Jonathan Caulkins:
A mathematician looks at what works and what doesn’t in America’s war on drugs
Posted on Carnegie Mellon Today, Dec 18, 2006

For more than 15 years, Professor Jonathan Caulkins has turned his mathematical model-building talents to one of the most intractable and emotion-laden social questions of all: drug abuse.

“America’s drug problem is more severe than that of any other developed country,” Caulkins says. “America has more drug dependence, more overdose deaths, more drug-related HIV-infections, and more drug-related violence. Its impact is widespread and costly; it taxes our criminal justice system, our hospitals, our schools. The cost in dollars and in lives is enormous.”

Yet, despite these high stakes, Caulkins believes that much of U.S. policy is distorted by wishful thinking, bureaucratic silos, and simple misinterpretation of the data. “When you have such a long term and costly problem as drug use has been, it makes sense to root strategies in objective evidence of what works and what doesn’t,” Caulkins says. “We have not always done that.”

After leading the Drug Policy Research Center at the Rand Corporation and designing innovative and influential efforts to assess cocaine control strategies, Caulkins became concerned that the lessons from cocaine were being generalized too broadly to other drugs at different stages in the cycle of adoption. When experts in dynamic modeling approached him about marrying methods from mathematical biosciences, epidemiology, and product diffusion modeling with traditional drug policy analysis, Caulkins jumped at the opportunity.

He now brings this dynamic modeling perspective to a range of problems pertaining to drugs, crime, violence, delinquency and prevention to understand the effect of policy initiatives on those problems as they evolve over time.

The markets for drugs are in some crucial respects not really that different from markets for other types of consumer products. Consumer product marketers, of course, want to expand product sales, while drug policy makers want to curtail them, but the underlying math of the models is the same, Caulkins says.

Drug use follows well-documented cycles of introduction, growth, and maturity. A newer drug, such as methamphetamine, requires a different response than does a “mature” product such as heroin or cocaine. Just as marketers use different tactics with brand new products and established brands, so the approaches to curbing drug use must differ.

“We need to make data-driven decisions about when to emphasize prevention and when to emphasize enforcement,” Caulkins says. “No one approach is the single right answer at every point. In the early phase of a drug epidemic, for example, treatment programs are not as important as they are in the later stages, when users are older, have more health problems, and may be more compliant with treatment. On the other hand, law enforcement has a much more dramatic impact on containing the spread of a drug early in the cycle, but almost none once a drug is in widespread use.”

Caulkins’s fresh approach is attracting attention. He was named a Robert Wood Johnson Foundation Health Policy Fellow in 2006, which is supporting his current project, “Synthesizing Lessons for Drug Policy and Policy Research.”

“We will not have more success in coping with drug abuse until we have a more dispassionate debate,” Caulkins says. “We must look more systematically at what has worked and when it has worked.

“Let’s take a more dynamic approach to respond to a dynamic problem.”

AIDS Group Asks Viagra Maker to Halt Ad Campaign
Advocacy panel says the marketing effort promotes the drug's recreational use. Company denies claim
Los Angeles Times
By Rong-Gong Lin II
Times Staff Writer

A Los Angeles-based AIDS advocacy group is calling for the manufacturer of Viagra to halt a marketing campaign that the group says promotes the drug's recreational use, increasing the risk of acquiring HIV or other sexually transmitted diseases.

The AIDS Healthcare Foundation will run advertisements in publications in New York, San Francisco and South Florida, with the first in Southern California to run today in the L.A. Weekly. The group is particularly concerned that Viagra, manufactured by Pfizer Inc., has become popular among gay and bisexual men who use methamphetamine, which has been associated with risky sexual behavior and HIV infection.

"We call on Pfizer to exercise responsibility by discontinuing marketing to men with mild erectile dysfunction, and by initiating an educational campaign on the dangers of Viagra and meth targeting men who have sex with men," the ad said.

Pfizer denied the AIDS group's claim that its advertising encourages recreational use of the drug, and said its advertising already states that Viagra does not protect against sexually transmitted diseases.

"We've always been committed to the safe and appropriate use of Viagra," said Shontelle Dodson, Pfizer's senior medical director. "We always encourage men to see their physicians for the proper diagnosis."

Michael Weinstein, president of the AIDS Healthcare Foundation, said Pfizer has one ad showing an attractive, smiling man holding a football with the tagline, "Be this Sunday's MVP"; and another with the line, "What are you waiting for?" as a heterosexual couple, after hearing their movie is sold out, smile at each other.

"This is like saying, 'Have a party. Have a good time. Use Viagra,' " Weinstein said.

"Such marketing could make Viagra sound like a party drug, and for a drug to be used when one wants to take risks," said Dr. Jeffrey Klausner, deputy health officer for the San Francisco Department of Public Health.

In 2004, the U.S. Food and Drug Administration ordered Pfizer to stop running TV ads for Viagra that featured a middle-aged man looking at his wife, with an announcer saying: "Remember that guy who used to be called Wild Thing? He's back."

The FDA said the TV ads implied that Viagra promised "a return to a previous level of sexual desire and activity," which the agency called an unsubstantiated claim.

Needle Exchange and Drug Treatment More Effective HIV Prevention
By Yale School of Medicine
Dec 18, 2006, 07:00

(HealthNewsDigest.com).. New Haven, Conn.- For injection drug users, the
most productive and cost-effective approach to managing the spread of HIV is
expanding syringe exchange and drug treatment, as well as promoting
antiretroviral treatment for those already infected with HIV, according to a
new study by researchers at Yale School of Medicine.

