Alcohol and Drug Abuse in High Risk Geographic Areas of the State of Delaware

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1 Alcohol and Drug Abuse in High Risk Geographic Areas of the State of Delaware An Analysis of the Need for Treatment in the Household Population Aged 18 Years and Over Prepared for State of Delaware Health and Social Services Division of Alcoholism, Drug Abuse, and Mental Health by Health Services Policy Research Group College of Human Resources, Education, and Public Policy University of Delaware October, 1999

2 Alcohol and Drug Abuse in High Risk Geographic Areas of the State of Delaware: An Analysis of the Need for Treatment within the Household Population Aged 18 Years and Over State of Delaware Health and Social Services Division of Alcoholism, Drug Abuse, and Mental Health Robert A. Wilson Health Services Policy Research Group College of Human Resources, Education, and Public Policy University of Delaware ii

3 Table of Contents Chapter 1: Introduction 6 Chapter 2: Alcohol and Drug Use 11 Chapter 3: Alcohol and Drug Abuse and Dependence 12 Chapter 4: Summary and Conclusions 21 Appendix: Response Rate for Statewide Alcohol and Drug Survey 24 iii

4 List of Figures Figure 1: Sampling Frame for High Risk Area Study 7 Figure 2: Map of High Risk ZIP Code Areas 9 Figure 3: Respondent Sample by ZIP Code Area 10 Figure 4: Alcohol and Drug Use by Lifetime and 18-Month Prevalence 11 Figure 5: DSM-IV Criteria for Substance Abuse 12 Figure 6: DSM-IV Criteria for Substance Dependence 13 Figure 7: Alcohol and Drug Abuse and Dependence in High Risk Geographic Areas 14 Figure 8: Lifetime Prevalence of Alcohol Abuse and Dependence 15 Figure 9: Map of Lifetime Prevalence of Alcohol Abuse and Dependence by ZIP Code Areas 16 Figure 10: Last 18-Month Prevalence of Alcohol Abuse and Dependence 17 Figure 11: Map of ZIP Code Areas with 18 Month Highest Prevalence of Alcohol and Drug Abuse 18 Figure 12: Lifetime Drug Use by ZIP Code Area 19 Figure 13: Map of Lifetime Drug Use by ZIP Code Area 20 Figure 14: Survey Based Need for Alcohol and Drug Treatment 22 Figure 15: Map of Need for Alcohol and Drug Treatment High Risk ZIP Code Areas 23 iv

5 Preface This report is the second of a series focusing on the need for alcohol and drug and alcohol treatment services in the State of Delaware. These studies analyze the prevalence of alcohol and drug abuse and the patterns of treatment throughout the State. This project is supported by the federal government through an ongoing State Needs Assessment program initiated by the Substance Abuse and Mental Health and Mental Health Administration, Center for Substance Treatment (CSAT). This report is prepared for the State of Delaware, Health and Social Services, Division of Alcoholism, Drug Abuse, and Mental Health administer the studies. This analysis is performed by the University of Delaware, Health Services Policy Research Group. Special acknowledgement is due to the following people: Elizabeth Ableman produced the prevalence estimations and needs assessment calculations. Na Yang and Guneet Knaur performed much of the computer work. Patricia Powell prepared the tables and graphs. Mary Jo McDuffie and David Pizzi prepared the maps. The Advisory Committee of the Division of Alcoholism, Drug Abuse, and Mental Health reviewed the findings and provided valuable insights. Staff of the Division of Alcoholism, Drug Abuse, and Mental Health provided technical assistance and encouragement throughout the research. v

