This report is designed to inform the residents of Denver and the rest of Colorado about the dimensions of the problems caused by alcohol, tobacco and other drugs in the state’s capital city. The report focuses on:

Denver: On the Horizon—Reducing Substance Abuse and Addiction is animated by the recognition that while substance abuse is a nationwide problem, its consequences are felt most acutely in individual neighborhoods, and policy responses play out in local settings that vary enormously. Indeed, cities differ remarkably from one another, each with its own particular history and spirit. Clearly, national and even state-level data are inadequate to capture the crucial distinctions required to shape effective local substance abuse strategies. This report provides the latest available information on Denver, complemented whenever possible by national and state data to provide a comparative perspective.

Drug Strategies, a nonprofit research institute, promotes more effective approaches to the nation’s drug problems and supports private and public initiatives that reduce the demand for drugs through prevention, education, treatment and law enforcement. In preparing this report, Drug Strategies consulted numerous city, state and federal government agencies and non-governmental organizations. The project was guided by a distinguished Advisory Panel, convened by the Mayor’s Office of Drug Strategy and composed of representatives from public and private agencies with substance abuse expertise and responsibilities. While we are grateful for the insight and wisdom of those who contributed to our research, Drug Strategies is solely responsible for the content of this report.

Since its incorporation more than 140 years ago, Denver has been the preeminent city of the Rocky Mountain West—politically, economically and culturally. Known as the “Queen City of the Plains,” Denver sits at the western edge of the Great Plains and eastern front of the Rocky Mountain range. Denver today remains Colorado’s largest city, with an impressive 18.6 percent growth rate during the 1990s.^[1] Only 24 cities in the country are more populous than Denver (554,636 residents, according to the year 2000 census). Denver is not only Colorado’s political capital, it is also the anchor of a tremendously productive metropolitan economy. Between 1990 and 2000, the Denver metropolitan area’s gross product more than doubled, rising to $91 billion—more than the gross product of a number of states, including neighboring Kansas ($86 billion) and Utah ($69 billion).^[2] Denver took full part in America’s prosperous 1990s. As per capita income rose 46 percent nationwide and 60 percent in Colorado over the course of the decade, per capita income in Denver rose 72 percent, to nearly $41,000.^[3] The proportion of Denver residents living in poverty fell from 17 percent in 1990 to 11 percent in 2000.^[4] Denver’s strong economy and growing population translated into a 68 percent increase in total tax revenues between 1990 and 1999.^[5] As the national crime rate fell 19 percent from 1996-2000, crime in Denver declined by 28 percent.^[6] Along a range of social and economic indicators, Denver’s performance compares favorably to most other big U.S. cities. When the American Hospital Association’s “Deprivation Index” ranked the 100 largest cities according to poverty rate, educational attainment, unemployment rate, per capita income and crime rate, Denver ranked 30^th best overall, with only nine comparably-sized cities scoring better.^[7]

Denver, nevertheless, is not without challenges. As this report documents, substance abuse generates an array of costly problems for Denver residents, businesses and government. According to a study sponsored by the U.S. Department of Health and Human Services, Colorado ranks second among the 50 states in the relative severity of its alcohol and drug abuse problems.^[8] In Denver, by many measures, substance abuse and addiction problems are considerably more severe than in the nation as a whole.

· Rates of binge drinking and chronic drinking are about 40 percent higher among Denver adults than among adults nationwide.^[9]

· Denver residents are hospitalized for alcohol-related illnesses at nearly twice the national rate.^[10]

· Drug-related hospital emergencies occur in Denver at 2½ times the national rate.^[11]

· Denver’s alcohol and drug-related death rate is more than 50 percent higher than the national average.^[12]

· Drug-related AIDS cases are diagnosed in Denver at twice the national rate.^[13]

· Denver’s crime rate is 15 percent higher than the national average, even after having fallen sharply in the late 1990s.^[14]

· Denver arrests^[15] and imprisons^[16] drug offenders at more than twice the rate nationwide.

