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Epidemiology of Drug Abuse in the United States: A Summary of Methods and Findings NICHOLAS J. KOZEL~ 444 Epidemiology has recently been used to effectively track and analyze drug abuse patterns. This article generally desm’bes methods used in the United States for estimating and monitoring drug abuse. It outlines the advantages and limitafions of suck data sources as surveys, indicators, and etknograpky, and briefly explores the work and utility of local, national, and international drug surveillance net- works. In addition, it desrribes national and local patterns of heroin, cocaine, and marijuana abuse. he recent use of epidemiology to METHODS FOR ESTIMATING AND T study drug abuse has been of great MONITORING DRUG ABUSE value. Although drug abuse, because of its illicit nature and because of the unique The fact that nor-medical use of licit behavior patterns of abusers, has proven drugs and the abuse of illicit drugs is pro- very difficult to measure, the epidemio- scribed in society poses major difficulties logic approach has provided tools to ac- and limitations for most methodologies curately quantify data and to calculate used to measure the nature and extent of with scientific rigor such things as inci- drug abuse. However, there exist several dence and prevalence rates. These rates, data sources, each with its own unique in turn, can provide insight into the con- perspective, from which drug abuse ditions which place people at risk for trends can be tracked. The main data sys- drug abuse and into the etiology and con- tems used in the United States are sur- sequences of abuse. Medical epidemiol- veys, indicators, and ethnography. ogy holds that once the causes and risk factors of a disease have been identified, Surveys a program of education, intervention, and prevention can be implemented. Surveys provide the most direct mea- Even though the study of drug abuse dif- surement of the scope of drug abuse, of- fers significantly from the study of infec- fering the most comprehensive technique tious disease-the phenomenon upon for estimating the prevalence and inci- which medical epidemiology origin- dence of drug abuse as well as patterns of ated-the paradigm still applies. use and opinions about drugs; in addi- tion, surveys allow for in-depth question- ing on a variety of behavioral and attitu- ‘Division of Epidemiology and Statistical Analysis, dinal issues. Futhermore, cross-sectional National Institute on Drug Abuse. Mailing ad- dress: 5600 Fishers Lane, 11-A-55, Rockville, Mary- surveys repeated over time can be used land 20857, U.S.A. to monitor changes in trends. Surveys Bulletin ofPAH0 24(Z), 1990 53 can cover the general population or a sive and time-consuming, and collecting special population, and they can be con- data on a sensitive subject such as drug ducted through a variety of techniques, abuse poses reliability and validity prob- including face-to-face interviews, tele- lems. Also, surveys cannot reasonably be phone or mail questionnaires, and inter- expected to provide information on rela- views administered privately or in group tively rare events such as heroin abuse. settings. In those cases, other methodologies are The National Institute on Drug Abuse needed to complement surveys in con- (NIDA) sponsors two major national ducting a descriptive drug abuse epide- surveys-the National Household Sur- miology program. vey on Drug Abuse and the High School Senior Survey. The former is a personal, Indicators face-to-face interview with household residents based on a multistage, strati- Drug abuse indicators reflect the health fied, random sample design; the latter is and social consequences of drug abuse, a self-administered questionnaire con- and can be used to monitor changes in ducted in a group setting and based on a trends. Over the years, several indicators multistage random sample of high have emerged as the most reliable and schools in the contiguous United States. useful for monitoring trends. Primary Both surveys use probability samples, among these are treatment data. For ex- thus allowing for generalizations to be ample, treatment admission data can be made about the total population. analyzed to plot epidemic curves, and NIDA also includes drug-use questions demographic and geographic characteris- in ongoing surveys sponsored by other tics can help identify high risk popula- offices and agencies, such as the National tions and sites where drug abuse may be Health Interview Survey, the Hispanic prevalent. These analyses have implica- Health and Nutrition Evaluation Survey, tions for such policy decisions as where the Department of Labor National Longi- to direct intervention and outreach activi- tudinal Survey of Youth, the Maternal ties, where to locate treatment programs, and Infant Health Survey, the Family and in the identification of potential cli- Growth Survey, and the National Ado- ents for treatment. lescent Student Health Survey. Including Other significant indicators are drug- drug-related questions in comprehensive related emergencies and deaths. For health surveys, which often are con- more