"YOKELS BREEDING INTOLERANCE":

The headline "Yokels Breeding Intolerance" from a column in the Edmonton (Canada) Sun, 14 July, describes the "fine line between grassroots protest and a lynch mob." It goes on to give an example of each. The "lynch mob" is exemplified by the case of a Calgary methadone clinic that was "literally run out of town" earlier this month in the face of threats to the facility and its staff. The "grass roots" protest that is described involved a concerted effort to ensure "proper processes and protocols are in place to keep everyone safe" in a neighborhood in which a group home for deeply troubled teens is located; two residents of the home had been charged recently with murdering a local couple. The contrast is well written and compelling. click here to read the article

MR HANON: My congratulations on recognizing the distinction, and expressing it so eloquently. As you see, we're taking the liberty of posting a blog referring to your column on our website - www.opiateaddictionrx.info

CALGARY (CANADA) METHADONE CLINIC CLOSURE:

As noted in previous postings a clinic has been forced to give up the battle to continue operations. An editorial 11 July in the Calgary Herald is a voice of reason, though perhaps too late to avoid the therapeutic abandonment facing the more than 500 patients now receiving treatment. Some excerpts:

“The loss of Second Chance Recovery is a blow to both drug addicts seeking treatment and to the city's reputation. The closure of the methadone clinic could have been avoided had aldermen shown a willingness to address residents' concerns with facts, or seek another solution, such as changing the zoning law to allow the clinic in an industrial park.

“Now Calgary looks like a city that would rather deny the existence of social problems than deal with them... The problem is a lack of leadership. The clinic's operators are tired of fighting City Hall, and who can blame them. They've been shut down three times in six years, and have reasonably concluded Calgary will not support the clinic.

“Police say they have never recorded increased crime rates where clinics have been located, and are more concerned about the impact the closure will have on the city.”

For full editorial click here

PUTTING NIMBY INTO PERSPECTIVE:

A letter to the editor appeared on July 11 in the Calgary (Canada) Herald. It is entitled, “Here goes the neighbourhood” – a commentary on an article 2 days earlier reporting that a methadone clinic has been forced to close, leaving the fate of over 500 patients in severe jeopardy. The letter can be found by clicking here.

CONTINUED SHARP DROP IN DRUG-RELATED DEATHS IN BALTIMORE ATTRIBUTED TO TREATMENT AND HARM REDUCTION MEASURES:

The Baltimore Sun 1 July reported that the number of drug-related deaths in the city dropped by a third between 2007 an 2008, from 281 to 176. “'Short and sweet: Treatment works,'" said Gregory Warren, executive director of Baltimore Substance Abuse Systems. 'There are literally hundreds of people alive today because of what's happening.'" He also credited a variety of harm reduction measures, including teaching drug users to reverse opiate overdose by administering Narcan.

But there’s also a decidedly negative side to the story: “Some 74,000 people needed substance abuse treatment last year, according to state estimates, but Warren's organization was only able to reach 16,000 of them …” Full story

TREATMENT ON DEMAND: AN OLD CRY, STILL UNANSWERED

In 1988 the Presidential Commission on the Human Immunodeficiency Virus issued its report. Among other things it called for “…greatly expanded [addiction] treatment capacity, with the goal of treatment on demand...“ (page XVIII). So...how does one measure the adequacy of the treatment capacity for opiate-dependent individuals? Very simply: by the ability to publicize that treatment on demand exists, and by doing everything possible to encourage those who need help to seek it. And where in the United States does one see public service announcements to this effect? Cynics might well conclude that no one gives a damn. Meanwhile the common-sense conclusion of the Commission more than two decades ago continues to be ignored.

PATIENT BELIEFS ABOUT METHADONE MAINTENANCE:

A study that is 7 years old but still of vital importance describes the results of a survey of patient beliefs about methadone maintenance – which, on average, the 315 respondents had been receiving for seven years in a public clinic in NYC. Among the findings:

. although 79% agreed that “methadone has helped me change my life in a good way,”
the negative beliefs that were expressed were distressing.
. 47% believed methadone “is bad for your health (additional 32% “not sure”)
. 39% believed higher doses “are less healthy than lower doses” (30% unsure)
. 71% (!) believed “methadone gets into your bones” (19% unsure)
. 80% believed “people should try to get off methadone” (11% unsure)

There is no reason to believe that in the intervening years since this study was done much has changed (certainly the public’s perception does not seem to have become more favorable, so there’s presumably no cause for optimism regarding a change among recipients of care). The responses can be interpreted in only one way: the clinic staff have been woefully ineffective at educating their patients about the medication that is fundamental to the care provided. Even more distressing is the possibility that many patients may be mirroring the attitudes and beliefs of staff members.

