Epidemiology of illicit and abused drugs in the general population, emergency department drugrelated episodes, and arrestees

Transcription

1 linicalhemistiy 42:8(B) (1996) Epidemiology of illicit and abused drugs in the general population, emergency department drugrelated episodes, and arrestees BEATRIE A. ROUSE National trends in substance abuse are presented: the civilian noninstitutionalized general population; drug-related emergency department episodes; and booked arrestees. Major metropolitan differences are also noted. This study was based on the primary national data systems for these groups: The Substance Abuse and Mental Health Services Administration (SAMHSA) National Household Survey on Drug Abuse, SAMHSA s Drug Abuse Warning Network (DAWN), and the National Institute of Justice Drug Use Forecasting (DUF) system. While the most prevalent drug differed in the three data sources, all three showed recent increases in marijuana. Despite the general decline in drug use seen in the general population, both the number of drug-related cases in the DAWN system and the drug use detected in the DUF arrestees showed recent increases. INDEXING Th1tiiS: forensic medicine #{149} emergency medicine methamphetamines #{149} marijuana #{149} cocaine #{149} opiates #{149} heroin A substantial proportion of the US population has used illicit drugs, resulting in increased risk of injury, disease, and death. Moreover, a larger segment of the public (64%) believes that drugs are a critical cause of crime than those who cite the availability of guns (45%) or the influence of television (3 8%) [1]. Indeed, 31% of the inmates in the 1991 State orrectional Facilities Survey reported that they were under the influence of a drug at the time of their offense [1]. The Substance Abuse and Mental Health Services Administration (SAMHSA) conducts scientific national surveys to monitor the nature and extent of such drug use. In SAMHSA s Office of Applied Studies, Substance Abuse and Mental Health Services Administration, Parklawn Bldg., 56 Fishers Lane, Rockville, MD Fax ; brouse@samhsa.gov. Nonstandard abbreviations: DAWN, Drug Abuse Warning Networlq DUF, Drug Use Forecasting program; ED, emergency department; NHSDA, National Household Survey on Drug Abuse; PS primary sampling unit; and SAMHSA, Substance Abuse and Mental Health Services Administration. Received February 21, 1996; accepted June 6, National Household Survey on Drug Abuse (NHSDA), 1% of those age 12 and older reported nonmedical use of a prescription drug, 38% had used an illicit drug, and 85% had drunk an alcoholic beverage in their lifetime. About 79 million people have used an illicit drug at least once in their lifetime and >12 million are current users [2]. Since 199, -6% of the general population reported current use of an illicit drug and 5% reported heavy drinking, defined as 5 or more drinks per day at least 5 days in the past month. Although the overall rate of current illicit drug users in the general population has remained fairly stable for the last several years, the rates in some segments of the population have increased significantly. This study examines recent drug abuse trends from three different perspectives: the civilian noninstitutionalized general population; drug-related emergency department (ED) episodes; and booked arrestees. It is based on the primary national data systems for these groups: The NHSDA, the Drug Abuse Warning Network (DAWN), and the Drug Use Forecasting system (DUF). Each of these different data systems focuses on specific segments of the population; each has a different purpose and its own assets and limitations. Each of these major data systems also has its own means of determining drug use and the completeness of each drug category. For example, for opiates, NHSDA collects data only on heroin use, whereas the DUF also tests for morphine, codeine, and methadone. All three systems include hashish in their marijuana category. Finally, the NIHSDA directly asks about alcohol use, whereas the DAWN system includes only those alcohol cases that involve illegal or nonmedical drug use. Neither DAWN nor DUF report data on tobacco. Therefore, this study includes only illegal and nonmedical drug use; alcohol and tobacco are excluded. Selt-Repoited Drug Use in the General Population: SAMHSANHSDA The NHSDA is a national probability survey of drug use, attitudes, and consequences in the noninstitutionalized civilian population, ages 12 and older. It was conducted periodically from 1972 until 199 and annually since then. Sample sizes before 1991 were <1. In, the sample size was

