26

Substance Abuse

Overview

Substance abuse and its related problems are among society’s most pervasive health and social concerns. Each year, about 100,000 deaths in the United States are related toalcohol consumption.[1] Illicit drug abuse and related acquired immunodeficiency syndrome (AIDS) deaths account for at least another 12,000 deaths. In 1995, the economic cost of alcohol and drug abuse was $276 billion.[2] This represents more than $1,000 for every man, woman, and child in the United States to cover the costs of health care, motor vehicle crashes, crime, lost productivity, and other adverse outcomes of alcohol and drug abuse.

Issues and Trends

A substantial proportion of the population drinks alcohol. Forty-four percent of adults aged 18 years and older (more than 82 million persons) report having consumed 12 or more alcoholic drinks in the past year.[3] Among these current drinkers, 46 percent report having been intoxicated at least once in the past year—nearly 4 percent report having been intoxicated weekly. More than 55 percent of current drinkers report having consumed five or more drinks on a single day at least once in the past year—more than 12 percent did so at least once a week. Nearly 20 percent of current drinkers report having consumed an average of more than two drinks per day. Nearly 10 percent of current drinkers (about 8 million persons) meet diagnostic criteria for alcohol dependence. An additional 7 percent (more than 5.6 million persons) meet diagnostic criteria for alcohol abuse.[4]

Alcohol use and alcohol-related problems also are common among adolescents.[5] Age at onset of drinking strongly predicts development of alcohol dependence over the course of the lifespan. About 40 percent of those who start drinking at age 14 years or under develop alcohol dependence at some point in their lives; for those who start drinking at age 21 years or older, about 10 percent develop alcohol dependence at some point in their lives.[6] Persons with a family history of alcoholism have a higher prevalence of lifetime dependence than those without such a history.[7]

Excessive drinking has consequences for virtually every part of the body. The wide range of alcohol-induced disorders is due (among other factors) to differences in the amount, duration, and patterns of alcohol consumption, as well as differences in genetic vulnerability to particular alcohol-related consequences.[8]

Light-to-moderate drinking can have beneficial effects on the heart, particularly among those at greatest risk for heart attacks, such as men over age 45 years and women after menopause.[9] Moderate drinking generally refers to consuming one or two drinks per day. Moderate drinking, however, cannot be achieved by simply averaging the number of drinks. For example, consuming seven drinks on a single occasion will not have the same effects as consuming one drink each day of the week.

Long-term heavy drinking increases risk for high blood pressure, heart rhythm irregularities (arrhythmias), heart muscle disorders (cardiomyopathy), and stroke. Long-term heavy drinking also increases the risk of developing certain forms of cancer, especially of the esophagus, mouth, throat, and larynx.[10] Heavy alcohol use also increases risk for cirrhosis and other liver disorders[11] and worsens the outcome for patients with hepatitis C.[12] Drinking also may increase the risk for developing cancer of the colon and rectum.10 Women’s risk of developing breast cancer increases slightly if they drink two or more drinks per day.[13]

Alcohol use has been linked with a substantial proportion of injuries and deaths from motor vehicle crashes, falls, fires, and drownings.11 It also is a factor in homicide, suicide, marital violence, and child abuse[14] and has been associated with high-risk sexual behavior.11, [15], [16] Persons who drink even relatively small amounts of alcoholic beverages may contribute to alcohol-related death and injury in occupational incidents or if they drink before operating a vehicle.11 In 1998, alcohol use was associated with 38 percent of all motor vehicle crash fatalities, a significantly lower percentage than in the 1980s.[17]

Although there has been a long-term drop in overall use, many people in the United States still use illicit drugs. In 1998, there were 13.6 million current users of any illicit drug in the total household population aged 12 years and older, representing 6.2 percent of the total population.[18] Marijuana is the most commonly used illicit drug, and 60 percent of users abuse marijuana only.18 Among persons aged 12 years and older, 35.8 percent have used an illegal drug in their lifetime. Of these, more than 90 percent used marijuana or hashish, and approximately 30 percent tried cocaine.18 Relatively rare in 1996, methamphetamine use began spreading in 1997.18, [19]

Estimated rates of chronic drug use also are significant. Of the estimated 4.4 million chronic drug users in the United States in 1995, 3.6 million were chronic cocaine users (primarily crack cocaine), and 810,000 were chronic heroin users.[20]

