Substance Abuse

Goal

Reduce substance abuse to protect the health, safety, and quality of life for all, especially children.

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:

n	Whites and Hispanics are more likely than African Americans to use alcohol.

n	Whites are more likely than African Americans and Hispanics to use tobacco.

n	Whites and Hispanics are more likely than African Americans to use illicit drugs.

Additional findings include the following:

Substance Use in the Past Year, 1998
Substance	White, Not Hispanic		Hispanic		African American, Not Hispanic
	All Ages	Aged 12 to 17 Years	All Ages	Aged 12 to 17 Years	All Ages	Aged 12 to 17 Years
	Percent
Alcohol	67.8	35.1	58.5	29.4	50.4	22.3
Cigarette	30.8	26.9	29.6	20.4	31.2	16.2
Any illicit drug	10.4	16.9	10.5	17.4	13.0	14.0
Marijuana	8.4	14.6	8.2	14.4	10.6	12.1
Cocaine	1.7	1.9	2.3	2.5	1.9	DSU
Inhalants	1.0	3.4	0.9	2.8	0.3	1.0
Heroin	0.1	DSU	0.1	DSU	0.2	DSU

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.)

Interim Progress Toward Year 2000 Objectives

Of the 20 substance abuse objectives in Healthy People 2000, 2 have met or surpassed their targets. More than 90 percent of worksites with 50 or more employees have adopted policies on alcohol and drugs (1995), exceeding the Healthy People 2000 target of 60 percent. One additional target has been met—monitoring access to treatment programs by underserved persons (1996).

Progress has been made toward other objectives. Alcohol-related motor vehicle crash deaths declined to 6.5 per 100,000 population (1996), attributed in part to passage of State laws mandating administrative license revocation (ALR), setting maximum blood alcohol concentration (BAC) levels of 0.08 percent for drivers aged 21 years and older, and establishing zero tolerance for alcohol in the blood of drivers under age 21 years. The cirrhosis death rate declined to 7.4 per 100,000 population (1995), although the rate for American Indians or Alaska Natives remains significantly higher than that of other groups. Average age of first use of harmful substances by adolescents aged 12 to 17 years has increased. In addition, past-month use of alcohol by adolescents aged 12 to 17 years has declined, as has steroid use by high school seniors.

Less progress has been made toward other targets. Past-month use of marijuana and cigarettes among adolescents aged 12 to 17 years has increased since 1994. Among high school seniors, both perception of harm and perception of social disapproval of substance abuse have declined. For the total population, rates of drug-related deaths and drug-abuse-related emergency department (ED) visits have increased.

Note: Unless otherwise noted, data are from the Centers for Disease Control and Prevention, National Center for Health Statistics, Healthy People 2000 Review, 1998–99.

Healthy People 2010—Summary of Objectives

Substance Abuse

Goal: Reduce substance abuse to protect the health, safety, and quality of life for all, especially children.

Number	Objective Short Title
Adverse Consequences of Substance Use and Abuse
26-1	Motor vehicle crash deaths and injuries
26-2	Cirrhosis deaths
26-3	Drug-induced deaths
26-4	Drug-related hospital emergency department visits
26-5	Alcohol-related hospital emergency department visits
26-6	Adolescents riding with a driver who has been drinking
26-7	Alcohol- and drug-related violence
26-8	Lost productivity
Substance Use and Abuse
26-9	Substance-free youth
26-10	Adolescent and adult use of illicit substances
26-11	Binge drinking
26-12	Average annual alcohol consumption
26-13	Low-risk drinking among adults
26-14	Steroid use among adolescents
26-15	Inhalant use among adolescents
Risk of Substance Use and Abuse
26-16	Peer disapproval of substance abuse
26-17	Perception of risk associated with substance abuse
Treatment for Substance Abuse
26-18	Treatment gap for illicit drugs
26-19	Treatment in correctional institutions
26-20	Treatment for injection drug use
26-21	Treatment gap for problem alcohol use
State and Local Efforts
26-22	Hospital emergency department referrals
26-23	Community partnerships and coalitions
26-24	Administrative license revocation laws
26-25	Blood alcohol concentration (BAC) levels for motor vehicle drivers

 

Healthy People 2010 Objectives

Adverse Consequences of Substance Use and Abuse

26-1.		Reduce deaths and injuries caused by alcohol- and drug-related motor vehicle crashes.

