Publications by authors named "Beau Kilmer"

58 Publications

Estimating the impact of state cigarette tax rates on smoking behavior: Addressing endogeneity using a natural experiment.

Drug Alcohol Depend 2021 Aug 18;225:108807. Epub 2021 Jun 18.

RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407, USA.

Introduction: Cigarette excise taxes are a well-established policy lever for reducing tobacco use. However, estimating the effect of taxes on smoking behavior can be confounded by endogeneity concerns such as selection. This study leverages a unique natural experiment -compulsory relocation of U.S. military service members to installations - to estimate the relationship between state cigarette taxes and smoking behavior without concerns about selection into environments.

Methods: The current study uses data from the Department of Defense's 2011 Health-Related Behaviors Survey and 2011 state cigarette excise taxes from the CDC STATE System. Logistic and Poisson regression analyses estimate the cross-sectional associations between state cigarette excise taxes and the following smoking behaviors: current cigarette smoking, frequency of smoking, heaviness of consumption, and cigarette cessation among individuals who smoked while at the current installation.

Results: Higher taxes are associated with lower odds of current cigarette smoking (AOR = 0.94; 95 % CI: 0.89-0.98), fewer smoking days per month among current cigarette smokers (IRR = 0.98, 95 % CI 0.97-0.996), and higher likelihood of quitting smoking among individuals who had smoked at their current installation (AOR = 1.14, 95 % CI 1.05-1.25). Taxes are not associated with the number of cigarettes smoked per day among current smokers.

Conclusions: Exogenous assignment to installations in states with higher cigarette taxes is associated with lower likelihood of smoking and greater likelihood of quitting. Findings provide novel evidence in support of a causal impact of cigarette taxes on lower smoking levels among adults.
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http://dx.doi.org/10.1016/j.drugalcdep.2021.108807DOI Listing
August 2021

Community perspectives on supervised consumption sites: Insights from four U.S. counties deeply affected by opioids.

J Subst Abuse Treat 2021 Apr 20;131:108397. Epub 2021 Apr 20.

Drug Policy Research Center, RAND Corporation, 1776 Main St., Santa Monica, CA 90407, United States of America.

Background: To address the overdose crisis in the United States, expert groups have been nearly unanimous in calls for increasing access to evidence-based treatment and overdose reversal drugs. In some places there have also been calls for implementing supervised consumption sites (SCSs). Some cities-primarily in coastal urban areas-have explored the feasibility and acceptability of introducing them. However, the perspectives of community stakeholders from more inland and rural areas that have also been hard hit by opioids are largely missing from the literature.

Methods: To examine community attitudes about implementing SCSs for people who use opioids (PWUO) in areas with acute opioid problems, the research team conducted in-depth interviews and focus groups in four counties: Ashtabula and Cuyahoga Counties in Ohio, and Carroll and Hillsborough Counties in New Hampshire, two states with high rates of opioid overdose. Participants were policy, treatment, and criminal justice professionals, frontline harm reduction and service providers, and PWUO.

Results: Key informants noted benefits to SCSs, but also perceived potential drawbacks such as that they may enable opioid use, and potential practical barriers, including lack of desire among PWUO to travel to an SCS after purchasing opioids and fear of arrest. Key informants generally believed their communities likely would not currently accept SCSs due to cultural, resource, and practical barriers. They viewed publication of evidence on SCSs and community education as essential for fostering acceptance.

Conclusions: Despite cultural and other barriers, implementation of SCSs may be more feasible in urban communities with existing (and perhaps more long-standing) harm reduction programs, greater treatment resources, and adequate transportation, particularly if there is strong evidence to support them.
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http://dx.doi.org/10.1016/j.jsat.2021.108397DOI Listing
April 2021

Can novel 'swift-certain-fair' programs work outside of pioneering jurisdictions? An analysis of 24/7 Sobriety in Montana, USA.

Addiction 2021 May 25. Epub 2021 May 25.

RAND, Santa Monica, CA, USA.

Background And Aims: The US state of South Dakota's 24/7 Sobriety Program (24/7) requires individuals charged or convicted of alcohol-involved offenses to avoid alcohol and submit to twice-daily or continuous alcohol testing. We evaluated the impact of the 24/7 program in the US state of Montana.

Methods: Using data from everyone in Montana who was convicted of their second driving under the influence (DUI) offense from 2009 to August 2013, we described program violations among 24/7 participants and then estimated the effect of 24/7 participation on the probability of DUI re-arrest. To address potential selection issues related to individual-level 24/7 participation, we used an instrumental variables approach that exploits county-level variation in program adoption.