It is difficult to imagine that treatment will be optimally effective when patients believe the medication they receive is injurious to their health and should be given in doses that may be inadequate. Patients who believe one should aim to discontinue treatment will be likely to do so - notwithstanding the high rate of recidivism and all the concomitant risks (including, very specifically, the risk of death).

Surely patient knowledge about their treatment is a most important parameter of quality care. Is anyone aware of programs that focus on this treatment imperative? Do the accreditation bodies assess the process and outcome of this aspect of care?

Comments welcomed.
Citation: Stancliff S, Myers JE, Steiner S and Drucker. Beliefs about methadone in an inner city methadone clinic. 2002. Bull NY Acad Med. 79(4):571-578.

NIMBY SUCCEEDED BY "BANANA" (BUILD ABSOLUTELY NOTHING ANYWHERE NEAR ANYTHING):

That could be the conclusion drawn from an article in the Herald-Citizen (Tennessee) on 28 June. The headline: "Methadone clinic denied in Spencer." The 2007 population of Spencer, Tenn, was 1685. the reason the State denied approval for a proposed methadone clinic: "the rural status of Spencer." Go figure....!

DRUG PROBLEMS OF IRAQ/AFGHAN VETS COULD DWARF THOSE OF VIETNAM ERA:

That is the alarming (but not surprising) headline of a news story in JoinTogether. And yet, when it comes to vets dependent on opiates (whether illicit drugs or prescribed painkillers), the DoD not only erects barriers but has an absolute bar against provision of the "gold standard" of care, "maintenance" with methadone or buprenorphine. TRICARE, the insurance policy for vets and their dependents, simply denies coverage for such treatment, without qualification or explanation. The article notes that only 1/4 to 1/3 of vets choose to get medical care through the VA - the only option for most of the others is TRICARE, but not if they need and want medication-based treatment for opiate dependence. And yet, US taxpayers fund methadone programs around the world - e.g., in Vietnam. Go figure! Full story click here>

PARENTS INITIATIVE FOR TOLERANT DRUG POLICY (GERMANY):

An article in June 09 Die Strasse presents an interview with Juergen Heimchen, head of the organization for almost 16 years. The fundamental goal of the "Initiative" - which is both a self-help and advocacy group - is to do everything possible to allow drug users to survive. Heimchen describes the advances made in the last 2 decades; initially, methadone in Germany was only available to addicts who had a terminal illness! It is very largely the effort of parents of addicts that turned the tide in Germany; today an estimated 70,000 patients receive methadone maintenance.

TREND TO FOR - PROFIT ADDICTION TREATMENT

A study just published in J Subst Ab Treatm (vol 36, 355-365) found that in 2005, 34%of outpatient substance abuse treatment recipients obtained care in for-profit facilities compared to less than 10% ten years earlier. The bad news: not unexpectedly, for-profit services were more likely than others to refuse admission – and to terminate prematurely - based on inability to pay. The disparity was particularly great among methadone treatment programs. Of course, unequal access to care based on financial considerations is the norm in all areas of medicine in this, the wealthiest nation on earth.

HEROIN AND/OR COCAINE NOT GOOD IN PREGNANCY

This conclusion was reached by a Swiss laboratory study on placentas from mothers who received methadone treatment during pregnancy. Hardly surprising: risk of adverse consequences of heroin and cocaine obviously is not limited to the placenta, or to pregnant women, or to women or men who are not receiving methadone treatment. The study did not compare the harm of the illicit substances in placentas from women who did and who did not receive methadone treatment during pregnancy.

News summary available at http://news.bbc.co.uk/go/em/-/2/hi/health/8092732.stm

COMPARED TO WHAT:

A commentary in the Albany (NY) Times Union on June 4 begins, "Rarely has there been a prouder moment in the history of our state Legislature than when Democrats and Republicans came together earlier this year to reform the Rockefeller Drug Laws, which over more than three decades wreaked havoc on thousands of people whose addictions should have been treated by health care professionals -- not by the criminal justice system." Seems to set a mighty low threshold for pride - and of course even this break through of common sense, fairness and community self-interest is currently stymied by political wrangling.