2 linicalhemistry 42, No. 8(B), respondents. Response rates for the surveys are at least 8% each year. Data are collected on alcohol, tobacco, illegal drugs, and the nonmedical use of any psychotherapeutic drugs. Nonmedical use is defined as the use of stimulants, sedatives, tranquilizers, and analgesics without a doctor s prescription, for getting high, or in nonprescribed amounts or purposes. The NHSDA survey consists of household residents and does not include high-risk drug-using persons in criminal or health institutions. It also is subject to all the difficulties associated with self-reported information, such as forgetting and unwillingness to admit to illegal or stigmatized behaviors. Therefore, estimates of drug use (especially of heroin and other low-prevalence drug use) are conservative. On the other hand, the NHSDA is more likely to include school absentees and dropouts missed in school surveys. In addition, self-reported data provide information on attitudes and consequences, for which biological testing is either not available or is too expensive. It also provides information on larger intervals of time or patterns than can be detected with biological testing. NHSDA SAMPLE AND METHODOLOGY The sampling design consists of a national multistage area probability sample, the first stage of which consists of a sample of >1 primary sampling units (PSUs). The NIHSDA had 127 PSUs. The PSU consists of administrative subdivisions of states such as counties or metropolitan areas. Within each PSU in the sample, area segments such as city blocks or enumeration districts are selected. VVithin each sampled segment, all addresses are listed and a sample of the addresses is drawn. The addresses are checked to determine whether they are eligible sample units, i.e., households or units within eligible group quarters. Using a random selection procedure determined to produce adequate sample sizes for each population group of interest, interviewers randomly select respondents from the eligible sampled housing units. Youths and black and Hispanic adults are oversampled to get more reliable estimates of their drug use. Since 1991, the NHSDA has added to the sampling universe Alaska and Hawaii, civilians living on military bases, and persons living in noninstitutional group quarters, e.g., college dormitories, rooming houses, and homeless shelters. Trained interviewers conduct the data collection in the randomly selected respondents homes. The interviewers obtain parental consent for respondents of ages About 2% of the interviewers speak both Spanish and English. Questionnaires and answer sheets in Spanish are available. A combination of techniques is used within the interview to assure confidentiality and increase response rates. The interviewer contacts the respondent in person to arrange an appointment for the interview and to conduct the data collection in private. The interviewers assure confidentiality and anonymity, provide oral instructions, and ask for the demographic information. When the questions deal with drug use or other sensitive issues, the interview switches to the use of self-administered answer sheets. To maintain confidentiality, the answer sheets are designed to conceal information from the interviewer. When each answer sheet is completed by the respondents, they placed it unseen by the interviewer into an envelope. At the end of the interview, the respondent seals the envelope. Because of the anonymity and confidentiality of the information collection system, no effort can be made to check with the respondents to clarify any of their answers after the interview. The answer sheets and specialized data-collection technique have been tested to ensure confidentially and anonymity and to decrease fear of disclosure. Periodic methodological reviews and studies are conducted to improve and refine the data collection to ensure valid and reliable measurement [3, 4]. These include cognitive experiments testing new questioning strategies, follow-up studies of nonrespondents, and field experiments to determine the effects of the mode of administration, instructions, and question wording. NHSDA 5. 1). IS I RESULTS Illicit use of drugs in the general population has decreased from its peak in 1979 of 2% who reported any illicit drug use in the past year to its lowest prevalence of 11% in (Fig. 1). The nonmedical use of stimulants, sedatives, and tranquilizers also has continued to decline. However, the past-year rate of nonmedical drug use in the general population has exceeded the use of cocaine since In fact, nonmedical drug use exceeds all other illegal drug use except for marijuana. Recently, however, this general decline has reversed for illicit drug use in general, primarily because of increased use of marijuana. The numbers of both occasional and weekly marijuana users increased between and in the total population age 12 and older (Fig. 2). Occasional use is defined as less than once a month in the past year. The number of occasional marijuana users increased from 8.8 million in to 1.2 million in. In contrast, the number of occasional cocaine users decreased between and from 3.4 million to 2.4 million. The increased marijuana rate has occurred primarily in youth (age 12-17), the current use reported in that age group nearly doubling between and. This also was the only age group that reported a significant increase in the ease of obtaining marijuana and perceived less risk in using marijuana. The.1. Any Illicit Drug NonMedical Inhalants Use I - N Marijuana ocaine Hallucinogens 1979 l982 l l99l Fig. 1. Percent using an illicit drug in the past year by type of drug: NHSDA (1979-).