· Substance abuse costs Denver residents, businesses and government at least $1.5 billion a year—in addition to the incalculable toll in human suffering.^[17]

Among the many challenges Denver faces in its efforts to reduce substance abuse, none is more crucial than closing the city’s treatment gap. Drug Strategies estimates that between 45,000 and 60,000 Denver residents need treatment for substance abuse^[18] but that only 7,000 of them, at most, actually receive treatment in any given year.^[19] A large and growing body of scientific research attests to treatment’s effectiveness in reducing substance abuse and its associated harms. Moreover, the benefits of treatment far exceed the costs.^[20] A landmark 1994 study in California found that every dollar invested in treatment saved taxpayers seven dollars in future costs.^[21]

Fortunately, Denver’s resilient economy and track record of sound fiscal management mean that the city can bring to bear a wealth of human and economic resources to address substance abuse.^[22] To target those resources, city leaders are charting a promising strategy that emphasizes significant new investments in prevention and treatment. The state government has an obvious stake in the well-being of its capital city, and a major role to play. The residents of Denver and the rest of Colorado would benefit tremendously if state lawmakers moved policy and funding priorities toward prevention and treatment.

Voters in Denver and the rest of the state overwhelmingly endorse just such a policy shift. A statewide survey in July 2001 found that nearly 75 percent of active voters favor “increasing funding to greatly expand the availability of treatment.”^[23] The great majority of Colorado voters (73 percent) also favor decreasing criminal penalties for people possessing small quantities of drugs and investing the prison cost savings in prevention and treatment. These preferences are especially pronounced among Denver voters, but strong support for change spans demographic categories across the state.

To build on the progress already being made in Denver, Drug Strategies offers recommendations in five key areas: leadership; information; enforcement and criminal justice; prevention; and treatment.

Leadership
Denver’s next mayor should reaffirm the role of the Director of the Mayor’s Office of Drug Strategy as a high-level official who reports directly to the mayor and is empowered to coordinate the city’s overall response to substance abuse.

· Denver’s elected representatives at the local and state levels should exercise their influence to reorient state legislative policy and budget priorities on substance abuse toward greater investment in prevention and treatment.

Information
City leaders should move quickly to undertake a comprehensive household survey of Denver residents on alcohol, tobacco and other drug use. The information derived will inform policy planning and serve as a baseline for measuring the future impact of Denver’s new strategies to reduce substance abuse.

· In setting substance abuse policy priorities, city leaders should take advantage of “Denver Benchmarks,” a community information system designed to provide detailed neighborhood-by-neighborhood data on health and quality of life.

· Denver should establish its own interdisciplinary substance abuse policy research team, and coordinate its efforts with other research conducted in the state.

Enforcement and Criminal Justice
A sharp enforcement focus on the most pernicious, flagrant offenders—those who engage in frequent violence and employ youth—would go far toward reducing the overall levels of crime perpetrated by drug offenders.

· Denver’s elected representatives in the Colorado General Assembly should join the effort to lessen the state’s costly reliance on imprisonment to punish low-level, nonviolent drug offenders.

· In concert with the state government, Denver should take advantage of the leverage afforded by the criminal justice system to reduce substance abuse among probationers and parolees through a mix of drug testing, incentives, sanctions and treatment.

· Denver’s elected representatives, law enforcement officials and public health officials should work to amend Colorado’s drug paraphernalia statutes so that state law would no longer impede the operation of city-licensed needle exchange programs in Denver.

Prevention
Denver residents and their elected representatives should press Colorado’s General Assembly for substantial increases in the state’s tobacco and alcohol excise tax rates, which are currently among the lowest in the country.^[24]

· Denver should adopt school and community prevention programs with a sound theoretical basis and backed by research-based evidence of success.

Treatment
The city should devote significantly more of its own revenues to treatment. As part of this increased investment, Denver should earmark funding for research to assess the effectiveness of local treatment services.

· The city’s new investments in treatment should also be geared toward strengthening the entire continuum of needed services.

Denver residents and elected officials should also seek to make state policies more supportive of substance abuse treatment. In particular, Denver should press state lawmakers to:

· Seek a federal waiver to expand Medicaid coverage for treatment. Medicaid accounts for nearly one-third of public funding for treatment nationally,^[25] but currently plays only a negligible role in Colorado.^[26]

· Require private health insurers to cover substance abuse treatment on par with coverage for any other illness. In Colorado, 1.8 million adults are enrolled in employer-sponsored health insurance plans.^[27] At least 100,000 of these insured Coloradans need treatment for alcohol or drug abuse,^[28] so parity for treatment benefits could make a sizeable contribution to closing the treatment gap, in Denver and statewide.

