Prescription Drugs in Nursing Homes: Managing Costs and Quality in a Complex Environment

This issue brief provides a description of prescription drug use in nursing homes and a summary of policy issues in this area. It first profiles the nursing home pharmaceutical market, outlining the major trends in demographics and drug utilization, the supply chain by which drugs go from manufacturers to pharmacies to nursing home residents, and the alternative arrangements by which prescription drugs in nursing homes are financed. The paper then provides a synopsis of current policy issues, focusing in turn on cost containment and quality improvement initiatives

The effects of purchasing alcohol and marijuana among adolescents at-risk for future substance use

BACKGROUND: Among high-risk youth, those who may be at increased risk for adverse alcohol and other drug (AOD) use outcomes may benefit from targeted prevention efforts; how youth acquire AOD may provide an objective means of identifying youth at elevated risk. METHODS: We assessed how youth acquired alcohol and marijuana (purchasing vs. other means), demographics, AOD behaviors/consequences, and environment among adolescents referred to a diversion program called Teen Court (N = 180) at two time points (prior to the program and 180 days from baseline). Participants were predominantly White and Hispanic/Latino(a). RESULTS: In cross-sectional analyses among alcohol and marijuana users, purchasing marijuana was associated with more frequent marijuana use and consequences, time spent around teens who use marijuana, higher likelihood of substance use disorders, and lower resistance self-efficacy compared to non-purchasers. Teens who purchased both alcohol and marijuana experienced similar outcomes to those who purchased only marijuana, and also reported more frequent and higher quantity of drinking, greater alcohol-related consequences, time spent around teens who use other drugs, and prescription drug misuse. Longitudinally, purchasing alcohol and marijuana at baseline was associated with more frequent and higher quantity of drinking compared to non-purchasers at follow-up. Marijuana only purchasers had a greater likelihood of substance use disorders at follow-up compared to non-purchasers. CONCLUSIONS: In an era where drinking is commonplace and attitudes towards marijuana use are becoming more tolerant, it is essential to evaluate how accessibility to AOD and subsequent purchasing behaviors affect youth consumption and intervene accordingly to prevent future consequences

Identifying optimal level-of-care placement decisions for adolescent substance use treatment

Background: Adolescents respond differentially to substance use treatment based on their individual needs and goals. Providers may benefit from guidance (via decision rules) for personalizing aspects of treatment, such as level-of-care (LOC) placements, like choosing between outpatient or inpatient care. The field lacks an empirically-supported foundation to inform the development of an adaptive LOC-placement protocol. This work begins to build the evidence base for adaptive protocols by estimating them from a large observational dataset. Methods: We estimated two-stage LOC-placement protocols adapted to individual adolescent characteristics collected from the Global Appraisal of Individual Needs assessment tool (n = 10,131 adolescents). We used a modified version of Q-learning, a regression-based method for estimating personalized treatment rules over time, to estimate four protocols, each targeting a potentially distinct treatment goal: one primary outcome (a composite of ten positive treatment outcomes) and three secondary (substance frequency, substance problems, and emotional problems). We compared the adaptive protocols to non-adaptive protocols using an independent dataset. Results: Intensive outpatient was recommended for all adolescents at intake for the primary outcome, while low-risk adolescents were recommended for no further treatment at followup while higher-risk patients were recommended to inpatient. Our adaptive protocols outperformed static protocols by an average of 0.4 standard deviations (95 % confidence interval 0.2-0.6) of the primary outcome. Conclusions: Adaptive protocols provide a simple one-to-one guide between adolescents' needs and recommended treatment which can be used as decision support for clinicians making LOC-placement decisions

The Relationship Between Firearm Availability and Suicide

Empirical research on the causal effects of firearm availability on the risk of suicide is consistent with the claim that firearms increase suicide risk, but this research cannot yet rule out some other explanations for observed associations between guns and suicide. There are, however, theoretical or logical arguments for believing firearms elevate suicide risk that are sufficiently compelling that individuals and policymakers might reasonably choose to assume that gun availability does increase the risk of suicide.