Results: Among 2768 people convicted of a second DUI in our analytical sample, 356 participated in 24/7 and were monitored for an average of 173 days (median = 112 days). Among the 332 participants monitored by breath test, 95.5% of scheduled alcohol breath tests were completed and did not lead to a program violation. After controlling for individual- and community-level covariates as well as year and county fixed effects, our instrumental variable models suggested that participation in 24/7 reduced the 1-year DUI re-arrest probability by at least 80% (preferred model: 86% decrease; 8.9 percentage points) compared with a counterfactual group of people convicted of a second DUI over the same period but not assigned to the program.

Conclusions: South Dakota USA's 24/7 Sobriety Program appears to work in Montana as well. Certain delivery of immediate but modest sanctions for repeat driving under the influence (DUI) arrestees who violate alcohol abstinence orders appears to be able to reduce future DUI arrests.
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http://dx.doi.org/10.1111/add.15584DOI Listing
May 2021

Exposure to new smoking environments and individual-level cigarette smoking behavior: Insights from exogenous assignment of military personnel.

Soc Sci Med 2021 07 4;280:113983. Epub 2021 May 4.

RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407, USA.

Despite overall declines in cigarette smoking prevalence in the United States (U.S.) in the past several decades, smoking rates remain highly variable across geographic areas. Past work suggests that smoking norms and exposure to other smokers in one's social environment may correlate with smoking risk and cessation, but little is known about how exposure to other smokers in one's community is causally linked to smoking behavior - in part due to endogeneity and inability to randomly assign individuals to different 'smoking environments.' The goal of this study was to evaluate how exposure to localities with high population-level smoking prevalence affects individual-level cigarette smoking behaviors, including quitting. The study addresses key limitations in the literature by leveraging a unique natural experiment: the plausibly exogenous compulsory assignment of military personnel to installations. Logistic and multivariate regressions estimated cross-sectional associations between smoking/quitting behaviors and our proxy for social environments for smoking, county-level smoking prevalence (CSP). Across 563 U.S. counties, CSP ranged from 3.8 to 37.9%. Among the full sample, a 10 percentage point increase in CSP was associated with an 11% greater likelihood of smoking. In subgroup analyses, young adults, women, those without children in the household, and risk/sensation-seekers were more likely to smoke and less likely to quit when exposed to counties with higher CSP. Relocation to areas with high population-level smoking prevalence may increase likelihood of smoking and impede quitting, and may disparately affect some population subgroups. Findings provide novel evidence that community smoking environments affect adult smoking risk and underscore a need for sustained, targeted efforts to reduce smoking in areas where prevalence remains high.
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http://dx.doi.org/10.1016/j.socscimed.2021.113983DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8223508PMC
July 2021

New synthetic drugs require new policies.

Addiction 2021 06 21;116(6):1317-1318. Epub 2021 Feb 21.

RAND Corporation, Santa Monica, CA, USA.

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http://dx.doi.org/10.1111/add.15442DOI Listing
June 2021

Illicit synthetic opioid consumption in Asia and the Pacific: Assessing the risks of a potential outbreak.

Drug Alcohol Depend 2021 03 2;220:108500. Epub 2021 Jan 2.

RAND Corporation, 1200 South Hayes Street, Arlington, 22202 VA, United States. Electronic address:

Background: Illegally manufactured potent synthetic opioids (IMPSO) like fentanyl have contributed to rises in overdose deaths in parts of North America and Europe. While many of these substances are produced in Asia, there is little evidence they have entered markets there. We consider the susceptibility to IMPSO's encroachment in markets in the Asia-Pacific region.

Methods: Our analysis focuses on Australia, China, India, and Myanmar. Using a mixed-methods approach comprising interviews, literature review, and secondary data analyses, we examine factors facilitating or impeding incursion of IMPSO. Finally, we illustrate the potential for IMPSO fatalities in Australia.

Results: Australia reports some signs of three facilitating factors to IMPSO's emergence: 1) existing illicit opioid markets, 2) disruption of opioid supply, and 3) user preferences. The other three countries report only existing illicit opioid markets. While diverted pharmaceutical opioids are a noted problem in Australia and India, heroin is the dominant opioid in all four countries. There are divergent trends in heroin use, with use declining in China, increasing in India, and stable in Australia and Myanmar. If IMPSO diffused in Australia as in North America from 2014 to 2018, and our assumptions generally hold, deaths from IMPSO could range from 1500-5700 over a five-year period.

