notice: The Health Minister announced in July 2001 a 7 million commitment to the city of Vancouver for community health promotion efforts.
The IDU population has a very high incidence of welfare receipt and hospital use, as will be discussed further in Section IV. Under B.C. Benefits Legislation, rates for
income assistance for an employable single adult effective October 1, 2002 include 325 for shelter and 185 for support allowance.
2
Individuals who have a severe mentalphysical impairment requires extensive assistance to perform daily tasks,
additional transportation costs, special diets that is confirmed by a physician to con- tinue for two years are eligible for full disability benefits Level II. Rates for Level
II benefits effective October 2002 include 325 for shelter and 461.42 for support allowance, which is the third highest in the country after Ontario and Alberta. Many
IDUs are eligible for Level II Disability due to advanced HIVAIDS-related illnesses.
Welfare checks are distributed once a month in the province of British Columbia, usually on the last Wednesday. In the “Downtown Eastside” of Vancouver—home to
around 10,000 IDUs McClean 2000—the notion that “Welfare Wednesday” is associ- ated with a number of days of binging on heroin, cocaine and alcohol has reached myth-
ical proportions in both the media and medical communities. Indeed, the weekend following Welfare Wednesday also is known as “Mardi Gras Weekend” Stevens 2000.
III. Welfare Checks and Drug Consumption
In the United States, over 200,000 individuals received SSIDI payments based on “drug and alcohol addiction” in 1996 Davies et al. 2000. Following P.L. 104-
121—passed on March 29, 1996—the Social Security Administration ceased to issue SSIDI payments to individuals whose drug or alcohol addiction DAA was a signifi-
cant factor in their disability. As well, as of January 1, 1997, eligibility for SSIDI was terminated for DAA cases.
3
It is noteworthy that even prior to 1996, receiving SSIDI in the United States was more difficult for individuals with a drug or alcohol dependency
than in Canada. Since 1972, DAA beneficiaries could only receive payment through a representative payee and had to participate in a treatment program if appropriate treat-
ment was available. Then in 1994, a three-year time limit on SSIDI benefits was placed on DAA beneficiaries. Outside the realm of Social Security, the 1996 “Gramm
Amendment” imposed a lifetime ban on Food Stamps and Temporary Assistance for Needy Families known as TANF, formerly the Aid to Families with Dependent Children
program to individuals with a drug felony conviction.
Essentially, the rationale behind the 1996-97 changes was that the federal govern- ment was subsidizing substance abuse in American communities in the first week of
the month Cohen 1994. However, as noted by Catalano and McConnell 1999, very
2. See the B.C. Ministry of Human Resources website www.mhr.bc.ca for further information on B.C.’s income assistance laws. In September 2003, sweeping changes were made to the Income Assistance laws in
British Columbia. The data in this paper cover the 1995 to 2000 period where no major amendments were made.
3. Davies et al. 2000 estimate that between December 1996 and January 1997 alone, 103,000 recipients lost their assistance. Beneficiaries were allowed to appeal that a drug or alcohol addiction was a significant
factor in their disability, and could continue to receive payments if their appeal was made before July 30, 1996, and had not received a medical determination by the end of calendar year 1996.
The Journal of Human Resources 140
little scholarly research was cited in the debate with the notable exception of Shaner et al. 1995. Those authors study a very small, and highly specialized, cohort of 105
schizophrenic cocaine users in Los Angeles and find that drug use, psychiatric symp- toms, and hospital admissions all increased around the first of the month—when wel-
fare checks in the United States are released.
4
From a theoretical perspective, the possible relationship between welfare checks and drug consumption has various components. One component is the pure income effect
story. Based on Cohen 1994, it is clear that the 1997 change in U.S. law was predi- cated on the notion that terminating SSIDI benefits may lead to reduced drug con-
sumption. To date, we are unaware of any study that has convincingly examined the income effect side of the substance use-welfare debate. Indeed, we are unable to directly
test for income effects in this paper since we do not observe an individual’s benefit level.
In this paper we address the question of whether the distribution of welfare pay- ments affects the distribution of drug consumption over time. The addiction literature
suggests that the key reason why we may see spikes in drug consumption in the days following welfare day is due to the link between environmental cues and the neuro-
physiology of drug use for literature reviews see Gawin 1991 for cocaine addiction and Goldstein 1991 for heroin addiction.
5
The more rapid a drug’s onset of action, the greater the euphoria users experience and the more they “like” the drug. Cocaine and heroin are especially rapid in their delivery
to the brain, particularly when administered via smoking and intravenous methods. Moreover, in the case of cocaine, the rate of removal from the brain is extremely fast.
6
Thus, there is something inherent to using cocaine that makes it more likely an individ- ual will want to use the drug again immediately after a hit. This is believed to be a key
reason why individuals who become addicted to cocaine tend to move toward a “binge and crash” pattern of use, in addition to moving from intranasal or oral administration
toward smoking and intravenous administration.
7
Individuals who progress toward a fully developed cocaine addiction will typically start in the evening, readminister
cocaine every 10 to 30 minutes, transition toward high-dose, and use the drug continu- ously until all cocaine on hand is gone with binges lasting as long as 200 hours.
