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....~.._ ..~..~._~_.~..__..,, . _.__.. Substance Abuse October 1993 51422 4577 „

;FURHEALTH _POLICY, BRANDEIS UNIVERSCI'Y for THE ROBERT WOO[> JONNSC~N FOUNDATION PRINCEI'ON, NF.W JERSEY October 1993

511B5T11111E JIB115E: THE NATION'S NUMBER ONE HEALTH PROBLEM Key Indicators for Policy 1'rcy,,o ,'rl fip [V; i i r(' ri~ EOEZ HE~.\t:rii PM«:Y, BizANDr.is UN ivrhsrrY f'or Tr-1E. RoBE:K-r V'ooi) JOHNsoN YouhuAriC>N hRfNCE"!Y)N, NI:Av JERSF.Y C)ctober• 1993 ^ \'\~ ~ ~. ~,.~.c..~ ...~es. ....r..

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~ ~ TABLE OF COnTEnTS .•.•.•........••.....•.........•••... ACKIlOIULEDGEItlEI1TS ......................................................... 5 PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 DATR UOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 ~ ~ OUERUIEW: THE COIITEHT OF SUBSTAIICE ABUSE .................................... 0 ~.~ Use, Abuse and Dependence, 8 ~ ~ Historical 'Irends in Consumption and Policy, 9 ~ ~ All Segments of Society Affected, 14 Societal Costs of Substance Abuse, 15 ~ Taking Action, 17 ~ ~ Monitoring Change, 17 Further Reading, 18 ~ A ~ 7 SECTIOII 1: PRTTERIIS OF USE .................................................. 19 ~ ~ Perception of Risk, 20 ~ ~ Implications of Early Use, 22 ~ i '1rends in Heavy Use, 24 ~ I)emographic Differences in Heavy Use, 26 , ~ Attempts to Quit, 28 Further Reading, 30 SECTIOII 2: COIISEQUEIICES OF USE .............................................. 31 ~ ~ "lobacco I)eaths, 32 Alcohol I)eaths, 34 ~ : Illicit I)rug I)eaths, 36 ~ ~: Strains on the Nation's Health Care System, 38 ~; Eflects of Substance Abuse on Families, 40 + Relationship to Crime, 42 a ~ Workplace Burden, 44 Further Reading, 46 ~ SECTIOIl3:C0It1BATTIIIGTHEPROBLEm...•.....,•,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47 Public Attitudes, 48 Illicit I)rug Control, 50 ~ ~ Community Coalitions, 52 ~ ~ Alcohol and Cigarette 'laxes, 54 Restrictions on Alcohol Use, 56 0' ~ Restrictions on Smoking, 58 Alcohol and I)rug Abuse Treatment, 60 Smoking Cessation Programs, 62 Further Reading, 64 ~. 00 . . ConClUSlo11 ,- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 ~-~ 00 ~, IIIDEH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 ~ ~ ~ r `. .r SUBSTAACE ABUSE . _ . . .... ........:~. . _.. ,., .~ -,.~.;

ACHOtULED GErClEI1TS ~ ~ ~ : ~ J ~ J ~ ~ -~ ~ ~ J ~ .~ ~ ~ ~ ~ ~ J ~ : ~ i ~ : . '~ a ~ ~ ~ -~ ~ 3 : ~ 0 1. WOU1.I)1.IKF, to thank a num- ber of people who provided very helpful advice on aspects of this report, including the overall orga- nization and content, the list of indicators, and locating data sources. The following people served on our Advisory Board: James J. Collins, John S. Gustafson, Michael Klitzner, Patrick M. O'Malley, Peter Reuter, Nancy Rigotti, and Robin Room. Also help- ful were government officials who served in an ex-oflicio capacity on the Advisory Board: Zili Amsel, Ann Blanken, Richard Fuller, Gary A. Giovino, Thomas Harford, Gale Held, Jerome Jaffe, and James Kaple. Dorothy Rice provided special cost calculations, and data also were provided by Rosanna Coffey, Joseph C. Gfroerer, Thomas Novotny, and Fred Stinson. Additional reviewers from Brandeis University were Deborah Garnick, Jeffrey Prottas, and Arthur Webb. Each provided useful advice on the most recent data sources as well as on accu- rate interpretation of data. C.H., M.E.M., M.J.L. i : : I SUBSTAIICE BBUSE

