Public Health & Policy Issues: Illegal Drugs

1. Public Health & Policy Issues: Illegal Drugs Sheila M. Bird MRC Biostatistics Unit, Cambridge Collaborations: Sharon Hutchinson & David Goldberg, HPS Brian Tom, Bo Fu & Elizabeth Merrall, BSU Ruth King & Gordon Hay @ St Andrews & Glasgow

2. Keep Injecting iLLEgal Drugs Murder Suicide Overdose Late sequelae of Hepatitis C Late sequelae of HIV Late sequelae of alcohol as co-factor Public costs. IDU  socially transmissible disease IDU  courts, prison, health & drug services

3. Keep Injecting iLLEgal Drugs Projecting Scottish IDUs’ late HCV sequelae required Past & recent injector incidence Past & recent off-injecting rates Past & recent drug-related death rates Other causes’ death-rate for ex-IDUs BBV transmission model: HCV infectiousness & prevalence, injecting frequency/partners BBV progression model: age at HCV infection, sex, alcohol co-factor, antiviral treatment BBV late sequelae: database linkage from HCV diagnoses (minimally) Costs overlay; policy changes; “if scenarios”.

4. Modelled prevalent IDUs in Scotland ? doubled from 1980-84 and again from 1985-89 120 Current & former IDUs 100 Current IDUs 80 60 Living IDUs (thousands) 40 20 0 1960 1970 1980 1990 2000 Year

5. Scotland’s HCV Action Plan(Hutchinson, Bird & Goldberg. Hepatology 2005; 42: 711-723) Despite harm reduction policies, high HCV incidence ~ 20-30 per 100 susceptible IDU-years. Past IDU epidemic’s current consequences:epidemic wave of DRDs in older current-IDUs ex-IDUs aged 30-49 years: HCV test & treat (to halt HCV progression) Clean needles don’t prevent DRDs:off-injecting does + reducing IDU initiations. Only HCV-contaminated works infect:? count HCV-contaminated injections since last –ve test.

6. NICE on Needle Exchange (NE): without comment, high baseline cost-per-QALY for IDUs of £38K to £45K. (UK-unaffordable) Possible NICE decision = HCV test every 6 months. This was not modelled . . . NICE Appraisal is Evidence + Judgment. Decision follows from 30% to 50% HCV prevalence among IDUs, transmission risk of 2% or 3% per contaminated injection 25% HCV risk after 10 contaminated injections. “What if” added IDU-years/DRDs facilitated by NE: was not modelled. National Institute for Health & Clinical Excellence: threshold of £20-30K per QALY

7. Missed UK target20% reduction in Drug-Related Deaths by 2005Policy implications?

8. Drugs-related deaths & Capture-Recapture (CR) in Scotland:2000+01+02; 2003+04+05; 2006+2007

9. Scotland’s drug-related deaths by: age-group, gender, region

10. Scotland’s drug-related deaths by: age-group, gender, region

11. Scotland’s drugs-related deaths & Bayesian CR estimates for current injectors (minor & major modes, King et al., SMMR in press)

12. Bayesian Capture-Recapture Not all DRDs occur in IDUs . . . Prior beliefs: % DRDs who are injectors? 80% for DRDs aged 15-44 years (75% to 85%) 20% for DRDs aged 45+ years (15% to 35%).

13. Bayesian Capture-Recapture, 2003-0580,20estimateiDRD rate per 100 IDUs

14. 21st Century Drugs and Statistical Science in UK Surveys, Design & Statistics Subcommittee of HOSAC • Landscape: Now surveys with/without biological samples; databases; cohorts; biological sample collections; tangle of technologies 2.Methodology Matters Database linkage & ‘virtual’ cohorts; Capture-recapture methods to estimate #injectors; Epidemics – initiations & removals; Evidence-synthesis, and biases; Formal experiments: randomization & cost-effectiveness; Genetics 3. Essential New Questions 4. New Prospects

15. Landscape: Now National databases ~ give event-dates (physical, mental health & CJ morbidity + mortality)  access to biological samples. Cohorts ~ conventionallycomprise individuals who meet eligibility criteria (born in week W; diagnosed with condition X in region R) & give informed consent for clinical or other re-contact. Identifiers ~ NIL, classificatory, linkable (such as master-index: initial of 1st name,soundexsurname, sex, date of birthS B630 f 180552), or personal number (PNC, NI, etc); DNA. Deductive disclosure about individuals:safe havens for linkage & analysis of linked, longitudinal data.

16. Gamut of surveys, databases, cohorts, biological sample collections. Representative surveillance?Health sites Self-report + biological sample?Schools New questions?Incidence & recovery (Ro) New tests?HCV-RNA for injectors Longitudinal linkage of “health”, drug referral, criminal databases? Coherent reports of IDU debut; powerful re trajectories. Birth & at-risk cohorts?Costly, losses, lack power ‘Virtual’ cohorts?Event-dates without context. Formal experiments in criminal justice?Efficacy, safety & cost-effectiveness.