Drug dependence is a chronic, relapsing disorder. Addicted persons frequently engage in self-destructive and criminal behavior. Research has confirmed that treatment can help end dependence on addictive drugs and reduce the consequences of addictive drug use on society. While no single approach for substance abuse and addiction treatment exists, comprehensive and carefully tailored treatment works.[21]

Drug use among adolescents aged 12 to 17 years doubled between 1992 and 1997, from 5.3 percent to 11.4 percent.18 Youth marijuana use has been associated with a number of dangerous behaviors. Nearly 1 million youth aged 16 to 18 years (11 percent of the total) have reported driving in the past year at least once within 2 hours of using an illegal drug (most often marijuana).[22] Adolescents aged 12 to 17 years who smoke marijuana were more than twice as likely to cut class, steal, attack persons, and destroy property than those who did not smoke marijuana.[23] Drug and alcohol use by youth also is associated with other forms of unhealthy and unproductive behavior, including delinquency and high-risk sexual activity.

Illegal use of drugs, such as heroin, marijuana, cocaine, and methamphetamine, is associated with other serious consequences, including injury, illness, disability, and death as well as crime, domestic violence, and lost workplace productivity. Drug users and persons with whom they have sexual contact run high risks of contracting gonorrhea, syphilis, hepatitis, tuberculosis, and human immunodeficiency virus (HIV). The relationship between injection drug use and HIV/AIDS transmission is well known. Injection drug use also is associated with hepatitis B and C infections.[24] The use of cocaine, nitrates, and other substances can produce cardiac irregularities and heart failure, convulsions, and seizures. Cocaine use temporarily narrows blood vessels in the brain, contributing to the risk of strokes (bleeding within the brain) and cognitive and memory deficits.[25] Long-term consequences, such as chronic depression, sexual dysfunction, and psychosis, may result from drug use.

Substance abuse, including tobacco use and nicotine dependence, is associated with a variety of other serious health and social problems. An analysis of the epidemiologic evidence reveals that 72 conditions requiring hospitalization are wholly or partially attributable to substance abuse.[26]

Substance abuse contributes to cancers that, until recently, were thought to be unrelated. Advances in research techniques since the 1980s, including advanced brain imaging and the study of the effects of alcohol and drug abuse on individual cells, have helped to document the alteration of healthy systems by all forms of substance abuse, including marijuana use. Researchers have identified lasting brain and nervous system damage from drugs, including changes in nerve cell structure associated with alcohol and drug dependence. Other research has focused on the long-term effects of alcohol and drug abuse on the immune system as well as the effects of prenatal alcohol and drug exposure on the behavior and development of children.

Research confirms that a substantial number of frequent users of cocaine, heroin, and illicit drugs other than marijuana have co-occurring chronic mental health disorders. Some of these persons can be identified by their behavior problems at the time of their entry into elementary school.[27] Such youth tend to use substances at a young age and exhibit sensation-seeking (or “novelty-seeking”) behaviors. These youth benefit from more intensive preventive interventions, including family therapy and parent training programs.[28], [29]

The stigma attached to substance abuse increases the severity of the problem. The hiding of substance abuse, for example, can prevent persons from seeking and continuing treatment and from having a productive attitude toward treatment. Compounding the problem is the gap between the number of available treatment slots and the number of persons seeking treatment for illicit drug use or problem alcohol use.

Disparities

Substance abuse affects all racial, cultural, and economic groups. Alcohol is the most commonly used substance, regardless of race or ethnicity, and there are far more persons who smoke cigarettes than persons who use illicit drugs. Usage rates for an array of substances reveal that for adolescents aged 12 to 17 years:

Additional findings include the following:

DSU = Data are statistically unreliable.
Source: National Household Survey on Drug Abuse: Population Estimates 1998, SAMHSA.

Older adolescents and adults with co-occurring substance abuse and mental health disorders need explicit and appropriate treatment for their disorders. Those who suffer from co-occurring disorders, however, frequently are turned away from treatment designed for one or the other problem but not for both. (See Focus Area 18. Mental Health and Mental Disorders.)