3 1332 Rouse: Epidemiology of illicit and abused drugs Marijuana-Occasional ocaine-occasional lo- I, >- 12 m8-. I6- w - 2. l S - - S III lit iii l III ill #{149}I - I - I - I - I - I - I - I - I - I - I - I - I - I - I - I 11 #{149} Total Pop III II Marijuana-Weekly - I - ocaine-weekly 1991 l994 Fig. 2. Number of occasional and weekly marijuana and cocaine users: NHSDA (1991-). highest rate of any drug use, however, is in the age group (Fig. 3). Men were more likely than women to use illicit drugs at all ages except age Drug-RelatedED Visit Information Based on Medical Records:DAWN DAWN provides estimates on drug-related visits to hospital EDs as determined from a review of medical records. The survey, established in 1972, is based on a national probability sample of hospitals. Trained reporters (nurses and other hospital personnel) review medical charts on persons at least 6 years of age for indications that drug use was the reason for the visit to the ED. To be eligible as a reportable DAWN case, a patient must meet all four of the following criteria [5]: I) The patient must have been treated in the hospital s ED; the treatment may be medical or psychiatric. 2) The patient s presenting problem(s) must have been induced by or related to drug abuse. The drug exposure can occur minutes or hours before the visit. An example of a case inducedby drug abuse is a person who free-based cocaine and I $ _ - I - - I - I 5 I 5 - I Fig. 3. Percent using any illicit drug in the past year by age group: NHSDA (199-). came to the ED complaining of rapid heart palpitations. An example of a case related to drug abuse is a person who smoked crack, drove his car into a tree, and then was brought to the ED with cuts and lacerations. An example of a nonreportable case is a person with a social history as a regular cocaine user who was brought to the ED complaining of abdominal pains and received a final diagnosis of urinary tract infection. For the purposes of this study, the data presented on drug-related cases include those defined as drug-induced as well as drug-related. 3) The case must have involved the nonmedical use of a legal drug or any use of any illegal drug. Nonmedical is defined as use of a prescription drug that is not in accordance with prescribed doctor s orders or use of an over-the-counter drug contrary to label instructions. 4) The patient s reason for taking the substance(s) must have included one of the following: dependence, suicide attempt or gesture, or psychic effects. For a case to be reportable, the patient must intentionally take the substance. Accidental inhalation or ingestion of prescription or over-the-counter drugs are not reportable unless these were used in combination with an illicit drug. A drug episode is an ED visit that is directly related to illegal or nonmedical drug use. No personal identifiers are collected; therefore, it is not possible to determine whether each drug episode represents a different individual or how many episodes any one person may have. In addition, it is not possible to determine whether increases in drug-related episodes are due to more individuals seeking treatment for their drug use or needing emergency care as a consequence of their drug use, or whether the same individuals are making more repeated visits for their drug use. A drug mention is a substance mentioned during a drugrelated ED episode. Because a maximum of four drugs may be mentioned during a drug episode, the numbers of drug mentions for specific drugs may not be added together to get either the total number of drug-related visits or the total number of individuals involved. The DAWN system relies on abstracting medical records; therefore, the data are limited to the completeness and accessibility of the records. The medical record may include information from the patient, any persons accompanying the patient, and laboratory tests. DAWN was established primarily as a system to monitor the impact of illegal drugs on the emergency medical system. Therefore, alcohol cases are included only in combination with other drugs. DAWN also include population groups often missed in household surveys: transients, immigrants, and non-english-speaking persons. DAWN SAMPLE AND METHODOLOGY The present DAWN sample is composed of a representative sample of nonfederal, short-term general hospitals with a 24-h ED; --5 hospitals participate. The response rate in metropolitan areas varies from 7% to 9%. In, the national hospital response rate was 72%. DAWN data generate estimates of the total number of drug episodes for the nation and 21 metropolitan areas. In the mid-l98s, changes in the number and location of