8
What factors trigger a cocaine binge? The addiction literature overwhelming points to the importance of environmental cues. Addicts experience powerful urges to use
drugs when they encounter certain cues that they associate with prior drug use. Such conditioned
cues can include everything from mood states, to certain people or certain
4. However, Catalano and McConnell 1999 examine psychiatric admissions at a San Francisco hospital from 1994 to March 1998 and find strong evidence of check effects both before and after the change in law.
5. Liquidity constraints also could be a factor. IDUs are likely poor savers with limited access to credit markets. 6. In essence, cocaine provides a very powerful but very brief euphoric effect. In fact, cocaine also blocks
the removal of dopamine from the brain, resulting in an accumulation that causes continuous pleasurable stimulation of brain cells. Cocaine results in a high that last about 20 minutes with a half-life of about one hour
Gawin 1991. 7. Of course, not all individuals who try cocaine become addicts; in fact, it is estimated that only between
10 to 15 percent of those who try cocaine usually intranasally become addicted Gawin 1991. And then, not all addicts progress to the fully developed addiction stage characterized by high-dose, smoking
intravenous delivery, long duration binging. 8. In animal-based experiments, continuous and rapid cocaine use is observed if access is unrestricted, with
the animal typically dying in approximately two weeks. When access is restricted, an animal will “press a lever a thousand times for a single cocaine dose” Gawin 1991.
Riddell and Riddell 141
places. Bernheim and Rangel 2004 provide an extensive review. This notion implies that once a culture of drug use has been established—such as in the Downtown
Eastside of Vancouver—it would be very difficult for a user to resist drug use once exposed to that culture, even if their intention was not to use drugs. Indeed, Welfare
Wednesday itself may have become an environmental cue for some IDUs. As will be discussed later, a strong majority of the nonhomeless drug users in the data live in the
Downtown Eastside, making it difficult for them to escape environmental cues.
9
Heroin addiction typically involves a different pattern of use; specifically, a smooth consumption pattern that resembles someone taking medication. Nevertheless, heroin
binges do occur, and also have been linked to environmental cues. That said, for many IDUs—who, because they have made the transition toward intravenous use, have
well-advanced addictions—heterogeneity in drug type is not a critical issue because they either use cocaine and heroin simultaneously as in a “speedball”, in the same
session along with other drugs, or specialize in either cocaine or heroin for a short time, but regularly switch back and forth. For example, cocaine users typically com-
bine cocaine with other drugs—primarily heroin, alcohol, and marijuana—in order to mitigate certain negative characteristics of the cocaine experience, especially anxiety.
Environmental cues are a key component of recent addiction theories. For instance, Laibson 2001 incorporates “taste” shocks into the Becker and Murphy 1988
rational additional model where a taste shock is a cue-driven craving. With taste shocks, Laibson’s theory can explain the phenomenon of addicts—after exiting rehab
or incarceration—being more likely to resume use if they return to their original envi- ronment. In Bernheim and Rangel’s 2004 theory of addiction, drug-related cues
“trick” the brain into skipping its usual step in the decision-making process where every option is considered and appropriate expectations about future consequences
are considered. Instead, the brain only considers the pleasurable aspects of drug use. The authors’ theory explains many of the stylized facts of drug use including “ran-
dom” binges, and the importance of heterogeneity in drug type and method of deliv- ery. Both the above theories are consistent with binging on check day provided that
Welfare Wednesday either explicitly or implicitly leads to cue-driven cravings.
There is a case to expect binging after welfare day. The remainder of the paper tests this hypothesis. A key difference between a spike in drug consumption on welfare day
relative to a spike in overall consumption on welfare day as in Stephens 2003 is that “lumpy” drug consumption is likely more harmful than “smooth” drug consump-
tion—and thus there may be a role for public policy. For instance, the likelihood of overdosing may be greater when drugs are consumed in a binge and crash pattern.
10
9. Moreover, it is widely believed that most homeless IDUs live in the Downtown Eastside. 10. A drug overdose is the common term for drug poisoning, which is linked to the blood concentration of
a given drug. The blood concentration of, for example, morphine the metabolite of heroin depends on method of delivery, drug dosepurity including number of doses, body weight, and time elapsed since last
dose—in addition to individual-specific unobserved heterogeneity called individual pharmacokinetics. For literature reviews see White and Irvine 1999 and Warner-Smith et al. 2001. Under lumpy consumption,
blood concentrations levels may rise too quickly for the individual. In the case of heroin, most overdoses occur when drugs have been used over a period of several hours. Overdoses appear to be relatively common
for IDUs. In a typical cross-section, on the order of 50–65 percent of heroin users report a nonfatal overdose in their lifetime, a finding that is robust across countries. In the Hser et al. 2001 33-year longitudinal study
of nearly 600 narcotics addicts, the leading cause of death is overdose.
The Journal of Human Resources 142
As well, the long-term health consequences to the individual may be worse if they systematically use drugs in a lumpy manner Warner-Smith et al. 2001. Evidence
from nonfatal heroin overdose cases suggests that such users may suffer permanent pulmonary impairment, and an increased probability of developing pneumonia. For
heroin and cocaine, there is evidence that users suffer permanent cognitive impair- ments and muscular complications proportional to their overdose experiences.
Finally, lumpy drug use deteriorates your state of awareness and thus increases the chance of sharing needles Mandell et al. 1994—a key risk factor in contracting HIV.
IV. Data