Conclusions: This analysis and illustrative calculations serve as an early indication for policymakers. With the exception of Australia, many countries in the region fail to properly record overdose deaths or monitor changes in local drug markets. Early assessment and monitoring can give officials a better understanding of these changing threats.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108500DOI Listing
March 2021

Examining Associations Between Licensed and Unlicensed Outlet Density and Cannabis Outcomes From Preopening to Postopening of Recreational Cannabis Outlets.

Am J Addict 2021 03 30;30(2):122-130. Epub 2020 Dec 30.

RAND Corporation, Santa Monica, California.

Background And Objectives: To expand on epidemiologic studies examining associations between the legalization of recreational cannabis and use among young adults, we examined the associations between licensed and unlicensed cannabis outlet density and cannabis outcomes.

Methods: A total of 1097 young adults aged 21 and older living in Los Angeles County were surveyed before licensed recreational cannabis outlets opened (Time 1: July to December 2017) and after (Time 2: July 2018 to June 2019). Using a database of open licensed and unlicensed cannabis retailers to calculate individual-level cannabis outlet density measures, we examined associations between outlet density within a 4-mile radius of participants' residences with Time 2 outcomes of any past-month use, daily use, intentions to use, quantity used, consequences, and cannabis use disorder (CUD) symptoms.

Results: After controlling for demographic factors and cannabis outcomes at a time point prior to their opening (Time 1), licensed cannabis outlets were associated with young adults' cannabis use, heavy use, and intentions, and unlicensed outlets were associated with young adults' heavy cannabis use and CUD symptoms.

Conclusion And Scientific Significance: This study expands beyond studies of outlet prevalence to find that, after controlling for outcomes 1 year prior, licensed and unlicensed outlets were associated with young adults' cannabis outcomes. The current study is among the first to find associations between cannabis use outcomes and density of cannabis outlets among young adults using data from two time points: preopening and postopening of recreational cannabis retailers. Findings can inform policies around the density and placement of cannabis outlets. (Am J Addict 2020;00:00-00).
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http://dx.doi.org/10.1111/ajad.13132DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8157480PMC
March 2021

The dawn of a new synthetic opioid era: the need for innovative interventions.

Addiction 2021 06 31;116(6):1304-1312. Epub 2020 Aug 31.

RAND Corporation, Santa Monica, CA, USA.

Background: Overdose deaths related to illegal drugs in North American markets are now dominated by potent synthetic opioids such as fentanyl, a circumstance foreshadowed by often-overlooked events in Estonia since the turn of the century. Market transitions generate important and far-reaching implications for drug policy.

Argument And Analysis: The supplier-driven introduction of illegally manufactured synthetic opioids into street opioids is elevating the risk of fatal overdose. Using the most recent overdose mortality and drug seizure data in North America, we find that overdose deaths and seizures involving synthetic opioids are geographically concentrated, but this might be changing. Examination here suggests that in some places fentanyl and its analogues have virtually displaced traditional opioids, such as heroin. The concealing of synthetic opioids in powders sold as heroin or pressed into counterfeit medications substantially increases harms. The nature and scale of the challenge posed by synthetic opioids is unprecedented in recent drug policy history.

Conclusions: There is urgent need for policy and technological innovation to meet the challenges posed by illegally produced synthetic opioids. Novel interventions worth examining include supervising drug use, proactively deterring on-line distribution and new technologies aimed at improving transparency, such as point-of-use drug content testing. Continuing to approach this problem only with existing policies and available methods, such as naloxone, is unlikely to be enough and will result in many premature deaths.
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http://dx.doi.org/10.1111/add.15222DOI Listing
June 2021

Assessment of the impact of implementation of a zero blood alcohol concentration law in Uruguay on moderate/severe injury and fatal crashes: a quasi-experimental study.

Addiction 2021 05 24;116(5):1054-1062. Epub 2020 Sep 24.

RAND Corporation, Santa Monica, CA, USA.

Background And Aims: Debates regarding lowering the blood alcohol concentration (BAC) limit for drivers are intensifying in the United States and other countries, and the World Health Organization recommends that the limit for adults should be 0.05%. In January 2016, Uruguay implemented a law setting a zero BAC limit for all drivers. This study aimed to assess the effect of this policy on the frequency of moderate/severe injury and fatal traffic crashes.

Design: A quasi-experimental study in which a synthetic control model was used with controls consisting of local areas in Chile as the counterfactual for outcomes in Uruguay, matched across population counts and pre-intervention period outcomes. Sensitivity analyses were also conducted.