PREFRCE I MI'ROVING THE HFAI:r'H and health care of the American people is the mission of "I'he Robert \Cood Johnson Foundation. As a national philanthropy, the Founda- tion supports projects that provide ser- vices, conduct research and training and aa range of other activities that we hope will have an impact beyond our grantees' efforts: New models of care are tested so that others may adopt the most promising ones; health care leaders are trained so that they may discover new approaches and, in turn, influence the next generation. Policymaking takes place on many levels, with the participation of many people-busi- ness and communitv leaders, legislators, health professionals, interest group representatives, and voters. All have a role to play. Through the publication of a series of policy-relevant reports, the Foundation hopes to strengthen the ability of those participants to play effec- tive roles in the decision-making process, by arming them with simple, yet critical indica- tors that quickly summarize the nation's progress regarding specific health pol icy issues. Tracked over time, these indicators also can serve as early.varning signals, alerting policymakers to future problem areas. SUBST9]CE BBBSE Each report in the current indicator series describes one of the four health policy areas chosen by the Foundation as major program goals for the 1990s: • assuring access to basic health care for all Americans; • improving the way services are organized and provided to people with chronic health conditions; . promoting health and preventing disease by reducing harm from substance abuse; and • seeking opportunities to help the nation address the problem of escalating medical costs. Once our authors constructed a conceptu- al framework to measure each area, indica- tors were selected based upon their policy- relevance, the availability of data, and their ability to highlight a specific point and con- tribute to an overall understanding of the area. We hope this report will serve as a helpful resource, and we encourage readers to share its information with others. If you have comments or stiggestions, we would like to hear from you, as we decide whether subsequent editions would be usefitl. Please tell us what you think. STF\'EN A. SCHROEt)ER, \1D President ( ( ( 0 ( ( ( (

k , BOU7' THF. TERMS USEI) IN THIS REPORT... The labels used in this report for population groups, risk groups, and health problems are those used by the original data sources. In some cases, these labels--ethnic and racial identities are a good example-reflect old val- ues. We adopted this approach, despite our desire to be sensitive to changing preferences, because of the lack of consensus about which terms are preferred and to avoid potential con- fusion when people go back to an original data source to learn more about an issue. CAU'I'IONARY NO'FF;S FOR I)ATA INTERPRF:- T,tTIOti... "I-his report presents data on trends in substance use, consequences, and inter- DATA I10TES vention efforts, as well as comparisons among subgroups of the population on these issues. In most cases, available information was not sufficient to test for statistical significance of differences between years or between sub- groups. Accordingly, caution should be exer- cised in comparing the magnitude of such differences. In addition, trend data are gen- erally drawn from cross-sectional surveys or other data that do not represent the experi- ence of the same individuals over time. Despite these cautionary notes, the consistency of long-term trends and evidence from several sources is supportive of the major conclusions discussed here about the magnitude of the substance abuse problem and progress made in combatting it. SA85TA11CE BBU5E