The population aged 65 years and older faces risks for alcohol-related problems, although this group consumes comparatively low amounts of alcoholic beverages.[30] Adverse alcohol-drug interaction can put older people in the hospital, since many take multiple medications. In addition, many cases of memory deficits and dementia now are understood to result from alcoholism.[31]

Opportunities

The direct application of prevention and treatment research knowledge is particularly important in solving substance abuse problems. Developing adaptations of research-proven programs for diverse racial and ethnic populations, field testing them with high-quality process and outcome evaluations, and providing them where they are most needed are critical. Interventions appropriate to the population to be served, including interventions to address gaps in substance abuse treatment capacity, must be identified and implemented by Federal, Tribal, regional, State, and community-based providers in a variety of settings.

Scientific research has identified many opportunities to prevent alcohol-related problems. For example, studies indicate that school-based programs focused on altering perceived peer-group norms about alcohol use[32], [33] and developing skills in resisting peer pressures to drink[34], [35], [36] reduce alcohol use among participating students. Communitywide programs involving school curricula, peer leadership, parental involvement and education, and community task forces also have reduced alcohol use among adolescents.[37]

Raising the minimum legal drinking age to 21 years was accompanied by reduced alcohol consumption, traffic crashes, and related fatalities among young persons under age 21 years.[38] Reductions in alcohol-related traffic crashes are associated with many policy and program measures[39]—among them, administrative revocation of licenses for drinking and driving[40] and lower legal blood alcohol limits for youth[41] and adults.[42] Community programs involving multiple city departments and private citizens have reduced driving after drinking and traffic deaths and injuries.[43] In addition, a combination of community mobilization, media advocacy, and enhanced law enforcement has been shown to reduce alcohol-related traffic crashes and sales of alcohol to minors.[44]

Higher prices or taxes for alcoholic beverages are associated with lower alcohol consumption and lower levels of a wide variety of adverse outcomes—including the probability of frequent beer consumption by young persons,[45] the probability of adults drinking five or more drinks on a single occasion,[46] death rates from cirrhosis[47] and motor vehicle crashes,[48], [49] frequency of drinking and driving,[50] and some categories of violent crime.[51] One study suggests that, among adults, the effect of alcoholic beverage prices on frequency of heavy drinking varies with knowledge of the health consequences of heavy drinking: better informed heavy drinkers are more responsive to price changes.[52]

In college settings, brief one-on-one motivational counseling has proved effective in reducing alcohol-related problems among high-risk drinkers.[53] Research on the effect of the density of alcohol outlets on violence is inconclusive.[54], [55]

Many opportunities to prevent drug-related problems have been identified. Core strategies for preventing drug abuse among youth include raising awareness, educating and training parents and others, strengthening families, providing alternative activities, building skills and confidence, mobilizing and empowering communities, and employing environmental approaches. Studies indicate that making youth and others aware of the health, social, and legal consequences associated with drug abuse has an impact on use. Parents also play a primary role in helping their children understand the dangers of substance abuse and in communicating their expectation that drug and alcohol use will not be tolerated. Research suggests that improving parent/child attachment and supervision and monitoring also protect youth from substance abuse. Alternative activities for youth teach social skills and provide an alternative to substance abuse. According to one study, programs that help young persons develop psychosocial and peer resistance skills are more successful than other programs in preventing drug abuse.21 Findings suggest that having community partnerships in place for sustained periods of time produces significant results in decreasing alcohol and drug use in males. Literature shows that having “buy-in” from local participants greatly enhances the success of any endeavor. Studies also show that changing norms is extremely effective in reducing substance abuse and related problems.21

For substance abuse prevention to be effective, people need access to culturally, linguistically, and age-appropriate services; job training and employment; parenting training; general education; more behavioral research; and programs for women, dually diagnosed patients, and persons with learning disabilities. Particular attention must be given to young persons under age 18 years who have an addicted parent because these youth are at increased risk for substance abuse. Because alcoholism and drug abuse continue to affect lesbians, gay men, and transgendered persons at two to three times the rate of the general population,[56] programs that address the special risks and requirements of these population groups also are needed. Government, employers, the faith community, and other organizations in the private and nonprofit sectors must increase their level of cooperation and coordination to ensure that multiple service needs are met.

The prevention and treatment of substance abuse require that all abused substances be addressed—from tobacco and alcohol to marijuana and other illicit drugs. Tobacco prevention and treatment are equally important parts of a comprehensive substance abuse prevention program. (See Focus Area 27. Tobacco Use.)

Terminology

(A listing of abbreviations and acronyms used in this publication appears in Appendix H.)