The Science of Gun Policy: A Critical Synthesis of Research Evidence on the Effects of Gun Policies in the United States

The RAND Corporation's Gun Policy in America initiative is a unique attempt to systematically and transparently assess available scientific evidence on the real effects of gun laws and policies. Our goal is to create resources where policymakers and the general public can access unbiased information that informs and enables the development of fair and effective policies. Good gun policies in the United States require consideration of many factors, including the law and constitutional rights, the interests of various stakeholder groups, and information about the likely effects of different policies on a range of outcomes. This report seeks to provide the third factor—objective information about what the scientific literature examining gun policies can tell us about the likely effects of those policies. This report synthesizes the available scientific evidence on the effects of various gun policies on firearm deaths, violent crime, the gun industry, participation in hunting and sport shooting, and other outcomes.1 It builds and expands on earlier comprehensive reviews of scientific evidence on gun policy conducted more than a decade ago by the National Research Council (NRC) (see NRC, 2004) and the Community Preventive Services Task Force (see Hahn et al., 2005)

The Effects of Substance Use on Workplace Injuries

The article of record as published may be found at https://www.rand.org/pubs/occasional_papers/OP247.htmlOccupational injuries are a serious public-health issue and cause significant morbidity and mortality in the United States. In 2004, there were 3.4 million admissions to emergency rooms for job-related injuries and illnesses, a number that reflects an estimated rate of 2.5 admissions per 100 full-time equivalent (FTE) workers aged 15 and older (CDC, 2007b). In 2005, private industry employers reported 1.2 million injuries and illnesses that required days away from work, representing 135.7 per 10,000 FTE workers (IIF, 2007). The same year, data from the Census of Fatal Occupational Injuries (CFOI) estimated that there were approximately four occupational-injury deaths per 100,000 employed workers, which represented a total of 5,702 such deaths that year (CDC, 2007a). The costs of occupational injuries and illnesses in the United States exceed $100 billion annually and entail both direct (e.g., medical expenses) and indirect (e.g., loss of wages, loss of home, workplace disruption) costs borne by injured workers, their families, other workers through lower wages, firms through lower profits, and consumers through higher prices (Leigh, 2000). In this paper, we review the literature that has examined the impact of substance use on occupational injuries. We begin briefly by describing the so-called obvious associations between using on the job and occupational injuries and propose alternative reasons that sub- stance use may be linked to work-related accidents. We then review the most-recent empiri- cal literature that has attempted to document the relationship between substance use and occupational injuries. We highlight findings that are consistent across studies and address the limitations that most of these studies confront. We then proceed to examine the policies that attempt to address substance use at the workplace and, often without empirical analysis, hypothesize why each initiative may or may not influence rates of occupational injuries. We conclude by discussing what remains unknown about the relationship between substance use and occupational injuries and identify future avenues for research that could help fill some of these research gaps.The research reported in this paper was sponsored by the Commonwealth of Pennsylvania and the Allegheny County Department of Human Services and was conducted within the RAND Center for Health and Safety in the Workplace (CHSW).The research reported in this paper was sponsored by the Commonwealth of Pennsylvania and the Allegheny County Department of Human Services and was conducted within the RAND Center for Health and Safety in the Workplace (CHSW)

The War Within: Preventing Suicide in the U.S. Military, Summary

Since late 2001, U.S. military forces have been engaged in conflicts around the globe, most notably in Iraq and Afghanistan. These conflicts have exacted a substantial toll on soldiers, marines, sailors, and airmen, and this toll goes beyond the well-publicized casualty figures. It extends to the stress that repetitive deployments can have on the individual servicemember and his or her family. This stress can manifest itself in different ways -- increased divorce rates, spouse and child abuse, mental distress, substance abuse -- but one of the most troubling manifestations is suicide, which is increasing across the U.S. Department of Defense (DoD). The increase in suicides among members of the military has raised concern among policymakers, military leaders, and the population at large. While DoD and the military services have had a number of efforts under way to deal with the increase in suicides among their members, the Assistant Secretary of Defense for Health Affairs asked RAND to review the current evidence detailing suicide epidemiology in the military, identify "state-of-the-art" suicide-prevention programs, describe and catalog suicide-prevention activities in DoD and across each service, and recommend ways to ensure that the activities in DoD and across each service reflect state-of-the-art prevention science