OUERUIEUI: THE COI1TEXT OF SUBSTAIICE ABUSE R S THE NUMBER one health problem in the country, substance abuse places a major burden on the nation's health care system and con- tributes to the high cost of health care. In fact, substance abuse-the problematic use of alcohoZ illicit drugs and tobacco-places an enor- mous burden on American society as a whole. It can harm health, family life, the economy and public safety, and it threatens many other aspects of life as well. Substance abuse aects all segments ofsociety but it disproportionate- ly affects disadvantaged groups and threatens the future ofyoung people. ........................................................................... •'1'here are more deaths, illnesses and dis- abilities from substance abuse than from any other preventable health condition. Of the two million U.S. deaths each year, more than one in four is attributable to alcohol, illicit drug or tobacco use. Many of these deaths and other losses could be reduced-if not eliminated-- by changing people's habits. Alcohol and illicit drug use can result in family violence and maltreatment of children, and the loss of a family member due to sub- stance abuse has lifelong ramifications. Passive smoking causes respiratory problems in chil- dren and adults. The workplace is affected as well. Alcohol and drug abusers are costlier, less productive employees. Millions of people are arrested for driving under the influence of alcohol or drugs and for other crimes related to alcohol and illicit drug use. The safety of many neighborhoods-and the people living and working in them-is threatened bv vio- lence associated with drug sales. Federal, state, and local governments, as well as private citizens' groups, have acted to counter the enormous societal impact of sub- stance abuse, but much remains to be done. A great deal of the harm associated with sub- stance abuse can be prevented with increased public awareness of the problem and concerted public action. One step in this direction is the spread of effective prevention programs throughout the country with widespread sup- port from community groups, business and private citizens. GSE, ABUSE ANC) DEPF.NDENCE...Many people who drink, take illicit drugs or smoke occa- sionally do not experience problems from using these substances (although it is possible to have a serious injury or even to die from a single episode of alcohol or drug use). How- ever, with heavier, more frequent consump- tion, they are more likely to experience prob- lems with health, family members and other people, school, work or the law. Substance abuse refers to patterns of use that result in 51422 4585 SUBSTAACE ABU5E • • : t „ ..., ~, ,. , . . _. , . -. - , ,. . ,- .

. : 0 ~ y y V ~ : i i V 1; i V health consequences or impairment in social, psychological, and occupational functioning. While substance abuse concerns problems in living, dependence involves compttlsive use, craving, and increased tolerance. Although it is not possible to predict who will develop problems under what circum- stances, in general, moree serious problems develop when people become dependent on alcohol, illicit drugs or tobacco. A person who is dependent on a substance has a great need for it--often in inc.reasing amounts-in spite of trying to cut back. The process of becom- ing dependent is complex and is related to a number of factors, including the addictive properties of the substance, family and peer influences, personality and existing psychi- atric disorders. Genetics also plays a role in alcohol addiction, and recent research sug- gests that it may play a role in tobacco addic- tion, as well. At this time, its role in addiction to illicit drugs is not clear. Once a person is dependent on a substance, abuse becomes a chronic, relapsing condition characteriz.ed by waves of abuse, decreased use, and abuse again. It is very difficult to quit or curtail use, and frequently more than one attempt is nceded--sometimes over a long period of time-before a person suc- cessfully quits or gets use ttnder control. The likelihood of relapse is high. This report presents measures of use, abuse and dependence to illustrate the magnitude of thC substance abuse problem. Although the focus is substance abuse-use that has result- ed in significant problems for the user-infor- mation also is presented about patterns of use and the populations at risk. HISTORICAL TRENDS IN CONSUMPTION & PoI,ICY...The use of alcohol, illicit drugs and cigarettes has fluctuated during this century in response to shifts in public tolerance and with various political and economic events. In recent times, smoking began to decrease in the mid- 1960s, drug use in the late 1970s and alcohol consumption in the mid-1980s. Many people attribute these decreases to: • increased awareness of the health risks posed by substance abuse; • more governmental involvement in preven- tion, intervention and treatment efforts; and • the development of grassroots efforts and community coalitions directed toward decreas- ing substance abuse and its negative impacts. Alcohol... Alcohol consumption in the United States has risen and fallen over time. It was high during war years-the Civil War, World War I and World War 11-and low following Prohibition and during the Depression. Consumption was the lowest in U.S. history -0.9 gallons of ethanol per person aged 14 and older-in 1934, as the Depression was at its peak, and highest at 2.8 gallons per capi- ta-around 1980, following a period in which niore than half the states lowered the legal drinking age to 18. SU9STAUCE ABUSE