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An Agenda To Combat Substance Abuse
Despite their huge health toll, substance abuse disorders remain underappreciated and underfunded. Reasons include stigma, tolerance of personal choices, acceptance of youthful experimentation, pessimism about treatment efficacy, fragmented and weak leadership, powerful tobacco and alcohol industries, underinvestment in research, and difficult patients. Positive signs include declining prevalence rates, successful counter-marketing campaigns, changing public attitudes, new scientific discoveries that could yield new treatments, and effective new organizations. Further progress will require better treatment, more research, better education of health professionals, more nongovernmental support, and stronger leadership. Policy changes regarding each of the three substance groups are indicated, as are reforms in the criminal justice and educational systems.
The medical, social, and psychological toll from substance abuse disorders is enormous. In the United States it includes the 440,000 annual deaths from tobacco, plus the more than eight million people who are disabled with chronic obstructive pulmonary disease (COPD) and other tobacco-related illnesses; the 100,000 annual deaths from abuse of alcohol, as well as alcoholism’s devastating effects on families and communities; and the 20,000 yearly deaths from the use of illicit drugs, not to mention drug abuse’s domination of our criminal justice system.1 In the face of such overwhelming damage, two questions emerge: Why does substance abuse receive relatively little medical and public health attention and support compared with other medical conditions? And what can be done to reduce the harm from substance abuse disorders?
Stigma. Despite emerging scientific evidence that substance abuse alters neurotransmitter patterns, many still stigmatize smokers, alcoholics, and drug abusers for having made unwise choices.2 They feel that even if central nervous system changes result from substance abuse, the choices were wrong in the first place. Another factor is the popular (and spurious) association of substance abuse with minorities. All too often, substance abuse is seen as having a black face, even though differences between blacks and whites in the prevalence of smoking (22 percent versus 24 percent, respectively) and alcoholism and drug abuse (9.5 percent versus 9.3 percent, respectively) do not support such stereotyping.3 Finally, public exposure to substance abuse can be polarizing, whether through secondhand smoke, raucous drunks, endangerment by an intoxicated driver, or encounters with aggressive alcoholic or drug-abusing panhandlers. Civil liberties/free choice. A strong theme of U.S. culture is respect for choice and individual freedom. When the public health evidence is sufficiently compelling—such as with secondhand smoke or drunk-driving fatalities—regulatory measures can trump that civil libertarian tilt, but usually only after a long struggle.4 Tolerance of youthful experimentation. Most adults experimented in their youth with tobacco, alcohol, and drugs, and most drink responsibly as adults. They view these experiences as developmental rites of passage and may be unsympathetic to the minority who become addicted. Futility/hopelessness. The problems of substance abuse have been around so long that they seem to be intractable. In reality, there has been slow but impressive progress. U.S. smoking rates declined from 42 percent in 1965 to 22 percent by 2000, youth smoking is at a twenty-seven-year low, alcohol-related motor vehicle fatalities fell by 33 percent between 1982 and 2002 despite major increases in miles traveled, and the prevalence of illicit drug use fell from twenty-five million users in 1979 to fourteen million in 2000.5 Pessimism about treatment efficacy. Public officials and clinicians share a double standard about treating substance abuse. Although they embrace aggressive treatment for diseases with miserable prognoses (for example, pancreatic cancer and malignant gliomas), they are skeptical about funding substance abuse treatment, in which rates of one-year remissions may vary from 5 percent to 20 percent for smoking and from 40 percent to 60 percent for alcoholism and drug abuse.6 In clinical settings, this attitude is reinforced by clinicians’ natural reluctance to encounter failures—smokers and drinkers who will not or cannot quit. One reason for this double standard is that substance abuse disorders are seen as volitional, while aggressive cancers are not. And recent data show declines in receipt of substance abuse treatment under private health insurance.7 Leadership. In contrast to breast cancer or HIV/AIDS, there are no aroused citizen advocacy groups for substance abuse disorders. The important exceptions of Mothers Against Drunk Driving and Students Against Drunk Driving stand as lone outliers to this rule. Undoubtedly, stigma makes it difficult for concerned groups to coalesce for public action. Even the most successful citizens group, Alcoholics Anonymous (AA), works undercover by design. Thus, there is no "race for the cure" against smoking-induced lung cancer and no mobilized women’s group fighting to stop alcoholism, smoking, or drug abuse. Another impediment is fragmentation of the substance abuse field. Not only is there failure to coalesce among the three categories of substances, but even within each class there is rivalry, such as tensions between those who advocate for a twelve-step approach to drug and alcohol treatment and those who promote pharmaceutical treatment. Industries’ power. The tobacco industry spent $12.5 billion on advertising and promotion in 2002 alone, not to mention its contributions to political campaigns.8 Revenues from U.S. tobacco sales amounted to more than $88 billion in 2002, while alcohol sales generated $116 billion in 1999.9 These industries exert powerful political influence and have a track record of successful opposition to programs that would reduce use of their products. Investigators working to reduce harm from tobacco have been subjected to legal harassment, including suits requiring submission of voluminous primary data, depositions, and court testimony.10 Underinvestment in research. Despite the huge toll exerted by tobacco, only 1 percent of the National Institutes of Health (NIH) budget is devoted to tobacco research.11 Similarly, the combined budgets of the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) amounted to $1.38 billion in 2003, or less than 5 percent of total NIH expenditures.12 Difficult patients. Clinicians find it hard to care for patients with substance abuse problems. This reflects the limited education and training most clinicians receive on this topic and disappointment that so few patients follow their advice about quitting. At least in the case of drug-seeking behavior (when patients seek narcotics from physicians), the doctors may stop trusting these patients.