Denver: On the Horizon brings together the latest information on substance abuse in Denver, providing a snapshot of a dynamic and evolving situation. Drug Strategies hopes that this report will help the residents of Denver and Colorado to concentrate resources where they will have the maximum effect in reducing substance abuse and the damage it inflicts on society.

[7]. D. P. Andrulis & N. J. Goodman. The Social and Health Landscape of Urban and Suburban America. Chicago, IL: American Hospital Association Press, 1999. Among comparably-sized cities, the only nine to score better than Denver (rank #30) on the “Deprivation Index” (using 1996 data) were: Virginia Beach, Virginia (3); Honolulu, Hawaii (4); Seattle, Washington (10); Colorado Springs, Colorado (13); Mesa, Arizona (14); Charlotte, North Carolina (15); Omaha, Nebraska (20); Tulsa, Oklahoma (25); and Albuquerque, New Mexico (28).

[9]. Colorado Department of Public Health and Environment and U.S. Centers for Disease Control and Prevention. The CDC sponsors the Behavior Risk Factor Survey (BRFS), which is administered annually in Colorado by the Department of Public Health and Environment. Since 1993, questions on alcohol use have been included in the Colorado survey every other year (e.g., 1993, 1995, 1997 and 1999). According to BRFS results for 1993, 1995, 1997 and 1999, an average of 20.7 percent of Denver adults engaged in binge drinking (five or more drinks on one occasion at least once during the past month), compared to 14.5 percent of adults nationwide on average over the same years. The rate of binge drinking among Denver adults is therefore 42.7 percent higher than the national average. In the same years, an average of 5.1 percent of Denver adults engaged in chronic drinking (at least 60 drinks in the past month), compared to 3.1 percent of adults nationwide. The rate of chronic drinking among Denver adults is therefore 64.5 percent higher than the national average.

[10]. Colorado Department of Public Health and Environment.

National Institute on Alcohol Abuse and Alcoholism. Trends in Alcohol-Related Morbidity Among Short-Stay Community Hospital Discharges, United States, 1979-1999. December 2001.

From 1994-1998, the U.S. rate of alcohol-related hospital discharges declined steadily from 22.6 discharges per 10,000 population 15 and older to 19.3 per 10,000. According to data maintained by CDPHE, Denver’s rate of alcohol-related hospital discharges rose from 21.1 per 10,000 in 1995 to 35.2 per 10,000 in 1998, 82.4 percent higher than the U.S. rate in 1998.

[11]. Substance Abuse and Mental Health Services Administration. Year-End 2000 Emergency Department Data from the Drug Abuse Warning Network (DAWN). July 2001. The published DAWN report provides hospital emergency department (ED) data for 21 metropolitan areas in their entirety, without distinguishing between trends in each metro area’s central city and its surrounding counties. SAMHSA’s Office of Applied Studies provided Drug Strategies with hospital emergency department data for the City & County of Denver and for the surrounding counties separately. From 1996-2000, Denver averaged 563 drug-related hospital ED episodes per 100,000 residents age 6 and older, nearly 2½ times higher than the national average (227 per 100,000).

[12]. Colorado Department of Public Health and Environment and National Center for Health Statistics. From 1994-1998, Denver’s annual alcohol-related death rate of 58.5 per 100,000 residents and drug-related death rate of 18.5 per 100,000 residents totaled 77.0 deaths per 100,000 residents. During this five-year period, Denver’s overall alcohol and drug-related death rate was 54 percent higher than the national average (50.0 per 100,000).

[16]. Colorado Office of the State Court Administrator; Colorado Division of Criminal Justice; and Bureau Justice Statistics. In 1994, Denver’s rate of imprisoning drug offenders stood about 20 percent higher than the national average (73.0 versus 60.5 per 100,000 population). As the U.S. drug offense imprisonment rate rose slowly over the next five years, reaching 65.3 per 100,000 in 1998, Denver’s rate more than doubled. At 162.0 drug imprisonments per 100,000 population 1998, Denver’s rate was 2.48 times higher than the national average.