Published in the January issue of American Journal of Public Health, the
authors, led by Yale Public Health professor Robert Heimer, found that the
Centers for Disease Control and Prevention's (CDC) new approach of promoting
HIV testing, "Advancing HIV Prevention," may not be best for injection drug
users.

Heimer, professor in the Department of Epidemiology and Public Health at
Yale School of Medicine, said the CDC policy is based on the presumption
that the HIV epidemic can be curtailed in great part by promoting HIV
testing and that more resources should go to expanded testing of high-risk
populations. However, the results reported in this study revealed that
testing was already widespread for urban injectors.

Heimer and co-authors analyzed interviews conducted with 1,543 injection
drug users in five cities, including New Haven and Hartford, CT,
Springfield, MA, Chicago, IL, and Oakland, CA. Access to sterile syringes
through syringe exchanges or at pharmacies with a prescription was not
available in all cities. Injection drug users who participated in the study
were asked if they had been tested for HIV and if they had ever been told
they were HIV positive. From this, the research team estimated what
percentage had never been tested and what percentage did not know their
status.

Ninety-three percent of injectors had been tested, and of those currently in
need of testing, 90 percent were tested in the past three years and 70
percent within the past year. Less than three percent were infected with HIV
without their knowledge. Women and syringe-exchange participants were more
likely to have been tested at least once, and in the recent past. The team
estimated the number of undetected infections among urban injection drug
users in the United States to be fewer than 40,000.

"Our results highlight the need for shifting prevention dollars for urban
injection drug users," said Heimer, who is also an associate professor of
pharmacology at Yale. "It is more important to expend scant resources on
effective primary and secondary preventive programs including access to
clean syringes and helping users get into treatment for their addiction."

Heimer emphasized needle exchange programs, substitution therapy like
methadone and buprenorphine, and engaging those injection drug users already
infected with HIV in supportive anti-retroviral therapy. He said these
approaches have been shown to decrease the incidence of new infections at
rates sufficient to save money.

"When it comes to urban injection drug users, money will be wasted on
low-impact, low-yield counseling and testing programs," said Heimer.
"Prevention programs should not be compelled to generalize and accept a
single approach to preventing disease transmission. Injection drug users
should not be lumped in with other high risk groups. Instead, tailored
programs designed with their unique needs in mind will yield better
outcomes."

Since the study was conducted, Heimer and his colleagues have been working
to immunize injection drug users against hepatitis B, as well as developing
other interventions designed to reduce HIV infections in drug using
populations.

Other authors on the study were Lauretta Grau, Erin Curtin, Kaveh Khoshnood
and Merrill Singer.

Citation: American Journal of Public Health, Vol. 97, No. 1 (January 2007)

African American Safety Counts Group
John Cottrell

Since March 2006, HRP has been holding a Safety Counts Group specifically for African American substance users. What started out as a small group of 3 attendees, has blossomed into an engaging experience for all participants ranging from 9 to 12 participants each week. How did this happen?

Coming on earlier in the year as a health educator to run this group, personally, I was a bit nervous about being able to get people to attend……more specifically BLACK people to attend. I started with asking the people that I knew to make referrals: Sarah McClellan with the Northern Utah Coalition, Ernest Timmons from the Calvary Baptist Church, Janine Hansen from Project Reality, and others. I only hoped that we would have a few people. Outreach workers from HRP passed out flyers at the Weigand Center, Road Home, and Pioneer Park. I only hoped that we were covering our bases.

I have to say that I was pleasantly surprised. On the first day, we had 6 people attend. All seemed enthusiastic, they participated well in the group as we discussed ways to prevent getting HIV and hepatitis. And I do believe the $10 cash incentive helped, too!! After that initial group, though, the numbers dwindled to 2 or 3 each week. I got worried. So I asked the members if they knew people who might benefit from this type of class specifically for African Americans. Current members were only eager to bring more people. Since then, our numbers have grown.

It’s not so much that our numbers have grown or that each class is dynamic with each participant sharing their personal stories and triumphs. An interesting piece to this entire scenario is WHO the members are. This group was designed for African American drug users. Those that are attending happen to be all men. Interesting. And the average age of the group is 50 years of age. Also interesting. Where did these guys come from? Why do they keep coming? What are they getting from this group (besides some cash and an occasional clothing voucher)? And where are the women? These are the questions I have asked myself. It got me thinking about this particular demographic which is statistically and historically difficult to engage in services sometimes. When we look at HIV prevention in Utah, for example, this group is one that is not directly targeted. Perhaps HRP has fallen on to something here. Maybe we’re getting some of those “hard-to-reach” individuals.

The guys that have been coming, especially the new ones, are all brought by current group members. Some have said that they didn’t know they would get an incentive for attending. Some just heard that “there is a great class you should attend.” As mentioned, the classes are informative and definitely lively. We share knowledge with one another. I provide information about HIV and hepatitis, but we go further than that. We set goals to change their thinking or behavior about their drug use. We seek ways to increase their self esteem. We encourage one another. I think this is what the group does and the reasons why the guys keep coming back. It is an atmosphere where these gentlemen can speak their minds openly and honestly. They are among friends and peers. One of my mottos in the group is “stay aware, be conscious.” This relates to the knowledge they already possess. Be sure to bring that knowledge to the surface and use it.

We’ll see how things continue with this group. Will the same members keep attending? Will there continue to be new members? We’ll see.