Setting: Uruguay and Chile.

Cases: Panel data with crash counts by outcome per locality-month (2013-2017).

Intervention And Comparator: A zero blood alcohol concentration law implemented on 9 January 2016 in Uruguay, alongside a continued 0.03 g/dl BAC threshold in Chile.

Measurements: Per-capita moderate/severe injury (i.e. moderate or severe), severe injury and fatal crashes (2013-2017).

Findings: Our base synthetic control model results suggested a reduction in fatal crashes at 12 months [20.9%; P-value = 0.018, 95% confidence interval (CI) = -0.340, -0.061]. Moderate/severe injury crashes did not decrease significantly (10.2%, P = 0.312, 95% CI = -0.282, 0.075). The estimated effect at 24 months was smaller and with larger confidence intervals for fatal crashes (14%; P = 0.048, 95% CI = -0.246, -0.026) and largely unchanged for moderate/severe injury crashes (-9.4%, P = 0.302, 95% CI = -0.248, 0.058). Difference-in-differences analyses yielded similar results. As a sensitivity test, a synthetic control model relying on an inferior treatment-control match pre-intervention (measured by mean squared error) yielded similar-sized differences that were not statistically significant.

Conclusions: Implementation of a law setting a zero blood alcohol concentration threshold for all drivers in Uruguay appears to have resulted in a reduction in fatal crashes during the following 12 and 24 months.
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http://dx.doi.org/10.1111/add.15231DOI Listing
May 2021

Variation in the degree of concentration of prescription opioid utilization using different measures.

Drug Alcohol Depend 2020 Jun 11;213:108101. Epub 2020 Jun 11.

RAND Corporation, 4570 Fifth Avenue #600, Pittsburgh, PA, 15213, United States.

Background: Studies of opioid prescribing patterns have shown that a small percentage of prescribers are responsible for a large portion of total prescriptions. There is some evidence that prescription opioid use may be similarly concentrated, but patterns may differ by population and choice of opioid utilization measure. The objective of this study is to determine what proportion of prescription opioid utilization was attributable to the top utilizers among Medicaid beneficiaries and how this proportion varies by the measure used.

Methods: We analyzed 2008-2009 Medicaid claims data from 14 states and created three claims-based measures of aggregate opioid utilization: total number of annual prescriptions, total annual milligrams morphine equivalent, and total days supply. We tested two versions of the total days supply measure: one assuming consecutive use and the other assuming concurrent use of prescriptions.

Results: The top 20 % of prescription opioid users accounted for 66 % of prescriptions, 82-85 % of days supply depending on assumption, and 90 % of morphine milligram equivalents (MME). The degree to which prescription opioid utilization was concentrated among the top 20 % of users varied minimally across states.

Conclusions: A small percentage of prescription opioid users account for a large share of prescription opioid use. Policy efforts should use metrics pertaining to days supply and total MME, not numbers of prescriptions, to more efficiently target heavy utilization. Policies targeting high-dose prescribing should consider the different ways that overlapping prescriptions may be taken.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108101DOI Listing
June 2020

Being thoughtful about cannabis legalization and social equity.

World Psychiatry 2020 Jun;19(2):194-195

Beneficial State Foundation, Oakland, CA, USA.

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http://dx.doi.org/10.1002/wps.20741DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7215057PMC
June 2020

Intensity of cannabis use: Findings from three online surveys.

Int J Drug Policy 2020 Apr 22;79:102740. Epub 2020 Apr 22.

RAND Drug Policy Research Center, 1776 Main St., Santa Monica, CA 90401, USA.

Background: Drug use is often measured in terms of prevalence, meaning the number of people who used any amount in the last month or year, but measuring the quantity consumed is critical for making informed regulatory decisions and estimating the effects of policy changes. Quantity is the product of frequency (e.g., number of use days in the last month) and intensity (amount consumed per use day). Presently, there is imperfect understanding of the extent to which more frequent users also consume more intensively.

Methods And Data: We examine cannabis flower consumption reported in three similar online surveys fielded in times and places where cannabis was and was not legal. These convenience samples returned enough valid responses (n = 2,618) to examine consumption across different frequencies of use via analyses of measures of central tendency, data visualizations, and multivariate regressions. Additional calculations incorporate data from the National Survey on Drug Use and Health.

