INTRODUCTION

Assistive Technology users should contact Jinhee Lee, [Link]@[Link], 240-276-0545.

CHAPTER 1.
INTRODUCTION AND OVERVIEW
OF THE REPORT

Chapter 1 Preview
The United States has a serious substance misuse problem. Substance misuse is the use of alcohol or
drugs in a manner, situation, amount, or frequency that could cause harm to the user or to those around
them. Alcohol and drug misuse and related substance use disorders affect millions of Americans and
impose enormous costs on our society. In 2015, 66.7 million people in the United States reported
binge drinking in the past month and 27.1 million people were current users of illicit drugs or misused
prescription drugs.3 The accumulated costs to the individual, the family, and the community are
staggering and arise as a consequence of many direct and indirect effects, including compromised
physical and mental health, increased spread of infectious disease, loss of productivity, reduced quality
of life, increased crime and violence, increased motor vehicle crashes, abuse and neglect of children, and
health care costs.
The most devastating consequences are seen in the tens of thousands of lives that are lost each year as a
result of substance misuse. Alcohol misuse contributes to 88,000 deaths in the United States each year;
1 in 10 deaths among working adults are due to alcohol misuse.6 In addition, in 2014 there were 47,055
drug overdose deaths including 28,647 people who died from a drug overdose involving some type of
opioid, including prescription pain relievers and heroinmore than in any previous year on record.7
Even though the United States spends more than any other country on health care, it ranks 27th in life
expectancy, which has plateaued or decreased for some segments of the population at a time when life
expectancy continues to increase in other developed countriesand the difference is largely due to
substance misuse and associated physical and mental health problems. For example, recent research has
shown an unprecedented increase in mortality among middle-aged WhiteAmericans between 1999 and
2014 that was largely driven by alcohol and drug misuse and suicides, although this trend was not seen
within other racial and ethnic populations such as Blacks and Hispanics.8 An analysis from the Centers
for Disease Control and Prevention (CDC) demonstrated that alcohol and drug misuse accounted for
a roughly 4-month decline in life expectancy among White Americans; no other cause of death had a
larger negative impact in this population.9
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INTRODUCTION

Substance misuse and substance use disorders also have serious economic consequences, costing
more than $400 billion annually in crime, health, and lost productivity.10,11 These costs are of a similar
order of magnitude to those associated with other serious health problems such as diabetes, which is
estimated to cost the United States $245 billion each year.12 Alcohol misuse and alcohol use disorders
alone costs the United States approximately $249 billion in lost productivity, health care expenses, law
enforcement, and other criminal justice costs.10 The costs associated with drug use disorders and use of
illegal drugs and non-prescribed medications were estimated to be more than $193 billion in 2007.11
Despite decades of expense and effort focused on a criminal justicebased model for addressing
substance use-related problems, substance misuse remains a national public health crisis that continues
to rob the United States of its most valuable asset: its people. In fact, high annual rates of past-month
illicit drug use and binge drinking among people aged 12 years and older from 2002 through 2014
(Figure 1.1) emphasize the importance of implementing evidence-based public-health-focused strategies
to prevent and treat alcohol and drug problems in the United States.13A public health approach seeks
to improve the health and safety of the population by addressing underlying social, environmental, and
economic determinants of substance misuse and its consequences, to improve the health, safety, and
well-being of the entire population.

Figure 1.1: Past Month Rates of Substance Use Among People Aged 12 or Older:
Percentages, 2002-2014, 2014 National Survey on Drug Use and Health (NSDUH)

Notes: The National Survey on Drug Use and Health (NSDUH) obtains information on nine categories of illicit drugs: marijuana
(including hashish), cocaine (including crack), heroin, hallucinogens, and inhalants, as well as the nonmedical use of prescriptiontype pain relievers, tranquilizers, stimulants, and sedatives; see the section on nonmedical use of psychotherapeutic drugs for the
definition of nonmedical use. Estimates of illicit drug use reported from NSDUH reflect the use of these nine drug categories.
Difference between the Illicit Drug Use estimate for 2002-2013 and the 2014 estimate is statistically significant at the .05 level for
all years against 2014. Binge drinking for NSDUH data collected in 2014 is defined as five or more drinks on the same occasion
on at least one day in the past 30 days. There was no significant difference between 2002-2013 against 2014. In 2015, changes
were made to the NSDUH questionnaire and data collection procedures that do not allow comparisons between 2015 and
previous years for a number of outcomes.
Source: Center for Behavioral Health Statistics and Quality, (2015).13