6 Chapter 1: Introduction INTRODUCTION Background. Studies of the need for substance abuse treatment typically focus on the prevalence of pathological alcohol and drug use. Prevalence refers to the number of persons manifesting substance abuse within a specific time frame who reside in a specific geographic area. In this study both an eighteen-month and one year prevalence window is employed. Based on interviews with a random sample of residents of the area, the number of people with clinically defined alcohol and drug problems is estimated. By comparing the estimates of the number of people with alcohol and drug problems with the number treated for substance abuse, an estimate of the need for treatment is produced. This study explores on alcohol and drug problems in high-risk ZIP code areas of the State of Delaware. Twenty ZIP code areas were identified as being at risk for having a high prevalence of alcohol and drug abuse. A sample of the residents of these areas was interviewed. The interview required about 25 minutes. A number of social indicators were used to select the ZIP code areas to be characterized as high risk ZIP code areas were selected based on 1990 Census data and a series of social indicators drawn from State agencies. The indicators used to identify high risk areas included the following indicators were drawn from the 1990 federal population census: percent of civilian labor force, age 16 and over, unemployed; percent of males, age 15 and over, divorced or separated; percent of females, age 15 and over, divorced or separated; percent of occupied housing units with more than one person per room; percent of employed persons, aged 16 years and over, who are operators, percent of service workers and laborers; percent of families in 1989 with income below the poverty level; percent of female headed households; and percent of age 25 and over with less than a ninth grade education. High Risk ZIP code areas are also characterized by social indicators reflecting alcohol and drug problems (Figure 1). These indicators include: alcohol and drug mortality rates, alcohol- and drug-related court processings, hospital discharges in which substance abuse is indicated, and a composite health demographic indicator of alcohol and drug problems. The mortality indicators measure alcohol- and drug-related deaths by ZIP code. The composite variable for alcohol deaths includes deaths indirectly attributable to substance abuse, drug and alcohol-related underlying causes of deaths, and deaths directly attributable to alcohol. The composite variables for alcohol and drug 6

7 related deaths include both drug-related underlying cause of death and multiple cause of death. Cause of death was derived from ICD-9 codes extracted from death certificates for all Delaware decedents from Alcohol- and drug-related criminal prosecution ratios measured the proportion of total cases processed in Delaware s Superior Court from July 1, 1987 through June 30, 1992 which were associated with drugs or alcohol. Alcohol and drug-related hospital discharge ratios measured the proportion of total hospital discharges from 1992 to 1994 that registered to drug or alcohol problems. Figure 1 Sampling Frame for High Risk Area Study Rank of Alcohol and Drug Mortality Ratios, Alcohol and Drug Arrest Ratios, Hospital Discharge Ratio, and Composite Health Demographic Profile Rank for Top 20 Delaware ZIP Code Areas. Zip Code Area a Pop'n Aged b Alcohol Related Deaths c Drug Related Deaths d Alcohol Related Court e Filings Drug Related Court f Alcohol Related Hospital g Discharge Drug Related Hospital h Discharge Health Demogr Profile i , , , , , , , , , , , , , , , , , , , , ZIP Code Rank j a. These are the twenty highest ZIP code areas in the State with respect to the Health Demographic Profile. Higher numbers indicate more severe alcohol and drug problems or in the case of the Health Demographic Profile a higher risk of problems. b Census population c. ZIP code area rank on alcohol-related mortality d. ZIP code area rank on drug-related mortality e. ZIP code rank on alcohol-related court processings f. ZIP code rank on drug-related court processings g. ZIP code rank on alcohol-related hospital discharges h. ZIP code rank on Health Demographic Profile I. ZIP code rank is average rank of indicators a-h. ZIP code is the ZIP code area with the highest composite score. 7

8 A composite alcohol and drug indicator rank was computed for each ZIP code area. The Composite Social Indicator rank for each ZIP code area was derived by combining the eight social indicators. A map showing the location of the ZIP Code Areas from which the interview sample was drawn is shown in Figure 2. 8

9 Figure 2 High Risk ZIP Code Areas State of Delaware High Risk Area Study, Southwest Wilmington and Elsmere New Castle North Wilmington Central Wilmington Townsend Smyrna Leipsic/Dover Camden-Wyoming Magnolia Felton Lincoln Milton Bridgeville Georgetown Seaford Lewes Dewey/ Rehoboth Beach Millsboro Laurel Frankford Health Services Policy Research Group University of Delaware 9 Selbyville