Findings: Respondents who reported using daily (i.e., 30 days in the past month) consumed almost twice as much per day of use on average as did those reporting less than daily. We find only modest increases in intensity among those using less than daily, but then a substantial increase (p< 0.001) for those who use daily. Most respondents report that on heavy or light use days their consumption differs from a typical day of use by a factor of 2 or more, but only about 25% of days were described as heavy or light. We estimate those using cannabis 21+ days a month account for 80% of consumption vs. 71% of the days of use.

Discussion: Daily cannabis users consume more intensively than others, including near-daily users. When possible, survey questions should move beyond the presence or absence of use and number of days used.
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http://dx.doi.org/10.1016/j.drugpo.2020.102740DOI Listing
April 2020

Disagreeing on whether we agree.

Addiction 2020 04 8;115(4):785-786. Epub 2020 Jan 8.

RAND, Drug Policy Research Center, Santa Monica, CA, USA.

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http://dx.doi.org/10.1111/add.14915DOI Listing
April 2020

The benefits of evaluating literatures with essays.

Addiction 2019 12 28;114(12):2120-2121. Epub 2019 Oct 28.

RAND Drug Policy Research Center, Santa Monica, CA, USA.

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http://dx.doi.org/10.1111/add.14802DOI Listing
December 2019

Supervised consumption sites: a nuanced assessment of the causal evidence.

Addiction 2019 12 1;114(12):2109-2115. Epub 2019 Aug 1.

RAND Drug Policy Research Center, RAND, Santa Monica, CA, USA.

Background And Aims: Supervised consumption sites (SCS) operate in more than 10 countries. SCS have mostly emerged as a bottom-up response to crises, first to HIV/AIDS and now overdose deaths, in ways that make rigorous evaluation difficult. Opinions vary about how much favorable evidence must accumulate before implementation. Our aim was to assess the nature and quality of evidence on the consequences of implementing SCS.

Methods: We reviewed the higher-quality SCS literature, focusing on articles evaluating natural experiments and mathematical modeling studies that estimate costs and benefits. We discuss the evidence through the lens of three types of decision-makers and from three intellectual perspectives.

Results: Millions of drug use episodes have been supervised at SCS with no reported overdose deaths; however, uncertainties remain concerning the magnitude of the population-level effects. The published literature on SCS is large and almost unanimous in its support, but limited in nature and the number of sites evaluated. It can also overlook four key distinctions: (1) between outcomes that occur within the facility and possible spillover effects on behavior outside the SCS; (2) between effects of supervising consumption and the effects of other services offered, such as syringe or naloxone distribution; (3) between association and causation; and (4) between effectiveness and the cost-effectiveness of SCS compared to other interventions.

Conclusions: The causal evidence for favorable outcomes of supervised consumption sites is minimal, but there appears to be little basis for concern about adverse effects. This raises the question of how context and priors can affect how high the bar is set when deciding whether to endorse supervised consumption sites. The literature also understates distinctions and nuances that need to be appreciated to gain a rich understanding of how a range of stakeholders should interpret and apply that evidence to a variety of decisions.
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http://dx.doi.org/10.1111/add.14747DOI Listing
December 2019

Triangulating web & general population surveys: Do results match legal cannabis market sales?

Int J Drug Policy 2019 11 2;73:293-300. Epub 2019 Jul 2.

RAND Drug Policy Research Center, 1776 Main St., Santa Monica, CA 90401, USA.

Background: This paper combines complementary attributes of web and general population surveys to estimate cannabis consumption and spending in Washington State. It compares those estimates to legal sales recorded by the state's seed-to-sale tracking system, and thus exploits a rare opportunity to contrast two independent estimates for the same cannabis market. This sheds light on the question of whether nontrivial amounts of black market sales continue even after a state allows licensed production and sale.

Methods: Prevalence of past-month use is estimated from the 2015/16 U.S. National Survey on Drug Use and Health, adjusted for under-reporting. Estimates of consumption and spending per user broken down by age, gender, and frequency of use are developed from RAND's 2013 survey of cannabis users in Washington State. Supply side estimates come from the Washington State Liquor and Cannabis Board's seed-to-sale tracking system. They are expressed in terms of spending, equivalent-weight of flowers, and THC, with THC for edibles imputed using a machine learning technique called random forests.

Results: For the period July 1, 2016 to June 30, 2017, Washington's seed-to-sale data record sales from licensed cannabis stores of $1.17B and across all products an amount of THC that is equivalent to roughly 120-150 MT of flower. Survey responses suggest that amounts spent and quantities consumed are larger than that, perhaps on the order of $1.66B and over 200 MT, respectively.