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INTRODUCTION

This Surgeon Generals Report has been created because of the

important health and social problems associated with alcohol
and drug misuse in America. As described in this Report, a
comprehensive approach is needed to address substance
use problems in the United States that includes several key
components:
$$ Enhanced public education to improve awareness
about substance use problems and demand for more
effective policies and practices to address them;
$$ Widespread implementation of evidence-based
prevention policies and programs to prevent
substance misuse and related harms;
$$ Improved access to evidence-based treatment
services, integrated with mainstream health care,
for those at risk for or affected by substance use
disorders;
$$ Recovery support services (RSS) to assist individuals
in maintaining remission and preventing relapse; and
$$ Research-informed public policies and financing
strategies to ensure that substance misuse and use
disorder services are accessible, compassionate,
efficient, and sustainable.

The Public Health System. The

Public Health System is defined as
all public, private, and voluntary
entities that contribute to the delivery
of essential public health services
within a jurisdiction and includes
state and local public health agencies,
public safety agencies, health care
providers, human service and charity
organizations, recreation and artsrelated organizations, economic and
philanthropic organizations, and
education and youth development
organizations.2
The Health Care System. The World
Health Organization defines a health
care system as (1) all the activities
whose primary purpose is to promote,
restore, and/or maintain health, and (2)
the people, institutions, and resources,
arranged together in accordance with
established policies, to improve the
health of the population they serve.
The health care system is made up
of diverse health care organizations
ranging from primary care, specialty
substance use disorder treatment
(including residential and outpatient
settings), mental health care, infectious
disease clinics, school clinics,
community health centers, hospitals,
emergency departments, and others.5

Recognizing these needs, the Report explains the

neurobiological basis for substance use disorders and
provides the biological, psychological, and social frameworks
for improving diagnosis, prevention, and treatment of alcohol
and drug misuse. It also describes evidence-based prevention
strategies, such as public policies that can reduce substance misuse problems (e.g., driving under the
influence [DUI]); effective treatment strategies, including medications and behavioral therapies for
treating substance use disorders; and RSS for people who have completed treatment. Additionally,
the Report describes recent changes in health care financing, including changes in health insurance
regulations, which support the integration of clinical prevention and treatment services for substance
use disorders into mainstream health care practice, and defines a research agenda for addressing alcohol
and drug misuse as medical conditions.
Thus, this first Surgeon Generals Report on Alcohol, Drugs, and Health is not issued simply because of the
prevalence of substance misuse or even the related devastating harms and costs, but also to help inform
policymakers, health care professionals, and the general public about effective, practical, and sustainable
strategies to address these problems. These strategies have the potential to substantially reduce substance
misuse and related problems; promote early intervention for substance misuse and substance use disorders;
and improve the availability of high-quality treatment and RSS for persons with substance use disorders.

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INTRODUCTION

A Public Health Model for Addressing Substance Misuse and Related

Consequences
A public health systems approach to substance misuse and its consequences, including substance use disorders,
aims to:

Define the problem through the systematic collection of data on the scope, characteristics, and
consequences of substance misuse;

Identify the risk and protective factors that increase or decrease the risk for substance misuse and its
consequences, and the factors that could be modified through interventions;

Work across the public and private sector to develop and test interventions that address social,
environmental, or economic determinants of substance misuse and related health consequences;

Support broad implementation of effective prevention and treatment interventions and recovery
supports in a wide range of settings; and

Monitor the impact of these interventions on substance misuse and related problems as well as on risk
and protective factors.