NY SEEKS TO IMPROVE ADDICTION STRATEGIES - DON'T HOLD YOUR BREATH:

A "collaborative council" was established by Executive Order on April 15, 2009, with the lofty goal of "identifying ways in which statutes, regulations, rules and policies may be revised in order to promote addiction prevention, treatment and recovery efforts" (click here ). The timetable hardly suggests a sense of urgency: an "interim report is due in 18 months, and a final report a year after that - by October 31, 2011! Also to be noted is the statement that "involvement of non-governmental stakeholders, including community based organizations and business entities, is essential to the development of strategies to address the devastating effects of addiction" - but membership on the council is limited to 20 State agency heads.

GOVERNMENT PRIORITIES IN SPENDING - AND IN CUTS

A CNN report June 5th, states that Michigan is closing 8 prisons - allowing 1000 employees to be fired and saving $120 million; three facilities were closed earlier this year. The State has assured voters that no inmate will be released early as a result - i.e., displaced prisoners will be squeezed into other facilities. Currently 22% of the State's general fund budget is allocated to the Corrections Department (the amounts for cops, prosecutors, courts etc are not given - nor is the proportion of inmates incarcerated on drug-related charges).

EXCHANGE WITH NEWS EDITOR – PRISON FOR METHADONE POSSESSION

From Nevada: The article prompting the exchange can be found by clicking here.

LTE: Re "Methadone tablet earns prison term" (June 2) - for someone dependent on heroin one methadone tablet can prevent withdrawal symptoms and craving - and multiple injections of heroin - for 24 hours. Strictly from the perspective of the community's self-interest, punishing this with a 2-1/2 year prison term seems just plain dumb. He should instead have been referred to a methadone maintenance clinic where his dependence could be treated.

EDITOR’S RESPONSE: I don't know about New York City, but there is a point here in Nevada at which someone who continually breaks the law deserves a time-out to think about it. Mr. Jenkins is lucky he only got 2 and a half years. While being in possession of a single methadone tablet might not seem like much, in fact it was something else he stole from someone else, who might have needed it. No matter what the charge, Mr. Jenkins went to prison because he is a thief. No one would have even known he had the tablet if he hadn't been shoplifting, again. I believe people can be rehabilitated, but I also believe that the worst thing that can happen to a person is a lack of consequences as a result of their actions. Thanks for writing, Kurt Hildebrand editor

US DRUG POLICY: ARE THE TIMES A'CHANGING?

From JoinTogetherDirect (www.jointogether.org) June 1 - Obama's First Drug Budget Fails to Shift Priorities The chairman of a House oversight committee last week chided the Obama administration for failing to live up to its rhetoric about ending the war on drugs and taking a new approach to preventing drug use, challenging the composition of President Obama's first drug budget during new drug czar Gil Kerlikowske's first appearance as director of the Office of National Drug Control Policy (ONDCP).

TREATMENT OF SUBSTANCE ABUSE "NOT WIDELY AVAILABLE" IN CJS PROGRAMS :

That gross understatement headlines an article in NIDA-Notes, vol 22 no. 3. "Less than 10% of adults and about 20% of adolescents with substance abuse problems in the nation's jails, prisons and probation programs can receive treatment on a given day."

METHADONE FOUND EQUALLY EFFECTIVE FOR HEROIN AS FOR PRESCRIPTION OPIOID DEPENDENCE:

The headline represents the conclusion of a study by Banta-Green and colleagues, contradicting what an accompanying editorial describes as “the conventional wisdom that methadone treatment may be more effective for heroin users... “ At the same time, the editorial makes an assertion that seems to be at odds with consistently gloomy outcome evaluations once treatment (of any kind) for opioid dependence is terminated. Specifically, the editorial states “… for properly prepared patients a well-developed and deliberate plan for withdrawal that includes high-quality after-care and community supports should always be a potentially appropriate goal.” We are aware of no credible study that suggests relapse is the exception rather than the rule, regardless of “preparation,” planning or after-care support. This is a reality providers must keep in mind, and that must be stressed to patients.