4 linicalhemistry42, No. 8(B), hospitals necessitated a redesign of the DAWN sample. The American Hospital Association Annual Surveys of Hospitals in 1984 and 1985 were used to obtain a sampling frame. The hospitals were stratified by size and whether or not the hospital had an organized outpatient department or chemical/alcohol dependency inpatient unit. hospitals in the 21 metropolitan areas were oversampled; hospitals outside these areas were assigned to the National Panel of hospitals. By 1988, the recruitment of sample hospitals was sufficiently complete to make national estimates. To ensure that the DAWN sample is representative, the sampling frame and sample are updated annually. Sampling weights and nonresponse adjustments are applied to the data to produce the estimated number of drugrelated visits. The rates presented in this report are based on the population rather than the total number of ED visits. Trained reporters extract drug information from the ED medical records on the patient, the visit, and the drugs involved. Each drug-related ED visit may involve one or more mentions of specific drugs. Drug information on a maximum of four drugs may be recorded on the DAWN form for each drug episode. Drug information recorded includes the source of the substance, the route of administration, and the form in which the drug was acquired. In addition to on-site training, quarterly briefings are conducted through the DAWN newsletter. The newsletter provides case studies, clarification of problems uncovered by the DAWN central office periodic quality-assurance reviews, and other information used to accurately assess whether a case is reportable to the DAWN system. Reporters are advised to consider the drugs abused, the circumstances surrounding the drug-taking, the final diagnosis, the presenting complaint, and the patient s social history. DAWN RESULTS According to the DAWN data, hospital ED episodes in the US were directly related to illegal drug use or the nonmedical use of a legal drug-a 12% increase over data. In, the overall rate of ED drug-related episodes was 225 per 1 population. The rate for men was 237 per 1 population; for women, 21 per 1 population. The highest rates were for patients of ages (42 per 1 population) and (416 per 1 population). The lowest rate was for those 35 and older (156 per 1 population). Between 1991 and, the rates of cocaine, heroin, and marijuana episodes per 1 population increased significantly. The rate of cocaine-related episodes per 1 population reached an all-time high (Fig. 4). The increase in cocaine cases between 1991 and was significant in all but age groups and years. In contrast, the DAWN mentions of marijuana use were significantly increased in all age groups. Moreover, most of the marijuana-related episodes included mentions of other drugs, particularly alcohol and cocaine. The number of heroin cases has risen steadily since 1978 [6]. The highest rates in were in Baltimore (338 per 1 population), Newark (262 per 1 ), San Francisco (233 per 1 ), and New York (14 per 1 ). Most of the 7-6- o.5-.1 Q a) II - I - ocaine #{149} Heroin 1111 #{149} S - S Marijuana U.IIUIIIII 1991 Fig. 4. Rate of emergency department drug mentions per 1 population: DAWN (1991-). significant heroin increases for New York and other metropolitan areas occurred between 1991 and. Injection is the route of administration for most of the heroin cases. However, the number of DAWN cases reporting sniffed or snorted as the route of heroin administration increased more than fivefold from 1988 through and accounted for 22% of the increased heroin-related episodes during this period. Methamphetamine-related DAWN episodes more than tripled between 1991 and. Overall, the rate of methamphetamine DAWN cases increased from 2 to 8 per 1 population. During this period, the largest increases occurred in Phoenix, Denver, Minneapolis/St. Paul, and Seattle. In, the highest methamphetamine rates were in San Francisco (82 per 1 ), San Diego (4 per 1 ), and Phoenix (42 per 1 ). There were also significant increases between 1991 and in mentions of amphetamines (from 1 to 4 per 1 ), lorazepam (from 3 to 5 per 1 ), clonazepam (from 3 to 5 per 1 ), and hydocodone (from 2 to 4 per 1 ). Positive Drug Urinalysisin Booked Arrestees: DUF The National Institute of Justice has been conducting the DUF program since The early DUF program collected data from arrested and booked adult men in 12 sites. In 1991, women and juvenile arrestees were added. The juvenile arrestees range in age from 9 to 18 years. About 9% of the arrestees consent to give an interview and --8% provide an urine specimen. In, the DUF program collected data from 2 15 adult men booked arrestees in 24 sites, 7839 booked women at 21 sites, and 4558 booked male juvenile arrestees/detainees at 12 sites [7]. The DUIF data collection reflects police operations and arrest rates as well as recent drug use among arrestees. It does not include arrestees released before booking. Only juveniles who have been detained are included; those released to their parents are not included. No causal inferences can be made from these data and several caveats hold regarding the associations of drug use and particular offenses. The particular arrest may not