10 Study Base. The survey sample consisted of 2,859 adults aged 18 years and above who were residents of the high risk ZIP code areas. Estimations of the prevalence of substance abuse were calculated using the WESTVAR statistical program. This procedure allows for the specification of a confidence band around the estimates of alcohol and drug abuse that takes into account the multistage sample. The sampling stages included telephone exchange and eligible respondent within household. The demographic composition of the sample is shown in Figure 3. Figure 3 High Risk Area Study Respondent Sample by ZIP Code Area ZIPCODE County Community FEMALE MALE Total New Castle New Castle * New Castle Townsend New Castle Central Wilmington New Castle North Wilmington New Castle Southwest Wilmington and Elsmere Kent Leipsic/Dover Kent Camden/Wyoming Kent Felton * Kent Magnolia Kent/NC Smyrna * Sussex Bridgeville * Sussex Frankford Sussex Georgetown Sussex Laurel Sussex Lewes Sussex Millsboro * Sussex Milton Sussex Dewey/Rehoboth Sussex Seaford * Sussex Selbyville Total *These ZIP codes are excluded from cross-area comparisons because of the insufficient sample size within these areas. 10

11 Alcohol and Drug Use Chapter 2: Alcohol and Drug Use Ninety-three percent of the adult residents of high risk areas reported consuming alcohol at least once during their lifetimes. Sixty-seven percent had used alcohol within the 18 months prior to the interview. Thirty-two percent had used an illegal drug within their lifetimes and approximately four percent reported had used drugs within the last 18 months. Approximately four percent of the respondents had used marijuana within the last 18 months. Less than one percent had used hallucinogens, cocaine (crack) and heroin. Figure 4 High Risk Area Study Alcohol and Drug Use by Lifetime and 18-Month Prevalence Substance Lifetime Users Percentage 18-Month Users Percentage Alcohol Marijuana Hallucinogens Cocaine/Crack Heroin/Opiates 1.1 * Any Drug Alcohol and/or Drug *Number of heroin/opiates is to small for statistical reliability 11

12 Chapter 3: Alcohol and Drug Abuse and Dependence Alcohol and Drug Abuse and Dependence Treatment need in a geographic area is gauged through standardized questions on alcohol and drug abuse and dependence in the 18 months prior to the interview. Prevalence estimates are based on interviews with 2,859 respondents aged 18 years and above reside in High Risk ZIP Code Areas of the State. The interview incorporates the DSM-IV criteria to screen for alcohol and drug abuse and dependence. The DSM-IV criteria for alcohol and drug abuse are shown in Figure 5. The DSM-IV criteria for alcohol and drug dependence are shown in Figure 6. Figure 5 DSM-IV Criteria for Substance Abuse A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following: 1) Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household) 2) Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use) 3) Recurrent substance-related legal problems (e.g., arrests for substancerelated disorderly conduct) 4) Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights) B. The symptoms have never met the criteria for Substance Dependence for this class of substance. Source: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, American Psychiatric Associations,

13 Figure 6 DSM-IV Criteria for Substance Dependence A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following: (1) tolerance, as defined by either of the following: (a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect (b) markedly diminished effect with continued use of the same amount of the substance (2) withdrawal, as manifested by either of the following: (a) the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances) (b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms (3) the substance is often taken in larger amounts or over a longer period than was intended (4) there is a persistent desire or unsuccessful efforts to cut down or control substance use (5) a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain smoking), or recover from its effects (6) important social, occupational, or recreational activities are given up or reduced because of substance use (7) the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption) Specify if: With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 1 or 2 is present) Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 1 or 2 is present) Source: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, American Psychiatric Association,