A healthy community is one with not just a strong health care system but also a strong public health educational
system, safe streets, effective public transportation and affordable, high quality food and housing where
all individuals have opportunities to thrive. Thus, community leaders should work together to mobilize the
capacities of health care organizations, social service organizations, educational systems, community-based
organizations, government health agencies, religious institutions, law enforcement, local businesses, researchers,
and other public, private, and voluntary entities that can contribute to the above aims. Everyone has a role to
play in addressing substance misuse and its consequences and thereby improving the public health.

Substances Discussed in this Report

This Report defines a substance as a psychoactive compound with the potential to cause health and social
problems, including substance use disorders (and their most severe manifestation, addiction). These
substances can be divided into three major categories: Alcohol, Illicit Drugs (a category that includes
prescription drugs used nonmedically), and Over-the-Counter Drugs. Some specific examples of the
substances included in each of these categories are included in Table 1.1. Over-the-Counter Drugs are
not discussed in this Report, but are included in Appendix D Important Facts about Alcohol and Drugs.
Although different in many respects, the substances discussed in this Report share three features that
make them important to public health and safety. First, many people use and misuse these substances: 66.7
million individuals in the United States aged 12 or older admitted to binge drinking in the past month
and 27.1 million people aged 12 or older used an illicit drug in the past month.3

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INTRODUCTION

Table 1.1: Categories and Examples of Substances

Substance Category

Representative Examples

Alcohol

Beer
Wine
Malt liquor
Distilled spirits

Illicit Drugs

Cocaine, including crack

Heroin
Hallucinogens, including LSD, PCP, ecstasy, peyote, mescaline, psilocybin
Methamphetamines, including crystal meth
Marijuana, including hashish*
Synthetic drugs, including K2, Spice, and bath salts**
Prescription-type medications that are used for nonmedical purposes
o Pain Relievers - Synthetic, semi-synthetic, and non-synthetic opioid
medications, including fentanyl, codeine, oxycodone, hydrocodone, and
tramadol products
o Tranquilizers, including benzodiazepines, meprobamate products, and muscle
relaxants
o Stimulants and Methamphetamine, includingamphetamine,
dextroamphetamine, and phentermine products; mazindol products; and
methylphenidate or dexmethylphenidate products
o Sedatives, including temazepam, flurazepam, or triazolam and any barbiturates

Over-the-Counter
Drugs and Other
Substances

Cough and cold medicines**

Inhalants, including amyl nitrite, cleaning fluids, gasoline and lighter gases,
anesthetics, solvents, spray paint, nitrous oxide

Notes: The Report discusses the substances known to have a significant public health impact. These substances are also included
in NSDUH. Additionally, NSDUH includes tobacco products (cigarettes, smokeless tobacco, cigars, and pipe tobacco); however,
tobacco products are not discussed in this Report at length because they have been covered extensively in other Surgeon
Generals Reports.14-17
* As of June 2016, 25 states and the District of Columbia have legalized medical marijuana use, four states have legalized retail
marijuana sales, and the District of Columbia has legalized personal use and home cultivation (both medical and recreational). It
should be noted that none of the permitted uses under state laws alter the status of marijuana and its constituent compounds
as illicit drugs under Schedule I of the federal Controlled Substances Act. See the section on Marijuana: A Changing Legal and
Research Environment later in this chapter for more detail on this issue.
** These substances are not included in NSDUH and are not discussed in this Report. However, important facts about these
drugs are included in Appendix D - Important Facts about Alcohol and Drugs.

Second, individuals can use these substances in a manner that causes harm to the user or those around them. This
is called substance misuse and often results in health or social problems, referred to in this Report as

substance misuse problems. Misuse can be of low severity and temporary, but it can also result in serious,
enduring, and costly consequences due to motor vehicle crashes,18,19 intimate partner and sexual
violence,20 child abuse and neglect,21 suicide attempts and fatalities,22 overdose deaths,23 various forms of
cancer24 (e.g., breast cancer in women),25 heart and liver diseases,26 HIV/AIDS,27 and problems related to
drinking or using drugs during pregnancy, such as fetal alcohol spectrum disorders (FASDs) or neonatal
abstinence syndrome (NAS).28

Third, prolonged, repeated misuse of any of these substances can

produce changes to the brain that can lead to a substance use disorder,
an independent illness that significantly impairs health and function
and may require specialty treatment. Disorders can range from
mild to severe. Severe and chronic substance use disorders
are commonly referred to as addictions.