than 15 years, NIDA has sponsored ducted among populations that may be at the Drug Abuse Warning Network high risk for drug use, presents an op- (DAWN), a national morbidity and mor- portunity to analyze the association be- tality information system which collects tween drug use and a wide range of data from more than 700 hospital health practices and social behaviors. emergency rooms and 85 medical exam- Population-based surveys have some iners in the United States. DAWN has es- limitations, however. For example, cer- tablished a consistent reporting of drug tain segments of the population-the abuse cases based on standardized homeless and street people in the house- guidelines, resulting in a system which hold survey and absentees and dropouts produces invaluable trend information in the high school survey-are excluded, on health consequences and which is a and often these groups represent particu- major data source for identifying new larly vulnerable populations for drug drug abuse substances. Data such as abuse. In addition, surveys can be expen- DAWN’s also can be collected and ana- 54 Bulletin ofPAH0 24(l), 1990 lyzed from a few or even one hospital or searcher tallies the number of persons or medical examiner’s office in a city or activities occurring in a given area, such small region, if there is reason to believe as a street comer or a known drug mar- that drug-related cases would appear in ket; and (3) the participant observer ap- those facilities. proach in which the researcher plays an A third major indicator is law enforce- active role in a situation, such as asking ment records. Information on drug- conversational questions, while simulta- related arrests, numbers and amounts of neously observing activities and record- drug seizures, and drug price and purity ing responses unobtrusively. The choice gathered from local, regional, and na- of methodology has less to do with pref- tional police and from military, drug en- erence than with the options that circum- forcement, and customs officials and stances permit. The overall advantage of then analyzed by drug type, time, place, these approaches is that they involve and person can be extremely important real-life situations; their main limitation in documenting ongoing trends and in is the anecdotal nature of the data and identifying new patterns of abuse. It the lack of scientific control. should be kept in mind, however, that law enforcement statistics are particularly EPIDEMIOLOGY WORK GROUP subject to fluctuations from policy changes based on manpower, funding, The Community Epidemiology Work and community pressure. Group (CEWG), established by NIDA in The overriding limitation inherent in all November 1976, is composed of research- of these indicators is the fact that rather ers, primarily state, city, and local offi- than measuring prevalence or the magni- cials, who periodically analyze drug tude of the drug problem, they measure abuse patterns and trends in selected trends associated with the consequences metropolitan communities throughout of abuse. Also, unlike surveys, they often the United States. CEWG meets twice involve secondary analysis of limited in- yearly to (1) provide timely assessment of formation. However, with careful inter- drug abuse patterns and trends, (2) iden- pretation, treatment, health, and law en- tify emerging drugs of abuse, (3) deter- forcement data can be analyzed together mine at-risk populations, and (4) develop to yield a dynamic picture of specific as- methodologies for assessing data. pects of drug abuse. The importance of tapping local exper- tise in assessing drug abuse trends and in Ethnography identifying potential outbreaks cannot be overemphasized. While national data Ethnography offers another valuable systems provide valuable epidemiologic tool for studying drug abuse. It provides information, they often are limited by the an informal description of a specific situa- delay between data collection, process- tion, applying as much rigor to the study ing, analysis, and the dissemination of as circumstances will allow. Ethno- findings. In contrast, local-level data col- graphic studies usually involve one of lection and analysis, such as that pro- three general approaches: (1) the snow- vided by CEWG, have shorter lag time ball technique, in which a researcher will and, in some cases, increased accuracy. use a contact to provide someone to in- For example, local drug abuse experts’ terview, who, in turn, provides another unique knowledge regarding data pertur- person to interview, and so on; (2) a di- bations becomes critical during data in- rect count approach in which the re- terpretation. These researchers also have Kozel EpidemiologicStudies of Drug Abuse 55 access to local surveys and studies as well ditional research methods such as sur- as to other findings that provide an in- veys. Indicators such as treatment data, valuable complement to core drug abuse however, have been used effectively to indicator data such as morbidity, mortal- identify relative changes in incidence by ity, and law enforcement information.

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