14 Alcohol Abuse and Dependence Differences across High Risk ZIP-Code Areas This study estimates the prevalence of substance abuse and dependence across the high-risk geographic areas of the State of Delaware. Prevalence is measured through responses to an interview administered to 2,860 respondents. The number of completed interviews for each ZIP code area determines the feasibility of using the survey to measure prevalence within the area. ZIP code areas with fewer than 75 completed interviews were not included in the analysis. Fourteen ZIP Code areas met this minimum sample size. The appropriate statistical procedure for studying relatively rare phenomena, such as drug abuse, is the Poisson distribution. Geographic Areas having a significantly higher prevalence of substance abuse were identified through this procedure. ZIP code areas with a prevalence significantly higher than the overall high-risk sample are designated with an asterisk (*). Approximately three percent of the adult population of the High Risk ZIP Code Areas was dependent on alcohol or abused alcohol within the 18 months prior to the interview (Table 7). Alcohol abuse and dependence poses a clear hazard to general health and to the capacity to function in family and work roles. Alcohol abuse is a significant safety hazard at work, in motor vehicles, and in marine craft and airplanes. Pathological substance use effects not only the alcohol abuser and his immediate social environment, but also the broader community. Approximately one-half a percent of the population residing in these areas manifests drug abuse or dependence within the prior 18-months (Figure 7). Figure 7 Alcohol and Drug Abuse and Dependence High Risk Geographic Areas State of Delaware, Alcohol Abuse and/or Dependence Drug Abuse and /or Dependence Alcohol and/or Drug Abuse Dependence 18 Month Prevalence Percentage Lifetime Prevalence Percentage Estimate Low High* Estimate Low High* *High-low percentage are lower and upper 95 percent confidence bonds, computed with Westvar program 14

15 Slightly over three percent of the high risk Delaware population, aged 18 years and above, abused or was dependent upon either alcohol or drugs in the 18 months prior to the interview. Lifetime Alcohol Abuse and Dependence. Prevalence was significantly higher in four ZIP Code areas than in the overall high-risk area sample. These areas included ZIP Codes (New Castle), (Central Wilmington), (North Wilmington), (Southwest Wilmington/Elsmere) and (Smyrna), (Figure 8, Figure 9). Figure 8 Lifetime Prevalence of Alcohol Abuse and Dependence (DSM-IV) High Risk Area Study Survey State of Delaware, Percentage of Population Aged 18 Years and Above Zipcodes County Community Lifetime Alcohol Abuse and Dependence (DSM) Frequency (%) New Castle New Castle 4.5* New Castle Central Wilmington 17.1* New Castle North Wilmington 7.6* New Castle Southwest Wilmington/ 9.3* and Elsmere Kent Leipsic/Dover 5.5* Kent Camden/Wyoming Kent Felton Kent/New Castle Smyrna Sussex Georgetown Sussex Laurel Sussex Lewes Sussex Millsboro Sussex Dewey/Rehoboth Sussex Seaford 2.3 *p <.05 (Poisson). These ZIP code Areas are significantly higher in alcohol abuse and dependence than the overall high-risk area sample. 15

16 Figure 9 Alcohol Abuse and Dependence within Lifetime of Respondent ZIP Code Areas With Highest Prevalence High Risk Area Study, State of Delaware, Southwest Wilmington and Elsmere North Wilmington Central Wilmington New Castle Highest Prevalence Areas 2.3% - 5.5% 5.5% % Smyrna Leipsic/Dover Camden-Wyoming Felton Lewes Georgetown Seaford Dewey/ Rehoboth Beach Laurel Millsboro Health Services Policy Research Group University of Delaware 16

