THE PREVALENCE, ECONOMIC, AND SOCIAL COST OF METHAMPHETAMINE USE; AND THE EFFECTS OF ECONOMIC RECESSIONS, UNEMPLOYMENT RATES, AND METHAMPHETAMINE ARRESTS ON CHILD ABUSE IN HAWAI`I A DISSERTATION SUBMITTED TO THE GRADUATE DIVISION OF THE UNIVERSITY OF HAWAI`I AT MĀNOA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN EPIDEMIOLOGY May 1, 2020 By Nancy S. C. Linn Dissertation Committee: Eric Hurwitz, Chairperson Andrew Grandinetti Alan Katz Yan Yan Wu Deborah Taira Keywords: Methamphetamine, meth prevalence, cost of meth use, periodicity of meth arrests © 2020, Nancy S. C. Linn ii ABSTRACT This is the first study in Hawai`i to estimate the prevalence and cost of methamphetamine (meth) use and the first investigation of the association of the impact of the periodicity of economic recessions, unemployment rates, and meth arrests on child abuse for the years 2007 to 2017, based on free, open source, and unrestricted data gathered for other purposes. The Hawai`i age-adjusted meth use prevalence was above the national estimates and ranged from 5,050 per 100,000 in 2007 to 3,387 per 100,000 in 2017, with a range from 3,114 to 5,219 per 100,000. The economic and social cost estimates were found to average between 41 to 68 billion dollars (range 15 to 105 billion dollars) when the lost potential from meth use and meth-related impacts were included. The quality-adjusted life-years approach, the Department of Transportation (DOT) Maximum Abbreviated Injury Scale (range 1-6, 6=death), and the DOT Value of a Statistical Life were included in the computation of lost potential of meth users and abused children using the RAND and state of Montana approach. When lost potential was not included, the cost of meth use was found to average between 120 to 173 million dollars per year (range 49 to 269 million dollars). The five factors for the cost estimates included: 1) treatment costs, 2) health burden, 3) child endangerment, 4) criminal justice costs, and 5) lost productivity attributable to meth. Meth arrests were found to lag unemployment rates by one year while child abuse lagged about four years behind unemployment and meth arrests, although the Granger causalities were not significant. Word count: 262 iii Table of Contents ABSTRACT ..................................................................................................................... iii Table of Tables .............................................................................................................. vii Table of Figures .............................................................................................................. x Table of Acronyms ........................................................................................................ xiii Introduction ................................................................................................................... 16 National Methamphetamine Problem ......................................................................... 18 What is Methamphetamine? .................................................................................... 33 Effects of Methamphetamine Use ........................................................................... 36 Hawai`i Methamphetamine Problem .......................................................................... 39 Objective 1. Estimation of the Prevalence of Methamphetamine Users in Hawai`i ...... 43 Objective 1. Introduction ............................................................................................ 43 Part II Offenses Arrests ........................................................................................... 55 Methamphetamine Treatment Admissions .............................................................. 57 Wanted Meth Treatment but Did Not Receive ......................................................... 59 Objective 1. Methods ................................................................................................. 61 Part II Offenses Arrests Methodology ...................................................................... 61 Methamphetamine Treatment Admits Methodology ................................................ 62 Methamphetamine Treatment Wanted but Unavailable Methodology ..................... 63 Total Estimated Number of Meth Users in Hawai`i .................................................. 64 Objective 1. Results .................................................................................................. 69 Discussion and Public Health Implications ................................................................. 69 Strengths .................................................................................................................... 70 Assumptions and Limitations ...................................................................................... 70 Objective 2. Estimation of the Economic and Social Cost of Methamphetamine Use in Hawai`i .......................................................................................................................... 72 Objective 2. Introduction ............................................................................................ 72 Factor 1. Cost of Methamphetamine Treatment ...................................................... 76 1.A. Outpatient Drug Treatment Facilities ........................................................... 77 iv 1.B. Inpatient Drug Treatment Facilities .............................................................. 81 Factor 1. Methodology ......................................................................................... 85 Factor 1. Limitations ............................................................................................ 86 Factor 2. Health burden .......................................................................................... 87 2.A. Health burden Associated With Meth Use.................................................... 87 2.B. Health burden associated with meth production .......................................... 89 Factor 2. Methodology ......................................................................................... 90 Factor 2. Limitations ............................................................................................ 91 Factor 3. Meth-related child endangerment ............................................................ 91 3.A. Child Protective Services ............................................................................. 92 3.B. Foster Care .................................................................................................. 94 Factor 3. Methodology ......................................................................................... 98 Factor 3. Limitations ............................................................................................ 99 Factor 4. Criminal Justice Costs ........................................................................... 100 4.A. Hawai`i Department of Public Safety ......................................................... 101 4.B. Judiciary ..................................................................................................... 103 Factor 4. Methodology ....................................................................................... 104 Factor 4. Limitations .......................................................................................... 105 Factor 5. Lost Productivity Attributable to Meth .................................................... 106 5.A. Premature Mortality Due to Meth ................................................................ 106 5.B. Lost Productivity Associated With Absence for Treatment ......................... 109 5.C. Lost Productivity Associated With Meth Use Unemployment ..................... 113 Factor 5. Limitations .......................................................................................... 115 Objective 2. Overall Methodology............................................................................ 116 Objective 2. Overall Implications and Discussion .................................................... 122 Objective 2. Overall Limitations ............................................................................... 124 Objective 3. Investigation of the EffectS of Economic Recessions, Unemployment Rates, and Methamphetamine Arrests on Child Abuse in Hawai`i .............................. 125 Objective 3. Introduction .......................................................................................... 125 Objective 3. Methods and Results ........................................................................... 138 Objective 3. Discussion ........................................................................................... 161 Implications for Public Health ................................................................................... 163 v Strengths .................................................................................................................. 164 Limitations ................................................................................................................ 164 Overall Strengths and Limitations ............................................................................... 165 Overall Public Health Implications ............................................................................... 165 Recommendations ...................................................................................................... 167 References