Administrative license revocation (ALR): Legal procedure that allows an arresting officer to confiscate immediately the driver’s license of a driver who is found with a blood alcohol concentration (BAC) at or above the legally set limit or who refuses to take a BAC test. The officer usually issues a temporary driving permit valid for a short time, often 15 to 20 days, then notifies the offender of his or her right to an administrative hearing to appeal the revocation. If there is no appeal or if revocation is upheld, the offender loses his or her driver’s license for a set period (90 days in most States for a first offense and longer for subsequent offenses).

Alcohol abuse: A maladaptive pattern of alcohol use that leads to clinically significant impairment or distress, as manifested by one or more of the following occurring within a 12-month period: recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home; recurrent alcohol use in physically hazardous situations; recurrent alcohol-related legal problems; continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. In the literature on economic costs, alcohol abuse means any cost-generating aspect of alcohol consumption; this definition differs from the clinical use of the term, which involves specific diagnostic outcomes.

Alcohol dependence: A maladaptive pattern of alcohol use that leads to clinically significant impairment or distress, as manifested by three or more of the following occurring at any time in the same 12-month period: tolerance; withdrawal; often taking alcohol in larger amounts or over a longer period than was intended; persistent desire or unsuccessful efforts to cut down or control alcohol use; spending a great deal of time in activities necessary to obtain alcohol or recover from its effects; giving up or reducing important social, occupational, or recreational activities because of alcohol use; continued alcohol use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

Alcohol-related crash: A motor vehicle crash in which either a driver or a nonmotorist (usually a pedestrian) had a measurable or estimated BAC of 0.01 grams per deciliter (g/dL) or above.

Binge drinking: The National Household Survey on Drug Abuse defines binge drinking as drinking five or more drinks on the same occasion on at least 1 day in the past 30 days. The Monitoring the Future Study defines binge drinking as drinking five or more drinks on the same occasion during the past 2 weeks.

Blood alcohol concentration (BAC): The amount of alcohol in the bloodstream measured as a percentage, by weight, of alcohol in the blood in grams per deciliter (g/dL). Legal intoxication has been defined by States to occur at ranges from as low as 0.05 g/dL to as high as 0.10 g/dL.

Chronic drug use: Use of any heroin or cocaine more than 10 days in the past month.

Co-occurring disorders: The simultaneous presence of two or more disorders, such as the coexistence of a mental health disorder and substance abuse problem.

Current drinkers: Persons who have consumed at least 12 drinks of any kind of alcohol in the past year.

Drug dependence: A pattern of drug use leading to clinically significant impairment or distress, as manifested by three or more of the following occurring at any time in the same 12-month period: tolerance; withdrawal; use in larger amounts or over a longer period of time than intended; persistent desire or unsuccessful efforts to cut down; spending a great deal of time in activities necessary to obtain drug(s); giving up or reducing important social, occupational, or recreational activities; continued use despite knowledge of having a persistent or recurrent physical or psychological problem.

Fatal crash: A police-reported crash involving a motor vehicle in transport on a traffic way in which at least one person dies within 30 days of the crash.

Hepatitis B and C: Viral infections of the liver spread through contact with infected blood products, injection use of drugs, and needle-sharing.

Indicated preventive interventions: Interventions targeted to reach high-risk individuals who are identified as having minimal but detectable signs or symptoms foreshadowing substance abuse or biological or familial markers indicating predisposition for substance abuse, even though they do not meet DSM-III-Rdiagnostic levels at the current time.

Inhalants: Fumes or gases from common household substances, such as glues, aerosols, butane, and solvents, that are inhaled to produce a high.

Injection drug use: The use of a needle and syringe to inject illicit drugs(for example, heroin, cocaine,steroids) into the vein, muscle, skin, or below the skin. Injection drug use places the user at great risk for transmitting or contracting a number of bloodborne infectious diseases, including HIV, hepatitis B, and hepatitis C.

Selective preventive interventions: Interventionstargeted to individuals or a subgroup of the population whose risk of developing substance abuse is significantly higher than average. The risk may be imminent, or it may be a lifetime risk. The basis may be biological, psychological, or environmental.

Substance abuse: The problematic consumption or illicit use of alcoholic beverages, tobacco products, and drugs, including misuse of prescription drugs.

Universal preventive interventions: Interventionstargeted to the public or a whole population group that has not been identified on the basis of individual risk. The intervention is desirable for everyone in that group. Universal interventions have advantages in terms of cost and overall effectiveness for large populations.

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