17 Alcohol Abuse and Dependence within Last 18 Months. Prevalence of alcohol abuse and dependence was highest in ZIP Code areas (New Castle), (Central Wilmington), (North Wilmington), (Southwest Wilmington/Elsmere), (New Castle) and (Smyrna), (Figure 10, Figure 11). Figure 10 Last 18-Month Prevalence of Alcohol Abuse and Dependence (DSM-IV) High Risk Areas by ZIPCode Area, State of Delaware, Percentage of Population Aged 18 Years and Above Zipcode County Community Percentage of Population Area with 18-Month Alcohol Abuse and Dependence (DSM) New Castle New Castle (3.1)* New Castle Central Wilmington (7.9)* New Castle North Wilmington (2.8)* New Castle Southwest Wilmington (4.8)* and Elsmere Kent Leipsic/Dover (2.2)* Kent Camden/Wyoming (5.3) Kent Felton (2.7) Kent/New Castle Smyrna (3.2) Sussex Georgetown (1.9) Sussex Laurel Sussex Lewes (1.0) Sussex Millsboro (3.3) Sussex Dewey/Rehoboth (2.6) Sussex Seaford (2.3) *p <.05 (Poisson) These ZIP code areas are significantly higher in 18 month prevalence than the high risk area as a whole. 17

18 Figure 11 Alcohol Abuse and Dependence within Last 18 Months ZIP Code Areas With Highest Prevalence, High Risk Area Study State of Delaware, Southwest Wilmington and Elsmere New Castle North Wilmington Central Wilmington 1.0% - 2.8% 2.8% - 7.9% Smyrna Leipsic/Dover Camden-Wyoming Felton Georgetown Seaford Lewes Dewey/ Rehoboth Beach Millsboro Health Services Policy Research Group University of Delaware 18

19 Lifetime Drug Abuse and Dependence. Prevalence was significantly higher in five ZIP Code areas than in the overall high-risk area sample. These areas included ZIP Codes (New Castle), (Central Wilmington), (North Wilmington), (Southwest Wilmington/Elsmere), and (Smyrna), (Figure 12, Figure 13). Figure 12 Lifetime Drug Use by Zipcode Area High Risk Area Study State of Delaware, Percentage of Population Aged 18 Years and Above Zipcodes County Community 18-Month Drug New Castle New Castle 1.4* New Castle Camden/Wyoming New Castle Central Wilmington 9.7* New Castle North Wilmington 2.8* New Castle Southwest Wilmington 1.3* and Elsmere Kent Leipsic/Dover Kent Camden/Wyoming Kent Felton Kent/New Castle Smyrna 4.8* Sussex Georgetown Sussex Laurel Sussex Millsboro Sussex Dewey/Rehoboth Sussex Seaford 1.2 *p <.05 (Poisson) These ZIPcode areas have significantly higher 18-month prevalence than the high risk areas as a whole. Drug Abuse and Dependence within Last 18 Months. Prevalence of drug abuse and dependence was significantly higher in only one ZIP Code area (Wilmington) (Figure 14). However, eighteen-month drug use provides some indication of the relative intensity of the drug problem within the high-risk areas of Delaware. Four areas register an 18-month prevalence that is significantly higher than the high-risk areas as a whole. These areas are New Castle (19920), Central Wilmington (19801), North Wilmington (19802), and Southwest Wilmington/Elsmere (19805), and Dover (19901). 19

20 Figure 13 Drug Use Within Respondent s Lifetime ZIP Code Areas With Highest Prevalence High Risk Area Study, State of Delaware, Southwest Wilmington and Elsmere North Wilmington Central Wilmington New Castle Townsend % - 2.5% 2.5% % Smyrna Leipsic/Dover Camden-Wyoming Felton Georgetown Seaford Dewey/ Rehoboth Beach Laurel Millsboro Health Services Policy Research Group University of Delaware 20