Conclusion: A perfect match is not expected because of sales to tourists, residual black market activity, production for medical purposes, and diversion across state lines. Nonetheless, the results suggest that three years after state-licensed stores opened, there remained considerable consumption of cannabis supplied outside of the licensed system.
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http://dx.doi.org/10.1016/j.drugpo.2019.06.010DOI Listing
November 2019

How will cannabis legalization affect health, safety, and social equity outcomes? It largely depends on the 14 Ps.

Authors:
Beau Kilmer

Am J Drug Alcohol Abuse 2019 2;45(6):664-672. Epub 2019 Jul 2.

RAND Drug Policy Research Center, Santa Monica, CA, USA.

Jurisdictions considering or implementing alternatives to cannabis supply prohibition will confront several decisions that will influence health, safety, and social equity outcomes. This essay highlights 14 of these design considerations, which all conveniently begin with the letter : 1) Production, 2) Profit motive, 3) Power to regulate, 4) Promotion, 5) Prevention and treatment, 6) Policing and enforcement, 7) Penalties, 8) Prior criminal records, 9) Product types, 10) Potency, 11) Purity, 12) Price, 13) Preferences for licenses, and 14) Permanency. For each factor, the paper explains why it is important, describes the various approaches, and highlights how some of the jurisdictions that have legalized have addressed these choices. The primary audiences are decision makers considering alternatives to prohibiting cannabis supply and analysts making projections or conducting evaluations of these changes.
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http://dx.doi.org/10.1080/00952990.2019.1611841DOI Listing
July 2020

Commentary on Bainbridge (2019): Improving the evidence base for 24/7 Sobriety.

Authors:
Beau Kilmer

Addiction 2019 09 20;114(9):1706-1707. Epub 2019 Jun 20.

RAND Drug Policy Research Center.

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http://dx.doi.org/10.1111/add.14657DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7161575PMC
September 2019

Prescribing diamorphine in the United States: Insights from a nationally representative survey.

Drug Alcohol Depend 2019 03 4;196:62-65. Epub 2019 Jan 4.

Carnegie Mellon University Heinz College, 5000 Forbes Ave., Pittsburgh PA 1521, United States.

Background: Some countries allow physicians to prescribe pharmaceutical-grade diamorphine to dependent users who have previously undergone treatment but are still using street-sourced heroin; this is not allowed in the US. This study provides the first nationally representative US data concerning public support for prescribing diamorphine to dependent users. We also test the hypothesis that calling it "diamorphine" instead of "heroin" increases support for this approach.

Methods: The RAND American Life Panel is a nationally representative, probability-based survey of US adults. Of the 3345 panel members invited to take the survey, 2530 (75.6%) provided a valid response to our question module. Respondents were randomly assigned to have the question refer to the prescribed drug as either "heroin" or "diamorphine." The groups did not significantly differ on sex, age, race/ethnicity, or education. We compare the distribution of responses for the two groups and conduct Pearson's chi-squared test with the Rao-Scott correction.

Results: For those asked whether the US should try prescribing pharmaceutical-grade "heroin," the share answering "Yes" (20.8%) was 15 percentage points lower than those responding "No" (35.8%). When the question asked about "diamorphine," the results were nearly reversed: the share answering "Yes" (30.6%) was almost 12 percentage points higher than those responding "No" (18.9%). The distributions of responses were significantly different (p < 0.001).

Conclusions: Support for prescribing diamorphine to dependent users is low in the US. While the results are consistent with the hypothesis that referring to heroin as diamorphine may reduce stigma associated with the substance and increase support for prescribing it, opinions may change as individuals learn they are different names for the same substance.
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http://dx.doi.org/10.1016/j.drugalcdep.2018.12.007DOI Listing
March 2019

Big data on a big new market: Insights from Washington State's legal cannabis market.

Int J Drug Policy 2018 07 27;57:86-94. Epub 2018 Apr 27.

RAND Drug Policy Research Center, 1776 Main St., Santa Monica, CA 90401, USA.

Introduction: Voters in eight U.S. states have passed initiatives to legalize large-scale commercial production of cannabis for non-medical use. All plan or require some form of "seed-to-sale" tracking systems, which provide a view of cannabis market activity at a heretofore unimagined level of detail. Legal markets also create a range of new matters for policy makers to address.

Data: Publicly available data were obtained on approximately 45 million individually priced items purchased in the 35 million retail transactions that took place during the first two and a half years of Washington State's legal cannabis market. Records include product type (flower, extract, lotion, liquid edible, etc.), product name, price, and potency with respect to multiple cannabinoids, notably THC and CBD. Items sold can be traced back up the supply chain through the store to the processor and producer, to the level of identifying the specific production batch and mother plant, the firm that tested the product, and test results.