Article (pages 775-783) and editorial (pages 784-785) in Addiction, 104, 2009

FEDERAL POLICY REGARDING NEEDLE/SYRINGE EXCHANGE FUNDING: THE TITLE SAYS IT ALL

Obama Retains Ban on Federal Funding of Needle Exchange, May 12 2009
http://www.jointogether.org/news/headlines/inthenews/2009/obama-retains-ban-on-federal.html

DECRIMINALIZATION - DEBATE SHOULD FOCUS ON EXPERIENCE

That experience, in Portugal, now exists and has been published (see extensive summary at http://www.mapinc.org/drugnews/v09/n435/a10.html which links to Apr 18 article in Vancouver Sun). In a nutshell: the fears that decriminalizaiton would lead to increased use of illicit drugs did not materialize; to the contrary, use went down. As for concomitant criminality and medical problems associated with drug use, they too decreased markedly. The Sun article concludes: "Now that the evidence in favour of decriminalization is in, politicians should no longer be permitted to corral support for criminalization by stirring up public fear of a bogeyman that doesn't exist."

PROVIDING METHADONE TREATMENT ALLEGED TO AID HEROIN DEALERS:

That's the bizarre conclusion reached by to economists(!) at Massey University in New Zealand. The thinking goes like this: methadone takes "high risk users out of the market," and since these users "can't always pay the dealers...when they are out of the market the dealers' distribution costs drop." Go figure! To download Story (on air) click here

NIMBY- NEVER BEEN WORSE:

In Calgary, Canada, a methadone clinic serving 500 patients for years has given up hope of finding a new site when its lease expires shortly. According to the news article, “Even the superintendent of the RCMP . . . went public in the newspaper and said since the clinic has opened, crime has dropped.” The only other clinic in the area, run by the Province, already has 300 patients; it hopes to take over the displaced patients, but there is a likelihood of “a potential three-month window” when care will be interrupted. The clinic owner stated, “I’ve been doing this for 16 years and I’ve never run into opposition like this in my life.”
Full story: http://calsun.canoe.ca/News/Alberta/2009/04/13/9096751-sun.html

PUTTING NIMBY IN PERSPECTIVE:

From the University of Canada (Calgary) student newspaper a thoughtful commentary pointing out the self-defeating, counter-intuitive and counter-productive nature of a battle over a methadone treatment facility site. Click Here to Read Article

ADDICTION TREATMENT – SOME PEOPLE JUST DON’T GET IT (BUT HEALTH MINISTERS SHOULD!):

the Irish Health Minister was quoted as saying, “I have grave concern that people seem to be on methadone for an extended period of time. . . . I want to see an active methadone-reduction program.” (http://www.free-articles-zone.com/print.php?id=240473)

LEGISLATORS LOVE THOSE DRUG TESTS (USA):

In Kansas, the State House “. . . just voted 99-26 in favor of implementing random drug tests for those receiving cash assistance from the state.” (http://primebuzz.kcstar.com/?q=node/17811) And in West Virginia, State Delegate Craig Blair has issued a statement urging that the State “…should require random drug testing for every individual receiving welfare, food assistance or unemployment benefits.” (http://notwithmytaxdollars.com/ )

For sure there will be legal challenges and critics will also point out that the costs of such programs will be enormous. Those who nevertheless want to introduce and who are willing to vote for such measures should be obliged to submit – themselves – to the same urine tests, collected and analyzed in an identical manner to what they want to impose on those receiving public assistance - and they should agree to promptly give up their (tax-paid!) salaries and positions should the results be “positive.” If they are willing to agree to such a precondition, then heir legislative initiatives would deserve serious consideration.

TAXING METHADONE PATIENTS - A TERRIBLE IDEA:

The Charleston (WVa) Gazette on March 21 reported on a bill introduced into the State legislature that would impose a unique tax on methadone treatment providers. The Chairman of the Committee on Health and Human Resources (!), Mr. Don Perdue, rationalized this plan claiming methadone treatment “has become a lucrative industry” (compared to what – radiology, cardiology, dermatology . . . ?). Even Mr. Perdue acknowledges that any tax would inevitably be passed on to the patients.

The fact that all methadone treatment in West Virginia is “for-profit”, and the inadequate availability of other forms of addiction treatment, reflect lack of State support for services that are desperately needed. It is simply wrong – and counter to the interests of every West Virginian - to focus on patients seeking to turn their lives around as the source of funds that the State can’t or won’t provide.