21 Chapter 4: Summary and Conclusions Summary and Conclusions This study employs a survey of high-risk geographic areas of the State of Delaware to explore the need for substance abuse treatment services. The need for treatment is assessed by standardized questions measuring whether the respondent abused alcohol and illegal drugs in the 18 months prior to the interview. The survey applies the DSM-IV clinical criteria for substance abuse and dependence, supported by the American Psychiatric Association. The DSM-IV criteria encompass a wide range of pathologies including addiction and destructive behaviors in many spheres of life. This approach produces an estimate of the number of persons in need of treatment, in contrast to those other surveys focusing on substance use without attention to the clinical consequences. The High Risk Area Survey was administered in twenty ZIP code areas throughout the State of Delaware. The designation of high risk is based on an area s demographics and its alcohol and drug problems confirmed through social indicators. The social indicators include mortality, criminal court processing, substance treatment admissions, and hospital discharges. The survey gauges the prevalence of current clinically defined alcohol and drug problems in geographic areas that have a both high-risk demographic profile and a high-risk social indicator profile. This approach is similar to the use of a fish-finder to predict the probable location of schools of fish. The fish-finder points to the areas of the sea with a high probability of having a lot of fish. The high-risk area profile points to the areas on the land with a high probability of having a high prevalence of clinically-defined substance abuse. By targeting geographic areas of high risk, scarce resources can be directed to study of the populations at highest risk. The High Risk Area Survey identifies five ZIP-Code areas that are significantly higher in the prevalence of alcohol and drug dependence in the 18 months prior to the interview (Figure 14, Figure 15). These locales include (New Castle), (Central Wilmington), (North Wilmington), (Southwest Wilmington/Elsmere), and (Leipsic/ Dover). Only one area, however, is significantly higher than the others in drug abuse and dependence (19801, Central Wilmington). 21

22 Figure 14 Survey Based Need for Alcohol and Drug Treatment High-Risk ZIP Code Areas, State of Delaware, ZIP-Code Areas with Highest Prevalence of Alcohol and Drug Dependence in 18 Months Prior to Interview ZIP Code County Community Drugs Alcohol Area New Castle New Castle X New Castle Central Wilmington X X New Castle North Wilmington X New Castle Southwest Wilmington and Elsmere X 19901* Kent Leipsic/Dover X *Estimated from 18-month drug use The final step in the planning process is to examine the gaps between the need for treatment services and the actual utilization of treatment services. This study focuses on the respondents who have abused or been dependent upon alcohol or drugs within the 18 months prior to the interview, are classified substance abusers or substance dependent. This population is the target for alcohol and drug treatment. The survey confirms that five geographic areas have a significantly higher need for treatment service than other areas throughout the State. However, it must be emphasized that interviews delving into illegal behavior by respondents, such as the use of illegal drugs, should be considered as but one possible sign of the need for treatment. Collectively, the wide range of substance abuse indicators employed in this study, including the survey and a full range of social indicators, present a balanced profile of the need for substance treatment across the geographic areas of Delaware. The final report of this series will integrate the findings from all of the studies conducted in this needs assessment. Surveybased estimates of substance abuse prevalence will be treated as one of many possible indicators of the need for treatment in a geographic area. The goal will be to present a balanced profile of treatment need based on demand for treatment, social indicators, demographics, and survey findings. 22

23 Figure 15 Survey-Based Need for Alcohol and Drug Treatment, High Risk ZIP Code Areas, State of Delaware, Southwest Wilmington and Elsmere New Castle North Wilmington Central Wilmington Highest Alcohol & Drug Prevalence Townsend Highest Alcohol Prevalance High Risk ZIP Codes Smyrna Leipsic/Dover Camden-Wyoming Magnolia Felton Bridgeville Georgetown Lincoln Milton Lewes Dewey/ Rehoboth Beach Seaford Laurel Millsboro Health Services Policy Research Group University of Delaware Frankford Selbyville

24 Appendix 24

25 Survey Response Rate Calculation Line # Status Number/Rate (%) 1 Total in sample 10,398 2 Disconnected 1,070 3 Unanswered 2,226 4 Known working (=Line 1 - Line 2 - Line 3) 7,102 5 Working business Working residential (= Line 4 - Line 5) 6,711 7 Ineligible respondents 1,253 8 Known eligible respondents (= Line 6 - Line 7) 5,458 9 Estimated eligible respondents for unanswered calls 1,810 (= Line 8/Line 6 * Line 3) 10 Total eligible (= Line 8 + Line 9) 7, Refused to be interviewed 2, Selected respondents not available 0 13 Incomplete interviews 0 14 Completed interviews 3, Response rate (= Line 14/Line 10) 41.36% 25

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