Declines in prevalence rates, morbidity, and mortality. Steady declines in tobacco and drug use, as well as motor vehicle accidents from drunk driving, have occurred during the past twenty years. Violent crime has long been associated with alcohol and drug abuse. Homicide rates declined from 10.2 deaths per 100,000 population in 1980 to 5.5 in 2000.13 Although these rates are still very high by international and historical standards, and the linkage with substance abuse may be indirect, the fact of improvement belies the pessimism that nothing can be done to improve difficult social problems. Successful countermarketing campaigns. Hard-hitting state-sponsored television and billboard campaigns in California, Massachusetts, and Florida, plus the national "truth" campaign sponsored by the American Legacy Foundation, have been credited with contributing to recent declines in both youth and adult smoking rates.14 The widely promoted designated driver campaign, featuring TV commercials and story lines in popular TV shows, has been acknowledged as helping reduce deaths from drunk driving.15 Some credit the antidrug commercials of the Partnership for a Drug-Free America with contributing to the decline of youth drug use.16 Changing public attitudes. Public backlash against substance abuse is most obvious for tobacco, spurred by mounting evidence of the dangers of secondhand smoke. Seven states have banned smoking in workplaces and public settings, including restaurants and bars, as have more than 1,600 localities.17 Revolts against alcohol abuse are evident in legislation to penalize drivers with elevated blood alcohol levels. Henry Wechsler has advanced the concept of secondhand damage that occurs from binge drinking on college campuses, whereby nondrinkers are exposed to risks ranging from date rape to vandalized rooms.18 Public attitudes about the dangers of illicit drugs show cyclical variations influenced by prominent tragedies, such as the 1986 death of basketball star Len Bias from cocaine, leading to major changes in attitudes: Between 1986 and 1990, the proportion of twelfth graders who reported that trying cocaine posed great risk rose from 33 percent to 59 percent.19 New science. Imaging and neurochemical techniques have identified pathways of dopamine neurotransmission and specific brain areas that change with addiction. The role of specific genes in predisposing to addiction or protecting against it is under active exploration. Newer pharmacological agents such as naltrexone, buprenorphine, and ondansetron build on older standbys of disulfiram and methadone to treat alcoholism and drug addiction. Smoking cessation now benefits from multiple forms of nicotine replacement therapy and psychoactive drugs such as bupropion. New technologies such as telephone quit lines and Web-based services are available for smokers who want to quit.20 New organizations. The past decade has seen the emergence of national advocacy groups against substance abuse. Two—the Campaign for Tobacco-Free Kids (CTFK) and the American Legacy Foundation—focus exclusively on tobacco, while the National Center on Addiction and Substance Abuse (CASA) at Columbia University deals with all three substance categories. Despite the facts that using tobacco alone, alcohol alone, or the two in combination increases the risk of cancer and that using tobacco causes both heart and lung disease, the major disease voluntary organizations have generally not seen substance abuse as a dominant concern. Nevertheless, the American Cancer Society (ACS) helped found the CTFK, and state ACS affiliates, the American Heart Association, and the American Lung Association have been key in state tobacco-control efforts.