PAGE | 1-5

See the section on Diagnosing a

Substance Use Disorder later in this
chapter.

INTRODUCTION

Key Terms Used in the Report

Addiction: The most severe form of substance use disorder, associated with compulsive or uncontrolled use of
one or more substances. Addiction is a chronic brain disease that has the potential for both recurrence (relapse)
and recovery.
Substance: A psychoactive compound with the potential to cause health and social problems, including
substance use disorders (and their most severe manifestation, addiction). For a list of substance categories
included in this Report see Table 1.1. Note: Cigarettes and other tobacco products are only briefly discussed
here due to extensive coverage in prior Surgeon Generals Reports.14-17
Substance Use: The useeven one timeof any of the substances in this Report.
Substance Misuse: The use of any substance in a manner, situation, amount, or frequency that can cause harm
to users or to those around them. For some substances or individuals, any use would constitute misuse (e.g.,
underage drinking, injection drug use).
Binge Drinking: Binge drinking for men is drinking 5 or more standard alcoholic drinks, and for women, 4 or
more standard alcoholic drinks on the same occasion on at least 1 day in the past 30 days.
Heavy Drinking: Defined by the CDC as consuming 8 or more drinks per week for women, and 15 or more
drinks per week for men, and by the Substance Abuse and Mental Health Services Administration (SAMHSA), for
research purposes, as binge drinking on 5 or more days in the past 30 days.
Standard Drink: Based on the 2015-2020 Dietary Guidelines for Americans, a standard drink is defined as shown
in the graphic below. All of these drinks contain 14 grams (0.6 ounces) of pure alcohol.
12 fl oz of
regular beer

8-9 fl oz of
malt liquor
(shown in a
12 oz glasss)

5 fl oz of
table wine

1.5 fl oz shot
of 80-proof
distilled spirits
(gin, rum, tequila,
vodka, whiskey, etc.)

about 5%
alcohol

about 7%
alcohol

about 12%
alcohol

40% alcohol

Source: U.S. Department of Health and Human Services and U.S. Department of Agriculture, (2015).29

Substance Misuse Problems or Consequences: Any health or social problem that results from substance
misuse. Substance misuse problems or consequences may affect the substance user or those around them,
and they may be acute (e.g., an argument or fight, a motor vehicle crash, an overdose) or chronic (e.g., a longterm substance-related medical, family, or employment problem, or chronic medical condition, such as various
cancers, heart disease, and liver disease). These problems may occur at any age and are more likely to occur with
greater frequency of substance misuse.
Substance Use Disorder: A medical illness caused by repeated misuse of a substance or substances. According
to the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5),30 substance use
disorders are characterized by clinically significant impairments in health, social function, and impaired control
over substance use and are diagnosed through assessing cognitive, behavioral, and psychological symptoms.
Substance use disorders range from mild to severe and from temporary to chronic. They typically develop
gradually over time with repeated misuse, leading to changes in brain circuits governing incentive salience (the

PAGE | 1-6

INTRODUCTION

ability of substance-associated cues to trigger substance seeking), reward, stress, and executive functions like
decision making and self-control. Multiple factors influence whether and how rapidly a person will develop a
substance use disorder. These factors include the substance itself; the genetic vulnerability of the user; and the
amount, frequency, and duration of the misuse. Note: A severe substance use disorder is commonly called an
addiction.
Relapse: The return to drug use after a significant period of abstinence.
Recovery: A process of change through which individuals improve their health and wellness, live a self-directed
life, and strive to reach their full potential. Even individuals with severe and chronic substance use disorders can,
with help, overcome their substance use disorder and regain health and social function. This is called remission.
When those positive changes and values become part of a voluntarily adopted lifestyle, that is called being in
recovery. Although abstinence from all substance misuse is a cardinal feature of a recovery lifestyle, it is not the
only healthy, pro-social feature.