Method: Data visualization methods are employed to describe spatial-temporal patterns of multiple correlated attributes (e.g., price and potency) broken down by product. Text-analytic methods are used to subdivide the broad category of "extracts for inhalation" into more homogeneous sub-categories. To understand the competitiveness of the legal cannabis market in Washington we calculate the Herfindahl-Hirschman index (HHI) for processors and retailers.

Results: Cannabis prices fell steadily and proportionally at the processor and retailer levels. Retail and wholesale price maintained a roughly 3:1 ratio for multiple product types after some initial fluctuations. Although a wide range of edibles are sold, they account for a modest share of consumer spending; extracts for inhalation are a larger and heterogeneous market segment. The HHI indicates the cannabis market is highly competitive at the processor level, but less so for retail markets at the county level.

Conclusions: Washington's state-legal cannabis market is diverse and rapidly evolving in terms of pricing, products, and organization. Post-legalization, researchers and policy makers may need to think in terms of a family of cannabis products, akin to how we think of new psychoactive substances and amphetamine-type stimulants, not a single drug "cannabis."
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http://dx.doi.org/10.1016/j.drugpo.2018.03.031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6948109PMC
July 2018

Exploring the perils of cross-national comparisons of drug prevalence: The effect of survey modality.

Drug Alcohol Depend 2017 12 18;181:194-199. Epub 2017 Oct 18.

Rand Corporation, United States.

Background: There is significant interest in comparing countries on many different indicators of social problems and policies. Cross-national comparisons of drug prevalence and policies are often hampered by differences in the approach used to reach respondents and the methods used to obtain information in national surveys. The paper explores how much these differences could affect cross-country comparisons.

Methods: This study reports prevalence of drug use according to the most recent national household survey and then adjusts estimates as if all national surveys used the same methodology. The analysis focuses on European countries for which the European Monitoring Centre for Drugs and Drug Addiction reports data, the United States, Canada, and Australia. Adjustment factors are based on US data.

Findings: Adjusting for modality differences appears likely to modestly affect the rankings of countries by prevalence, but to an extent that could be important for comparisons. For example, general population surveys suggest that the US had some of the highest cannabis and cocaine prevalence rates circa 2012, but this is partially driven by the use of a modality known to produce higher prevalence estimates. This analysis shows that country rankings are partly an artifact of the mode of interview used in national general population surveys.

Conclusions: Our preliminary efforts suggest that cross-national prevalence comparisons, policy analyses and, other projects such as estimating the global burden of disease could be improved by adjusting estimates from drug use surveys for differences in modality. Research is needed to create more authoritative adjustment factors.
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http://dx.doi.org/10.1016/j.drugalcdep.2017.09.027DOI Listing
December 2017

How Medical Marijuana Smoothed the Transition to Marijuana Legalization in the United States.

Annu Rev Law Soc Sci 2017 Oct 3;13(1):181-202. Epub 2017 Jul 3.

School of Law, Stanford University, Stanford, California 94305.

Public support for legalizing marijuana use increased from 25% in 1995 to 60% in 2016, rising in lockstep with support for same-sex marriage. Between November 2012 and November 2016, voters in eight states passed ballot initiatives to legalize marijuana sales for nonmedical purposes-covering one-fifth of the US population. These changes are unprecedented but are not independent of the changes in medical marijuana laws that have occurred over the past 20 years. This article suggests five ways in which the passage and implementation of medical marijuana laws smoothed the transition to nonmedical legalization in the United States: () They demonstrated the efficacy of using voter initiatives to change marijuana supply laws, () enabled the psychological changes needed to destabilize the "war on drugs" policy stasis, () generated an evidence base that could be used to downplay concerns about nonmedical legalization, () created a visible and active marijuana industry, and () revealed that the federal government would allow state and local jurisdictions to generate tax revenue from marijuana.
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http://dx.doi.org/10.1146/annurev-lawsocsci-110615-084851DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8152576PMC
October 2017

Variation in cannabis potency and prices in a newly legal market: evidence from 30 million cannabis sales in Washington state.

Addiction 2017 Dec 4;112(12):2167-2177. Epub 2017 Jul 4.

RAND Corporation, Santa Monica, CA, USA.

Aims: To (1) assess trends and variation in the market share of product types and potency sold in a legal cannabis retail market and (2) estimate how potency and purchase quantity influence price variation for cannabis flower.