NIMBY AT ITS MOST VISCIOUS:

The March 30 Clanton (Al.) Advertiser, and subsequent posted comments, represent the height of mean-spirited, misinformed, non-christian vitriol aimed at individuals who are seeking nothing more than a chance to live free of the horrors associated with dependence on illicit drugs (http://www.clantonadvertiser.com/news/2009/mar/30/appeal-methadone-clinic-fails). Among the venom that appears in the comments applauding rejection of a methadone treatment facility is this gem: "I personally don't mind them having methadone if it kills that many drug users." An appeal to humanitarianism clearly would miss the mark, but one might think some citizens would be moved purely by the general community's self-interest in ensuring treatment availability for those who want and need it.

CAN THE NEW BRUNSWICK (CA) HEALTH MINISTER REALLY HAVE SAID THAT:

A letter to the Telegraph Journal, 23 Mar, attributes to N.B. Health Minister Mike Murphy the statement, "Methadone... can be a bottomless pit - people get on it and they don't get off."

The writer goes on to note, ”The whole point of methadone maintenance treatment is that it's possible to be on methadone and hold down a job, raise a family - in general, have a life. If someone eventually weans off methadone entirely, that's fine, but just being on methadone is a huge step forward both for that individual and for the community as a whole. … A person on methadone is a person who has crawled out of the "bottomless pit" of addiction … and has a chance at building a life for themselves. Too bad New Brunswick has a Health Minister who's so poorly informed on this issue.”

URL: http://telegraphjournal.canadaeast.com/front/article/611551

THE WAR ON DRUGS: A DEVASTATING PUBLIC-POLICY DISASTER

That's the headline of an opinion piece written by four clinical and public health specialists in British Columbia (CA), and that headline says it all. It appeared in Lancet, vol 373, March 21, 2009. The concluding paragraph: "Clearly, the preponderance of evidence shows that the UN drug-control framework has not only been ineffective but has resulted in a range of severe unintended harms."

Authors: Evan Wood, Daniel Werb, Brandon Marshall, Julio SG Montaner, and Thomas Kerr, Brit Col Centre for Excellence in HIV/AIDS St Paul's Hosp; Fac of Medicine Univ of Brit Col; Sch of Pop and Public Health of Univ of Brit Col.

NEW BRUNSWICK POLICE CHIEFS INSIST ON MORE SUPPOT FOR METHADONE MAINTENANCE:

Police chiefs in St. John and Fredrickton (New Brunswick, Ca.) call for Provincial Health Minister’s support for expanding methadone treatment. According to the Fredrickton Chief, “We know with a large proportion of those cases [involving opioid dependent individuals], once they get onto methadone, they're not doing crime . . . Methadone is saving people's lives because it's giving them an opportunity to stabilize." Full story in the 16 March Telegraph-Journal at: http://telegraphjournal.canadaeast.com/city/article/604147

RUSSIA NOW WORLD'S TOP HEROIN USER:

According to someone who should know - the head of Russia's anti-narcotics bureau, Victor Ivanov. In an interview with BBC on 10 Mar he estimated there are 2.5 million heroin users in Russia. The report of his comments includes not a word about treatment, and in fact there is virtually no treatment available - methadone and buprenorphine are both absolutely forbidden. So what does the drug czar of Russia suggest? "He said it was time for the international community to take action against Afghan narcotics by spraying poppies and offering farmers incentives to grow other crops." Even for cynics it is difficult to comprehend how a person in authority can embrace an approach that America has demonstrated, conclusively and at a cost of many billions of dollars, is utterly futile! full story: http://news.bbc.co.uk/2/hi/europe/7935527.stm

CLINICIANS’ PREJUDICE WHEN IT COMES TO REPORTING PREGNANT DRUG USERS:

An old but still powerful reminder that clinicians, no less than society in general, have strong bias with regard to ethnicity and economic status. A study by Chasnoff and colleagues in 1989 in Florida screened 715 pregnant women for drugs. Whites and Blacks had approximately same frequency of positive toxicology: 15.4% and 14.1%, respectively, but “…black women were reported [to health authorities] at approximately 10 times the rate for white women, and poor women were more likely than others to be reported.” Yes, the study is 20 years old. Anyone have a basis for believing clinicians’ attitudes have changed? Article in NEJM 322(17):1202-1206.