Target and baseline:

Objective	Reduction in Consequences of Motor Vehicle Crashes	1998 Baseline	2010 Target
		Per 100,000 Population
26-1a.	Alcohol-related deaths	5.9	4
26-1b.	Alcohol-related injuries	113	65
26-1c.	Drug-related deaths	Developmental
26-1d.	Drug-related injuries	Developmental

Target setting method: Consistent with the U.S. Department of Transportation for 26-1a; 42 percent improvement for 26-1b.

Data sources: Fatality Analysis Reporting System (FARS), DOT, NHTSA; General Estimates System (GES), DOT.

Total Population, 1998 (unless noted)	Alcohol-Related Motor Vehicle Crashes
	26-1a. Deaths	26-1b. Injuries
	Rate per 100,000
TOTAL	5.9	113
Race and ethnicity
American Indian or Alaska Native	19.2 (1995)	DNC
Asian or Pacific Islander	2.4 (1995)	DNC
Asian	DNC	DNC
Native Hawaiian and other Pacific Islander	DNC	DNC
Black or African American	6.4 (1995)	DNC
White	6.0 (1995)	DNC
Hispanic or Latino	DNA	DNC
Not Hispanic or Latino	DNA	DNC
Black or African American	DNA	DNC
White	DNA	DNC
Gender
Female	2.3	DNA
Male	9.2	DNA
Education level
Less than high school	DNC	DNC
High school graduate	DNC	DNC
At least some college	DNC	DNC
Select populations
Age group
Persons aged 15 to 24 years	13.5	DNA

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.

Progress has been achieved in reducing the rate of alcohol-related driving fatalities, which declined from 9.8 deaths per 100,000 population in 1987 to 5.9 deaths per 100,000 in 1998. However, fatal injuries caused by motor vehicle crashes in which either a driver or nonoccupant (that is, pedestrian or bicyclist) was under the influence of alcohol or drugs remain a serious problem in the United States.

Of particular concern is the fatality rate among Native Americans and persons aged 15 to 24 years. In 1994, the alcohol involvement rate in fatal traffic crashes for American Indian or Alaska Native men was four times higher (28 per 100,000 population) than for the general population. For persons aged 15 to 24 years, the rate was 11.7 per 100,000 population in 1997. Based on these rates, about 3 in every 10 persons in the United States will be involved in an alcohol-related crash sometime in their lives. The alcohol-related traffic fatality rate for youth, however, has decreased by more than 50 percent since 1982, from 22 deaths per 100,000 population to 10 deaths per 100,000 population in 1996.[57] The National Highway Traffic Safety Administration estimates that since 1975, over 18,220 lives have been saved by enforcement of minimum drinking age laws.57

The number of children who are victims of alcohol- and drug-related traffic crashes also is significant. In 1998, of traffic crashes in which 2,990 children under age 16 years were killed,nearly 21 percent were alcohol related.[58]

Crash-related injuries also are a serious problem. In 1998, crash-related injuries totaled 3,192,000, compared to 41,471 crash-related deaths.58 A reduction in all injuries resulting from alcohol- and drug-related driving is needed. Such injuries significantly contribute to emergency department use and overall health care costs and cause personal tragedies for families.

Although alcohol and its relationship to motor vehicle crashes has been studied more extensively than other substances, tracking drug-related fatalities and injuries is needed. This extension will promote the understanding that driving while under the influence of drugs is a serious problem and will help reduce drug-related fatalities.

Reductions in motor vehicle crashes are the result, in part, of many policy and program measures—among them, raising the minimum legal drinking age to 21 years,[59] administrative revocation of licenses for drinking and driving,[60] lower legal blood alcohol limits for youth41 and adults,42 and higher prices through increased taxation of alcoholic beverages.48, 49 Higher prices for alcoholic beverages also are associated with reduced frequency of drinking and driving.50 In addition, community programs involving multiple city departments and private citizens have reduced both driving after drinking and traffic deaths and injuries.43

26-2.		Reduce cirrhosis deaths.