Design: Secondary analysis of publicly available data from Washington State's cannabis traceability system spanning 7 July 2014 to 30 September 2016. Descriptive statistics and linear regressions assessed variation and trends in cannabis product variety and potency. Hedonic regressions estimated how purchase quantity and potency influence cannabis flower price variation.

Setting: Washington State, USA.

Participants: (1) A total of 44 482 176 million cannabis purchases, including (2) 31 052 123 cannabis flower purchases after trimming price and quantity outliers.

Measurements: Primary outcome measures were (1) monthly expenditures on cannabis, total delta-9-tetrahydrocannabinol (THC) concentration and cannabidiol (CBD) concentration by product type and (2) excise tax-inclusive price per gram of cannabis flower. Key covariates for the hedonic price regressions included quantity purchased, THC and CBD.

Findings: Traditional cannabis flowers still account for the majority of spending (66.6%), but the market share of extracts for inhalation increased by 145.8% between October 2014 and September 2016, now comprising 21.2% of sales. The average THC-level for cannabis extracts is more than triple that for cannabis flowers (68.7% compared to 20.6%). For flower products, there is a statistically significant relationship between price per gram and both THC [coefficient = 0.012; 95% confidence interval (CI) = 0.011-0.013] and CBD (coefficient = 0.017; CI = 0.015-0.019). The estimated discount elasticity is -0.06 (CI = -0.07 to -0.05).

Conclusions: In the state of Washington, USA, the legal cannabis market is currently dominated by high-THC cannabis flower, and features growing expenditures on extracts. For cannabis flower, both THC and CBD are associated with higher per-gram prices, and there are small but significant quantity discounts.
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http://dx.doi.org/10.1111/add.13886DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5673542PMC
December 2017

Building the data infrastructure to evaluate cannabis legalization.

Addiction 2017 07 5;112(7):1140-1141. Epub 2017 May 5.

Drug Policy Research Center, RAND, Santa Monica, CA, USA.

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http://dx.doi.org/10.1111/add.13824DOI Listing
July 2017

Uruguay's middle-ground approach to cannabis legalization.

Int J Drug Policy 2017 04 30;42:118-120. Epub 2017 Mar 30.

RAND Drug Policy Research Center, United States. Electronic address:

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http://dx.doi.org/10.1016/j.drugpo.2017.02.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5505872PMC
April 2017

Recreational Cannabis - Minimizing the Health Risks from Legalization.

Authors:
Beau Kilmer

N Engl J Med 2017 Feb;376(8):705-707

From the RAND Drug Policy Research Center, Santa Monica, CA.

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http://dx.doi.org/10.1056/NEJMp1614783DOI Listing
February 2017

Considering marijuana legalization carefully: insights for other jurisdictions from analysis for Vermont.

Addiction 2016 12 7;111(12):2082-2089. Epub 2016 Feb 7.

RAND Drug Policy Research Center, Santa Monica, CA, USA.

Background And Aims: In 2014 the legislature of Vermont, USA passed a law requiring the Secretary of Administration to report on the consequences of legalizing marijuana. The RAND Corporation was commissioned to write that report. This paper summarizes insights from that analysis that are germane to other jurisdictions.

Method: Translation of key findings from the RAND Corporation report to the broader policy debate.

Results: Marijuana legalization encompasses a wide range of possible regimes, distinguished along at least four dimensions: which organizations are allowed to produce and supply the drug, the regulations under which they operate, the nature of the products that can be distributed and taxes and prices. Vermont's decriminalization had already cut its costs of enforcing marijuana prohibition against adults to about $1 per resident per year. That is probably less than the cost of regulating a legal market. Revenues from taxing residents' purchases after legalization could be many times that amount, so the main fiscal cost of prohibition after decriminalization relative to outright legalization may be foregone tax revenues, not enforcement costs. Approximately 40 times as many users live within 200 miles of Vermont's borders as live within the state; drug tourism and associated tax revenues will be important considerations, as will be the response of other states. Indeed, if another state legalized with lower taxes, that could undermine the ability to collect taxes on even Vermont residents' purchases.

Conclusions: Analysis of possible outcomes if Vermont, USA, legalized marijuana reveal that choices about how, and not just whether, to legalize a drug can have profound consequences for the effects on health and social wellbeing, and the choices of one jurisdiction can affect the options and incentives available to other jurisdictions.
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http://dx.doi.org/10.1111/add.13289DOI Listing
December 2016