Some of the barriers mentioned are resistant to specific policies and will change only as evidence and experience accumulate. But others are remediable by specific changes in the public and private sectors. Most of the changes depend on identifying new funding sources and public, professional, and political champions. Better approaches to treatment. Adequate treatment for substance abuse is particularly challenging for the forty-five million uninsured Americans. Even for the insured, many policies, including most Medicaid programs, do not cover the time for counseling or the costs of drugs such as nicotine replacement therapy and bupropion for smoking cessation, methadone for drug addiction, or disulfiram for alcoholism. As new, effective drugs come on the market, patients must have access to them. Clinicians and policymakers need to reframe how "successful treatment" is defined. Physicians caring for patients with asthma or diabetes understand that these are chronic illnesses and that the goal is to maximize functioning and minimize disability. By contrast, many clinicians become frustrated because it is difficult to "cure" smokers, alcoholics, or drug abusers. Rather than acknowledging that patterns of use often follow a waxing and waning course, that a year of sobriety is cause for triumph and social good, and that it may take many attempts before a patient is able to quit, they too often see the glass as half empty. Envisioning the goal of substance abuse treatment as managing chronic illness—including knowing appropriate referral sources within the community and the roles of nonphysician professionals—could help doctors celebrate the tangible benefits of such treatment, instead of lamenting the reality that cures for most chronic diseases are often elusive. Drug courts, which offer treatment as an alternative to incarceration, are a promising but greatly underused resource.21 More support for research. Since more than 550,000 (27 percent) of the 2,420,000 deaths that occur in the United States each year are from substance abuse, a reasonable target would be to devote 20 percent ($5 billion) of the current $27 billion NIH budget to substance abuse research rather than the current approximately $1.6 billion. Beyond studying the basic science of addiction and exploring new pharmacologic treatments, research could help us understand why some people who experiment with substances become addicted while others do not, the comparative efficacy of different modes of treatment, the complexities of dual diagnosis (coexisting mental illness and substance abuse), the social context of addiction, and the impact of various social policies on addiction and the harm it causes. Better education of health professionals. Substance abuse receives minimal notice in undergraduate and graduate medical education, specialty board certifying exams, continuing medical education, standard clinical textbooks, and medical journals. Not only is content slighted, but it is rare for medical education to acknowledge the role of other health professionals in treating substance abuse or the workings of twelve-step programs such as AA. This relative underemphasis reflects the reality that few medical faculty work in the area of substance abuse. The neglect is disappointing, given the extent to which substance abuse accounts for illness in Veterans Affairs (VA) and county hospitals—sites of intensive medical education for most academic medical centers. Nongovernmental funding. Although government will continue to provide the bulk of substance abuse treatment and research dollars, there are gaps in its funding. Some interventions—such as needle exchanges for heroin addicts as a way to reduce the transmission of HIV and hepatitis—may challenge strongly held ideological views, thus precluding government support. Also, the power of the tobacco and alcohol industries may deter adoption of proven public health strategies such as raising cigarette taxes or lowering the permissible blood alcohol level for drivers. Because there are areas where government either will not or cannot take a stand, private support matters. Examples are the role of the ACS and the Robert Wood Johnson Foundation in establishing the CTFK, the countermarketing of the American Legacy Foundation and the Partnership for a Drug-Free America, and the Conrad N. Hilton Foundation’s support for substance abuse educational programs in public schools. Stronger leadership. Greater recognition of substance abuse as a major health problem should encourage broader and more diverse leadership. Whether that leadership can or should transcend the individual substance categories is not clear. It may be that lumping together marijuana, beer, cigarettes, and heroin is too unwieldy to generate a unified constituency. Although substance abuse affects women’s health, it has yet to surface on the advocacy agenda of the women’s movement. Tobacco policies. The failure of nearly all states to meet the U.S. Centers for Disease Control and Prevention’s (CDC’s) minimal 5 percent spending on tobacco control from the $206 billion 1998 Master Settlement Agreement (MSA) is embarrassing.22 A small fraction of these funds could be used to expand and market the highly successful telephone quit lines, which now have a single national portal (1-800-QUIT NOW); to support other tobacco-control programs; and to provide treatment for smokers in Medicaid. In addition, raising federal and state tobacco excise taxes would discourage tobacco use and provide additional revenue for health programs. The federal tax is only thirty-nine cents per pack of cigarettes, with state taxes ranging from a low of 2.5 cents to a high of $2.50. A recent recommendation by an interagency task force on tobacco cessation to raise the federal tax by two dollars was vetoed by the Bush administration.23 Finally, expanding the number of