17. Methodology Matters Capture-recapture methods to estimate # current injectors POLICY PRIORITY for local estimates, v. capture propensities: 22 models v. all 2-way interactions . . . Assumptions matter: new CR results for England.

18. New estimates for current injectors: England

19. Epidemics: initiations into, & removals from injecting Back-calculation from overdose deaths to heroin/IDU incidence: needs duration of injecting Assumptions matter: surely,removal rate increased in 21st C? Injector careers: snapshot samples.

20. Referral to Edinburgh’s liver clinic in late 20th C: non-uniformKAPLAN, typically in last half/quarter of incubation period to cirrhosis (Fu et al., 2007) Clinic patients(if only 5% of community patients routinely referred, rest near to cirrhosis):over-estimate % fast progressors e.g. 55% v. 33% re community Covariate effect sizein clinic patients(such as heavy drinking):under-estimated re true effect in community

21. Judges prescribe sentence on lesser evidence than doctors prescribe medicines Is public aware?

22. Drug Treatment &Testing Orders (DTTOs) • England & Wales: 210 clients • Scotland: 96 clients • Targets for DTTO clients in E&W: 6,000+ per annum • DTTO clients: 21,000+ by end 2003

23. RSS Court DTTO-eligible offenders:do DTTOs work ? • Off 1DTTO • Off 2 DTTO • Off 3 alternative = • Off 4 DTTO • Off 5 alternative = • Off 6alternative = Count offenders’ deaths, re-incarcerations etc . . .

24. UK courts’ DTTO-eligible offenders: ? guess • Off 7 DTTO [ ? ] • Off 8 DTTO [ ? ] • Off 9 DTTO [ ? ] • Off10 DTTO [ ? ] • Off11 DTTO [ ? ] • Off12 DTTO [ ? ] • Off13 DTTO [ ? ] • Off14 DTTO [ ? ] (before/after) Interviews versus . . . [ ? ]

25. Evaluations-charade • Failure to randomise • Failure to find out about major harms • Failure evento elicit alternative sentence  funded guesswork on relative cost-effectiveness • Volunteer-bias in follow-up interviews • Inadequate study size re major outcomes . . .

26. The ‘business’ of judging &Judicial counting . . .

27. Custodial sentence lengths Male, Adults, Magistrates’ court, single offences, 2004 E&W

28. Awash with data . . . urines . . . Compulsory Drugs Testing in the British Army

29. 10% reduction in opiate +ve rate, weekday pattern in cannabis positive rates. National Offender Management Service in 21st C. • Weekend v. Mon-Wed v. Thurs/Fri testing. • Different test rate by prison: annual election for or against 5% rMDT! • Lowered % positive for cannabis & opiates between eras. 4. Prescribed methadone ~ rarely.

30. T=tests, P=prescribed methadone, O=opiates, C=cannabis (95% CI for rate per 1,000)

31. O=opiates, C=cannabis (95% CI: rate per 1,000)

32. Formal experiments: drugs courts “Hugs, not Drugs”

33. Harveian Oration: De Testimonio Evidence + Judgment Efficacy (typically in RCTs) v. Safety (rare events) + Effectiveness (promise into practice) Designs that are fit for purpose . . . (delayed judgments . . . ) Signal:noise ratio (usual outcome).

34. Guardian Society: 17 Nov. 2004 “Some statisticians are so severe that they would stop social policy making in its tracks. For example, Birdwould forbid the government to introduce any policy that had not been assessed through controlled trials. . . ”

35. Increased Efficiency at Detection masked trend in soldiers’ cocaine use British Army, 2003 - 2007 • Accentuated Monday testing • Differential testing by rank: privates! 3. Lowered threshold for cocaine

36. Privates in British Army: cocaine

37. Essential New Questions [1] Age at/year of starting to inject & at off-injecting.{up to 5 snapshots} # Periods “off-injecting for a least 1 year” since injecting debut. # New initiates to injecting, in your presence, in the past year. {3 present: count each 1/3rd responsible} # Injectors, known to you, who gave up injecting in past 2 years v. # injectors who died in past 2 years. {pause for reflection}

38. Four PQs for every CJ initiative • PQ1: Minister, why no randomised controls? • PQ2:Minister, whyhave judgesnot evenbeen asked to document offender’salternative sentencethat this CJ initiative supplants? {cf electronic tagging} • PQ3:What statistical powerdoes Ministerial pilot have rewell-reasonedtargets? {or, just kite flying . . .} • PQ4:Minister, cost-effectivenessis driven bylonger-term health & CJ harms, how are these ascertained?{ database linkage}

39. Bayesian Capture-Recapture80,20point-estimateiDRD rate per 100 IDUs applied to 2006+2007