5 1334 Rouse: Epidemiology of illicit and abused drugs be representative of the person s drug use or of his or her criminal activities. Moreover, the person may be booked for several offenses but currently DUF records only the most serious. Finally, the arrest may occur days or weeks after the alleged offense was committed. The DIJF measures recent drug use in convenience samples of those arrested and charged with criminal offenses in selected urban areas. At this time, the data cannot be aggregated to produce statewide or national estimates. The choice of locations depends on the site s ability to support the program and to process sufficient numbers of arrestees during the 2-week testing time. Therefore, the sites are generally major urban areas with populations >25 and vary in their distribution of arrestees across race, sex, age, and offense categories. DUF SAMPLE AND METHODOLOGY The DUF sampling plan limits the number of arrestees for drug offenses to no more than 2% of the sample. Most of those tested have been charged with property and violent offenses. Property offenses include larceny/theft, burglary, stolen vehicle, arson, possession of stolen property, bribery, and pickpocketing. Violent offenses include robbery, assault, weapon offenses, extortion, homicide, kidnapping, manslaughter, sexual assault, and rape. Drug offenses include drug possession and drug sales. The DUF staff try to get -225 males per site each quarter. The sites for women arrestees include all women regardless of arrest charge, to ensure sufficient numbers for analysis. About one-half of the sites with adult DUF data collection also collected data on male juvenile arrestees/detainees. Trained local DUF staff obtain voluntary and anonymous interviews and urine specimens from booked arrestee adults age 15 and older who have been in the facility for not more than 48 h. In each site, data are collected during the evening in the booking facilities for two consecutive weeks each quarter. The evening shift generally has arrests for the more serious offenses. The urine specimens are sent to a central laboratory for analysis. A panel of Emit (Syva, Palo Alto, A) screening tests is used to detect 1 drugs: cocaine, opiates, marijuana, phencyclidine, methadone, benzodiazepines, methaqualone, propoxyphene, barbiturates, and amphetamines. Emit detects most of these drugs if tested within 2-3 days of use; the detection period for marijuana and phencyclidine is longer. The DHHS screening cutoff values are used to detect marijuana, cocaine, opiates, phencyclidine, and amphetamines. [8] The screening cutoff for barbiturates, propoxyphene, methadone, methaqualone, and benzodiazepines is 3 ng/ml. Because the results are used only for research purposes, confirmation of the initial test findings is performed only for amphetamines, gas chromatography being used to eliminate positive results that are due to over-thecounter drugs. To maintain quality control, the DUF program has an advisory board and initiates studies to ensure methodological rigor and effective use of the data. For example, in 1991, they evaluated four available urinalysis technologies (including Emit) to determine their accuracy, adequacy, and acceptability for the criminal justice system [9]; gas chromatography/mass spectrometry was used as the comparison standard. Both false-positive and false-negative types of errors were examined. The falsepositive rate for Emit varied from <1% for phencyclidine and amphetamines to 3% for cocaine. The Emit false-negative rate ranged from 2% for amphetamines to 29% for marijuana. No one of the three immunoassay techniques assessed was clearly superior, but all were more accurate than thin-layer chromatography. The study also examined the adequacy of the current DHHS cutoff values. DUF Any drug ocaine RESULTS Among male juvenile arrestees/detainees, the positive urinalysis rate for a least one drug in ranged from 23% in Multnomha ounty (Portland, OR) to 64% in the District of olumbia. In general, the juveniles arrestees who reported that they still go to school had lower positive urines for drugs than those who said they no longer attend school. Marijuana was the drug most detected among juvenile arrestees. Furthermore, the rate of positive cocaine and marijuana urinalysis results has continued to increase. In, 11 of the 12 sites had increases in marijuana, particularly leveland, St. Louis, and Washington, D. As shown in Table 1, for the last 3 years of DUF testing over all sites, the median percent of positive urinalysis for at least one drug for adult women and men arrestees has not significantly varied. Among the most prevalent drugs detected, women had higher medians than men for cocaine and opiates but not for marijuana. The lowest rates of cocaine use and the highest rates of marijuana use in the DUF system were found among persons of age Among adult women arrestees, cocaine was the most-detected drug in the 21 sites in. The median rate of opiates detected in women was higher than in the men arrestees. The rates of opiates detected varied widely among the sites, from 2% in Omaha and New Orleans to 3% in New York ity; the median rate was 8%. The positive urinalysis rate for a least one Table 1. Summary measuresof positive urinalysisresults (%) for total DUF drug testing sites (-). Marijuana Opiates Range Men Median Range Women Median