Target: 3.0 deaths per 100,000 population.

Baseline: 9.5 cirrhosis deaths per 100,000 population occurred in 1998 (age adjusted to the year 2000 standard population).

Target setting method: Better than the best.

Data source: National Vital Statistics System (NVSS), CDC, NCHS.

Total Population, 1998	Cirrhosis Deaths
	Rate per 100,000
TOTAL	9.5
Race and ethnicity
American Indian or Alaska Native	25.9
Asian or Pacific Islander	3.5
Asian	DNC
Native Hawaiian and other Pacific Islander	DNC
Black or African American	9.9
White	9.4
Hispanic or Latino	15.4
Not Hispanic or Latino	9.0
Black or African American	10.2
White	8.8
Gender
Female	6.0
Male	13.4
Education level (aged 25 to 64 years)
Less than high school	19.9
High school graduate	14.2
At least some college	5.7

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

Sustained heavy alcohol consumption is the leading cause of cirrhosis, 1 of the 10 leading causes of death in the United States.[61], [62], [63], [64], [65] Cirrhosis occurs when healthy liver tissue is replaced with scarred tissue until the liver is unable to function effectively. Changes in alcohol consumption patterns over time are associated with changes in the death rate from cirrhosis. Improvements in disease management and in the availability of treatment for alcoholism, however, also may have contributed to a decline in cirrhosis deaths since 1973. In addition, higher State excise tax rates on distilled spirits are associated with lower death rates from cirrhosis.47

26-3.		Reduce drug-induced deaths.

Target: 1.0 death per 100,000 population.

Baseline: 6.3 drug-induced deaths per 100,000 population occurred in 1998 (age adjusted to the year 2000 standard population).

Target setting method: Better than the best.

Data source: National Vital Statistics System (NVSS), CDC, NCHS.

Total Population, 1998	Drug-Induced Deaths
	Rate per 100,000
TOTAL	6.3
Race and ethnicity
American Indian or Alaska Native	7.0
Asian or Pacific Islander	1.2
Asian	DNC
Native Hawaiian and other Pacific Islander	DNC
Black or African American	8.8
White	6.1
Hispanic or Latino	6.2
Not Hispanic or Latino	6.2
Black or African American	9.1
White	6.0
Gender
Female	3.9
Male	8.6
Education level (aged 25 to 64 years)
Less than high school	19.1
High school graduate	14.6
At least some college	5.3

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

Causes of drug-induced deaths include drug psychosis, drug dependence, suicide, and intentional and accidental poisoning that result from illicit drug use. Declining initiation, number of cases, and intensity of drug abuse should be reflected in fewer drug-induced deaths. However, the prevention of suicide, accidental poisoning, and fatal interaction among medications contributes to changes in the statistics measured in this objective.

26-4.		Reduce drug-related hospital emergency department visits.

Target: 350,000 visits per year.

Baseline: 542,544 hospital emergency department visits were drug-related in 1998.

Target setting method: 35 percent improvement.

Data source: Drug Abuse Warning Network (DAWN), SAMHSA.

Drug-related hospital emergency department (ED) visits are another major indicator of the harmful effects of drugs. In hospital EDs, a “drug-related episode” is defined as one resulting from the nonmedical use of a drug. This includes the unprescribed use of prescription drugs, use of drugs contrary to approved labeling, and use of illicit drugs. Episodes are abstracted from medical records by hospital staff or hired clerks. To be counted as having a drug-related episode, the ED patient must be aged 6 years or older and meet four criteria: the patient was treated in the hospital’s ED; the presenting problem was induced by or related to drug use; the case involved the nonmedical use of a legal drug or any use of an illegal drug; and the patient’s reason for taking the substance(s) included dependence, suicide attempt or gesture, or psychic effects.

“Suicide attempt or gesture” and dependence were the most frequently