Prevalence of Substance Use, Misuse Problems, and

Disorders
How widespread are substance use, misuse, and substance use disorders in the United States? The annual
National Survey on Drug Use and Health (NSDUH) gathers data on the scope and prevalence of substance
use, misuse, and related disorders, as well as utilization of substance use disorder treatment, among
Americans aged 12 and older, representing more than 265 million people. Table 1.2 provides selected
findings from the 2015 NSDUH. The table provides only general statistics for the United States as a
whole; readers are urged to consult NSDUHs detailed tables3 for subpopulation estimates.
Over 175 million persons aged 12 and older (65.7 percent
of this population) reported alcohol use in the past year,
with over 66 million (24.9 percent) reporting binge drinking
Prevalence. The proportion of a
in the past month (Table 1.2). More than 36 million (13.5
population who have (or had) a specific
characteristicfor example, an illness,
percent) reported using marijuana in the past year, 12.5
condition, behavior, or risk factor in a
million reported misusing prescription pain relievers, and
given time period.
over 300,000 reported using heroin in the past year. Almost
8 percent of the population met diagnostic criteria for a
substance use disorder for alcohol or illicit drugs, and another 1 percent met diagnostic criteria for both
an alcohol and illicit drug use disorder. Although 20.8 million people (7.8 percent of the population) met
the diagnostic criteria for a substance use disorder in 2015, only 2.2 million individuals (10.4 percent)
received any type of treatment. Of those treated, 63.7 percent received treatment in specialty substance
use disorder treatment programs.3

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INTRODUCTION

Several specific findings shown in Table 1.2 bear emphasis. Past year misuse of prescription
psychotherapeutic drugs was reported by 18.9 million individuals in 2015 (7.1 percent of the
population).3 Within this category, prescribed opioid pain relievers (e.g., OxyContin, Vicodin,
Lortab) accounted for 12.5 million people, followed by tranquilizers, such as Xanax, reported by 6.1
million people; stimulants, such as Adderall or Ritalin, reported by 5.3 million people; and sedatives,
such as Valium, reported by 1.5 million people.3

Substance Use Disorder Treatment Programs

Historically, treatment services were designed for people with severe substance use disorders (addictions),
and programs were generally referred to as specialty addiction treatment programs. Today, individuals with
mild to severe substance use disorders may receive treatment. These treatments are delivered by specialty
programs, as well as by more generalist providers (e.g., primary care and general mental health providers). Not
everyone with a substance use disorder will need ongoing treatment; many will require only a brief intervention
and monitoring. Because treatments vary substantially in level of specialization, content, duration, and setting,
and because those receiving services may differ substantially in the severity, duration, and complexity of their
substance use disorder, this Report uses the phrase substance use disorder treatment as the generic term to
capture the broad spectrum of advice, therapies, services, and monitoring provided to the group of individuals
with mild to severe substance use disorders. The programs and services that provide specialty treatment are
referred to as substance use disorder treatment programs or services.

The prevalence of past 30-day use of any illicit drugs (a broad category including marijuana/hashish,
cocaine/crack, heroin, hallucinogens, inhalants, and prescription psychotherapeutic medications used
nonmedically) rose from 9.4 percent in 2013 to 10.2 percent in 2014 among persons aged 12 and older
(Figure 1.2). This 2014 prevalence rate for illicit drugs is significantly higher than it was in any year
from 2002 to 2013. However, no significant changes were observed that year specifically in the use of
prescription psychotherapeutic drugs, cocaine, or hallucinogens, suggesting that the observed increase
was primarily related to increased use of marijuana. Marijuana was the most frequently used illicit drug
(35.1 million past year users).31 The rate for past month marijuana use in 2014 was significantly higher
than it was in any year from 2002 to 2013, with the prevalence of past 30-day marijuana use rising
from 7.5 percent in 2013 to 8.4 percent in 2014.13 (Note: In 2015, changes were made to the NSDUH
questionnaire and data collection procedures that do not allow for the presentation of trend data
beyond 2014. For more information, see Summary of the Effects of the 2015 NSDUH Questionnaire Redesign:
Implications for Data Users.32)