6 linicalhemistry42, No. 8(B), drug ranged from 32% in New Orleans to 9% in New York ity. Because of the small number of women at each site, trends should be interpreted with caution. In general, the rate of drugs detected between and decreased in all sites except Birmingham and St. Louis. Among the adult men arrestees, the positive urinalysis rate for at least one drug ranged from 48% in Houston to 82% in New York ity. The median rate for any drug slightly increased from 6% in to 63% in. During this period, about one-half of the sites showed an increase and half showed a decrease in detection rates for marijuana. For opiates, the median remained at 6%; the highest rate was 28% in hicago. ocaine was the most detected drug among men. However, between and, the rates of cocaine detected decreased in 13 of the 23 sites. Rates of cocaine use were high in those arrested for violent and property offenses as well as those arrested for drug offenses. Fig. 5 shows the percent of men arrestees by most severe type of offense with positive cocaine urinalysis in the six cities that are also in the DAWN system. onclusion This study examines national trends in substance abuse based on different segments of the population. Data are presented on the general population, drug-related ED episodes, and arrestees. I have described the three major relevant data systems and presented the assets and limitations of each system. Drug data on the general population are self-reported in the NSHDA. Data on drug-related episodes in DAWN are abstracted from medical records. Data on recent drug use about DUF arrestees are based on urinalysis. Given the different samples, datacollection techniques, and age groups covered, any similarities in drug trends might be considered more-reliable indicators of actual drug patterns than any one data system. Thus, the recent increase in marijuana rates in all three of the study groups, primarily among youth and young adults, is an important indicator for potential prevention and intervention efforts. Different trends among the groups also were evident. More people in the general population used marijuana than other #{149}Violence Property #{149} Drug hicago Denver LA Miami NewYork D.. Fig.5. Percent of positive cocaine urinalysis among men arrestees by type of offense: DUF (). illegal drugs, but cocaine was more likely to be detected in DAWN patients and DUF arrestees. Heroin rates remained low in the general population but high among DAWN cases and DUF arrestees. DAWN cases suggest an emerging shift from injecting to smoking/inhaling heroin, given the increased purity of the drug now found on the market. The Drug Enforcement Agency found the purity of street heroin to be -34% in 199; by, it was -66%. Any one of the three groups, however, can also be a signal for emerging new drug trends. For example, methamphetamineand amphetamine-related cases in DAWN have increased, primarily in the western US. This may be an early warning of a potential spread of methamphetamine use in the general population. Further study is needed to determine whether it is an indication of some users switching from cocaine to other stimulants or of an emerging new cohort of stimulant users. Several sources of information are often needed because of the difficulties in getting consistent, accurate data on illegal and nonmedical drug use. The careful examination and coordination of information on both high-risk drug-using groups and the general population help identify and effectively respond to emerging patterns of drug abuse. Tina ottone, Bill McKinstry, and Rick Albright provided expert technical assistance on the preparation of the graphics. Joseph Gfroerer and Linda Mcaig provided insightful comments on the manuscript. The views expressed in this article are those of the author and are not meant to represent the official position of the federal government or any agency. References 1. Maguire K, Pastore AL, eds. Source book of criminal justice statistics. US Dept. of Justice, Bureau of Justice Statistics Pubi. No. NJ-15491, Washington, D: Superintendent of Documents, US Government Printing Office, 1995: US Dept. of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA). Preliminary estimates from the National Household Survey on Drug Abuse. Advance ReportNo. 1. RockvilleMD: Office of Applied Studies, September Rouse BA, Kozel NJ, Richards LG, eds. Self-report methods of estimating drug use: meeting current challenges to validity. National Institute on Drug Abuse Research Monog. No. 57, DHHS Pubi. No. (ADM)85-142, Washington, D: Superintendent of Documents, US Government Printing Office, Turner F. Lessler JT, Gfroerer J. Survey measurement of drug use: methodological studies. DHHS PubI. No. (ADM) , Washington, D: Superintendent of Documents, US Government Printing Office,. 5. US Dept. of Health and Human Services, National Institute on Drug Abuse. DAWN instructionmanual for hospital emergency departments. DHHS PubI. No. (ADM) Washington, D: Superintendent of Documents, US Government Printing Office, US Dept. of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA). Preliminary estimates from the Drug Abuse Warning Network. January-June

7 1336 Rouse: Epidemiology of illicit and abused drugs 1995, drug-related ED episodes. Advance Report No. 14. Rockville, MD: Office of Applied Studies, May US Dept. of Justice, National Institute of Justice Research Report. Drug use forecasting: annual report on adult and juvenile arrestees. PubI. No. NJ Washington, D: Superintendent of Documents, US Govemment PrintingOffice,November US Dept. of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA). Part V: Mandatory guidelines for federal workplace drug testing programs; notice.fed RegistJune 9, ;59:299O Visher, McFadden K. A comparison of urinalysis technologies for drug testingin criminaljustice.nationalinstituteof Justice Research in Action PubI. No. NJ Washington, D: Superintendentof Documents, US Government Printing Office, June 1991.