NOT SHY ABOUT INTENTIONS (NIMBY in Tennessee):

Members of the Planning Council of Church Hill, Tenn., "weren't shy about their intentions" to make it almost impossible for a methadone treatment facility to be established in their city. Clinics would only be permitted in "industrial zones ... and would also have to be more than 1,000 feet from a school, day-care facility, park, church, mortuary, hospital, public recreation area, residential dwelling or establishment that sells alcoholic beverages."

There's a need to protect hospitals from patients receiving medical care? And just what fears might there be about a clinic's impact on mortuaries (or their owners or "clients")? And churches - no voice of compassion from the priests?

"Mayor Dennis Deal said . . .'I know you’ve got to have these (clinics), but you’ve also got to protect the taxpayers.'” Aside from the patent disingenuousness of the professed need for "these clinics," does the Mayor think his constituency will be well-served by abandoning addicts who desperately want and need and could benefit from treatment?
For the full story

METHADONE AND DRIVING: FURTHERING STIGMA, IGNORING THE EVIDENCE!

The Police Chief in Laconia, NH, is demanding a proposed methadone clinic hire an off-duty police officer whenever it is open - allegedly because of fear the methadone may render patients "unstable to drive safely" (the functions of the off-duty officer are not specified). Decades of studies and surveys around the world (most recently a 5.5 year study in Norway published this week in the Journal Addiction) document that methadone maintenance treatment is not associated with increased driving risks.

During these very difficult financial times a Police Chief should perhaps be applauded for seeking ingenious - even if disingenuous! - reasons for gaining overtime opportunities of fellow officers. In this instance, however, the Laconia Chief is displaying ignorance of or disregard for the facts and is doing the entire community a terrible disservice. Full story click here

REJECTING A METHADONE CLINIC – COMPASSION BE DAMNED:

that seems to sum up the sentiments of residents in Bustletown, a corner of the City of Brotherly Love, who responded with “thunderous applause” when a proposal to establish a methadone clinic was withdrawn in the face of vehement opposition. Apparently none of the “jubilant residents” (500 strong!) nor their elected officials who participated in the community meeting seem to care a whit for those who desperately want and need access to potentially life-saving medical care. It seems most unlikely that the namesake of the Anne Frank School, where this meeting was held, would have joined in the jubilation. Full story click here:

NIMBY WINS, PATIENTS LOSE - AGAIN...

This time in Northeast, PA (suburb of the City of Brotherly Love), where "plans for a methadone clinic...were quickly abandoned after heavy protest from residents. "The only resident quoted explained," "I have small children, I want to protect my children, I want my children to be safe." A commonly expressed concern, but one that is difficult to reconcile with either logic or experience, since - we believe - there has not been a single report of harm to children associated with the operation of a methadone program anywhere in America over the course of more than four decades.

For the full story click here

ONTARIO METHADONE PATIENTS DEMAND CONFIDENTIALITY:

Demonstrators in Toronto protested rules of the Ont. College of Physicians and surgeons that gives access to their personal information without assurances of how that information may be used. They also objected to the demand that "patients submit to weekly urine tests in the presence of a clinic worker or security camera." (Meanwhile, NY Sate operates a "methadone regiustry" that routinely violates US Federal regulations governing such registries - specifics on request). Full Ontario story: Toronto Star, 14 Fe 09

STRONG ENDORSEMENT OF “HARM REDUCTION” FROM THE HIGHEST OF AUTHORITIES:

The UNAIDS Director on 12 Feb wrote the chairperson of the Commission on Narcotic Drugs: “UNAIDS, including our Cosponsors and in particular UNODC and WHO, have amassed a considerable body of strong and consistent evidence on the effectiveness of harm reduction approaches. Conversely, there is no convincing evidence of major negative consequences of such interventions.” In addition, the Director of The Global Fund on 6 Feb. wrote the Chairperson: “...harm reduction is an essential, evidence-based AIDS response,” and mentions specifically “access to treatment, clean needles, opiate substitution therapy and a comprehensive package of services...”

STEREOTYPING:

Anything to suggest attitudes and practices have changed since a 1990 study in Florida? Anonymous urine screening for illicit drugs was performed on 715 pregnant women, roughly half in a public clinic and half seen in private physician offices. The frequency of positive urine results was essentially the same for whites and blacks (15.4% and 14.1%). During the time period of the survey, however, reports to health authorities for "substance abuse during pregnancy" were ten times greater for blacks than for whites, "and poor women were more likely than others to be reported." (Chasnoff et al. NEJM 322(17):1202-1206, 1990)