states and localities that prohibit smoking in public places would protect nonsmokers and create incentives for smokers to quit. Alcohol policies. Although the 1998 MSA restrained tobacco manufacturers from advertising to minors, there is no such formal agreement with the alcohol industry. Indeed, critics have contended that much alcohol advertising is directed at youth.24 The desirability of voluntary or regulatory limits to advertising is being debated.25 Restricting alcohol access among underage youth is a part of every state’s mandate but is variably enforced at liquor stores, bars, and restaurants. Penalties for drunk driving aim to reduce harm from alcohol abuse. In October 2000, Congress passed legislation requiring states to install a 0.08 percent legal limit for blood alcohol levels for drivers by 1 October 2003 or lose a portion of their federal highway funding annually until that law is passed. To date, forty-five states have a 0.08 limit, while five are still at 1.0. In France the legal limit is 0.05.26 Zero-tolerance laws for underage drivers, who have the highest rates of motor vehicle accidents and traffic fatalities, have been enacted in all fifty states. These laws provide penalties for drivers under age twenty-one who have any detectable blood alcohol. The effectiveness of such laws depends on their implementation. Rigorous enforcement includes passive breath testing, sobriety checkpoints, and serious administrative penalties such as loss of driver’s license.27 Drug policies. Providing adequate treatment for community-based and incarcerated people with drug addiction generates social and medical savings: lower crime, lower prison spending, less family dysfunction, and better health.28 A RAND report of mandatory minimum sentences for cocaine concluded that dollar for dollar, treatment is fifteen times more effective than incarceration in reducing serious crime.29 Another study showed that treatment for substance abuse in criminal justice settings lowers re-incarceration rates.30 Also, providing clean needles for heroin addicts reduces the transmission of bloodborne diseases.31 Reform of the criminal justice system for substance abuse. Federal and state legislation imposes mandatory terms for possession of illicit drugs, thereby removing sentencing discretion from the hands of judges. Greater flexibility would reduce the cost and burden of incarceration and give many a chance for rehabilitation. Despite evidence that providing treatment and drug testing instead of incarceration can reduce both penal and social costs and increase the rate of drug rehabilitation, these approaches remain rare. Expansion will require permissive laws and knowledgeable judges.32 State corrections officials estimate that 70–85 percent of inmates need some level of substance abuse treatment. But in approximately 7,600 correctional facilities surveyed in 1997, less than 11 percent of the inmates were in drug treatment programs.33 Requiring substance abuse treatment as a condition of parole has been shown to increase treatment as well as abstinence from drug use.34 Huge disparities exist between penalties for possessing cocaine in powder and crack form. Congress mandated five-year prison terms for possession of either 5 grams of cocaine in crack form or 500 grams in powder form.35 This 100-to-1 sentencing ratio makes no medical sense and has been criticized as a racist policy. The public schools. Illicit drug use by children is a "hot button" issue for parents and politicians. The federal Office of National Drug Control Policy (ONDCP) is promoting drug testing in schools to achieve its goal of reducing drug use by 10 percent over two years and 25 percent over five years. School drug testing involves random or periodic tests of urine, saliva, or hair for substances. Commonly, commercial laboratories test for up to five substances (cannabinoids, cocaine, amphetamines, opiates, and phencyclidine) but not for alcohol and tobacco. The tests can detect a single episode of use within days or up to a week later and habitual use as much as four to six weeks after the last use.36 Students who test positive are offered treatment, referred to their parents for disciplinary action, suspended, or expelled, depending on school policy. Since marijuana is by far the most commonly used of the substances tested for, it is the usual cause of a failed test.37 Data are lacking as to the effectiveness of drug testing. Does it protect students or contribute to a drug-free school environment? What happens to students who fail the test? What are the civil liberties and privacy implications? Substance abuse remains a serious medical, public health, and social problem. Yet it lacks champions, is underfunded, and is relatively neglected by clinicians and the medical establishment. Despite real progress in the past few decades, the United States still lags behind virtually every developed country in measures of health status. Our current national strategy to close that gap involves funding biomedical research to yield new treatments and improving access to care for minorities. Both are worthwhile goals but are doomed to failure unless they are coupled with effective policies to reduce harm from substance abuse.
Steve Schroeder (Schroeder{at}medicine.ucsf.edu) is distinguished professor of health and health care at the University of California, San Francisco. The author is indebted to Kristin Schubert, Brian Eule, Elissa Keszler, and Lucia Marques for their assistance and to Stephen Isaacs for editorial comments. This work was supported by the Robert Wood Johnson Foundation and adapted from a presentation at a National Center on Addiction and Substance Abuse meeting at Columbia University, "Positioning the Nation for Progress in the Twenty-first Century," New York City, 8–10 October 2003.
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