human Services [DHHS] 1989), issued in 1989, which reported
smoking attributable fractions (SAFs) for 10 selected causes of death
using data collected in a 4-year, 50-State study conducted by the
National Cancer Society. These SAFs represent the proportion of
deaths for a given disease that could have been avoided if cigarette
smoking were eliminated.
Many economic cost studies have relied on these estimates to
calculate the number of smoking-attributable deaths for specific
regions and the number of years of potential life lost as a result of
smoking. Some have also employed these mortality statistics to
estimate hospital utilization and costs. However, mortality SAFs,
which measure smokers’ risk of dying of a disease, are different than
morbidity SAFs, or smokers’ risk of contracting a disease. Thus,
mortality SAFs cannot be used reliably for estimating morbidity or
hospital costs.
Recognizing the shortcomings of using mortality SAFs in estimating
healthcare costs, Rice and colleagues (1990) developed a different
methodology for identifying smokers’ attributable risk of utilizing
health services using National Health Interview Survey (NHIS) data.
For people who had neoplastic, circulatory, and respiratory diseases,
Rice analyzed the use of hospital days and physician visits by
smokers compared to nonsmokers by age and sex. From these
comparisons, Rice was able to calculate morbidity-attributable risks,
which were then applied to hospital and outpatient expenditures for
these diseases to estimate annual smoking-related healthcare costs.
While not as disease-specific as the mortality-based studies, Rice’s
methodology set a standard for estimating annual healthcare costs
associated with smoking.
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