[17]. National Institute on Drug Abuse & National Institute on Alcohol Abuse and Alcoholism. The Economic Costs of Drug and Alcohol Abuse in the United States, 1992. September 1998.

Office of National Drug Control Policy. The Economic Costs of Drug Abuse in the United States, 1992-1998. September 2001.

NIDA and NIAAA (1998) estimated that alcohol abuse cost the nation $166.543 billion in 1995, and that drug abuse cost the nation $109.832 billion in 1995. Updating NIDA-NIAAA’s 1995 alcohol abuse cost figure for population growth and inflation, Drug Strategies estimates that alcohol abuse cost the nation $212.680 billion in the year 2000. ONDCP (2001) revised and updated NIDA-NIAAA’s drug abuse cost figure, estimating that drug abuse cost the nation $160.664 billion in the year 2000. Combining these revised and updated estimates yields $373.344 billion in economic costs to the United States due to alcohol and drug abuse in the year 2000.

In the year 2000, Denver accounted for 0.0019708 of the entire U.S. population (554,636 of 281,421,906). If the economic costs of alcohol and drug abuse in Denver were directly proportional to Denver’s share of the U.S. population, then Denver’s year 2000 economic costs due to alcohol and drug abuse would have been an estimated $735.786 million (0.0019708 times $373.344 billion).

In light of the numerous indicators for which the available data reveal Denver’s alcohol and other drug abuse problems to be considerably more severe than the national averages (as documented in this report), Drug Strategies estimates that the economic costs of alcohol and other drug abuse in Denver are between 50 percent and 100 percent higher than the $735.786 million figure derived assuming costs would be in direct proportion to Denver’s share of the total U.S. population. Therefore, Drug Strategies estimates the year 2000 economic costs of alcohol and drug abuse in Denver to have been between $1.104 billion and $1.472 billion (or, rounding to the nearest hundred million, between $1.1 billion and $1.5 billion).

[19]. Colorado Alcohol and Drug Division and Office of Denver Adult Probation. About 2,000 Denver residents participate in community-based treatment annually, according to FY1998-2002 admissions data from programs that report to Colorado’s Alcohol and Drug Abuse Division (ADAD). (Programs required to report to ADAD include all those that receive any public funding, as well as all methadone maintenance programs and all juvenile justice programs.) Another 1,500 Denver residents participate in treatment each year while on probation with the Denver Drug Court. In addition, 1,800 Denver residents take part in court-ordered drinking driver programs, and about 4,500 are admitted to detoxification programs. (For many people dependent on alcohol or other drugs, detox is a critical first step in the treatment process. Without subsequent treatment, however, detox alone is unlikely to lead to sustained periods of reduced substance use or abstinence.) There is no recent estimate of the number of Denver residents participating in treatment at programs which are not required to report to ADAD and which do not serve Denver Drug Court probationers. Based on past estimates, if another 3,500 people are assumed to be in treatment, then the total number of Denver residents in treatment over the course of a year rises to about 7,000.

[25]. Substance Abuse and Mental Health Services Administration. Health Care Spending: National Estimates of Expenditures for Mental Health and Substance Abuse Treatment, 1997. July 2000. According to SAMHSA, nationwide expenditures on substance abuse treatment (including detoxification) totaled $11.890 billion in 1997, including $7.345 billion in public funds. Medicaid (federal and state sources) accounted for $2.268 billion in substance abuse treatment expenditures, 19.1 percent of the total amount spent on treatment in 1997, and 30.9 percent of the public funds spent on treatment.

[26]. Colorado Alcohol and Drug Abuse Division; Colorado Department of Health Care Financing.

Substance Abuse and Mental Health Services Administration. Health Care Spending: National Estimates of Expenditures for Mental Health and Substance Abuse Treatment, 1997. July 2000.

Colorado’s FY2002 Medicaid spending on substance abuse treatment totaled $1.416 million, equivalent to 32¢ per Colorado resident. Nationwide, Medicaid spending on treatment in 1997 totaled $2.268 billion, equivalent to $8.31 per U.S. resident.