Demographics of Substance Use

Table 1.3 and Table 1.4 show substance use by demographic characteristics. Prevalence of substance
misuse and substance use disorders differs by race and ethnicity and gender, and these factors can
also influence access to health care and substance use disorder treatment. Past year alcohol use for
men was 68.6 percent and for women it was 62.9 percent. Past month binge alcohol use was 29.6
percent for men and 20.5 percent for women. The prevalence of past month binge alcohol use was 24.1
percent for American Indians or Alaska Natives, 25.7 percent for Hispanics or Latinos, and 26.0 for
Whites. Prevalence of an alcohol use disorder was 7.8 percent for men and 4.1 percent for women. The
prevalence of an illicit drug use disorder was 3.8 percent for men and 2.0 percent for women.

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INTRODUCTION

Table 1.2: Past Year Substance Use, Past Year Initiation of Substance Use, and Met Diagnostic
Criteria for a Substance Use Disorder in the Past Year Among Persons Aged 12 Years or Older
for Specific Substances: Numbers in Millions and Percentages, 2015 National Survey on Drug
Use and Health (NSDUH)
Past Year Use or
Misusev

Substance

Alcohol

Past Year
Initiation Among
Total Populationvi

Met Diagnostic
Criteria for a
Substance Use
Disordervi,vii

175.8

65.7

4.8

1.8

15.7

5.9

66.7

24.9

da

da

da

da

Drinking Pattern
Binge Drinkingi

17.3

6.5

da

da

da

da

Any Illicit Drugii

Heavy Drinking

47.7

17.8

nr

nr

7.7

2.9

Cocaine/Crack

36.0

1.8

1.0

0.4

0.9

0.3

Heroin

0.8

0.3

0.1

0.1

0.6

0.2

Hallucinogens

4.7

1.8

1.2

0.4

0.3

0.1

Marijuana

36.0

13.5

2.6

1.0

4.0

1.5

1.8

0.7

0.6

0.2

0.1

0.0

iii

Inhalants
Misuse of Psychotherapeutics

18.9

7.1

nr

nr

2.7

1.0

Pain Relievers

12.5

4.7

2.1

0.8

2.0

0.8

Tranquilizers

6.1

2.3

1.4

0.5

0.7

0.3

Stimulants

5.3

2.0

1.3

0.5

0.4

0.2

iv

Sedatives
Alcohol or Any Illicit Drugsii
Alcohol and Any Illicit Drugs

ii

1.5

0.6

0.4

0.2

0.2

0.1

182.3

68.1

nr

nr

20.8

7.8

41.3

15.4

nr

nr

2.7

1.0

Notes: Past year initiates are defined as persons who used the substance(s) for the first time in the 12 months before the date of
interview. The nr = not reported due to measurement issues notation indicates that the estimate could be calculated based on
available data but is not calculated due to potential measurement issues. The da indication means does not apply.
i. Binge and heavy drinking, as defined by SAMHSA, are reported only for the period of 30 days before the interview date.
SAMHSA defines binge use of alcohol for males and females as drinking five (males)/four (females) or more drinks on the
same occasion (i.e., at the same time or within a couple of hours of each other) on at least 1 day in the past 30 days and
heavy use of alcohol for both males and females as binge drinking on each of 5 or more days in the past 30 days.
ii. Illicit drug use includes the misuse of prescription psychotherapeutics or the use of marijuana, cocaine (including crack),
heroin, hallucinogens, inhalants, or methamphetamine.
iii. As of June 2016, 25 states and the District of Columbia have legalized medical marijuana use. Four states have legalized
retail marijuana sales; the District of Columbia has legalized personal use and home cultivation (both medical and
recreational). It should be noted that none of the permitted uses under state laws alter the status of marijuana and its
constituent compounds as illicit drugs under Schedule I of the federal Controlled Substances Act.
iv. Misuse of prescription-type psychotherapeutics includes the nonmedical use of pain relievers, tranquilizers, stimulants, or
sedatives and does not include over-the-counter drugs.
v. Estimates of misuse of psychotherapeutics and stimulants include data from new methamphetamine items added in 2005 and
2006 and are not comparable with estimates presented in NSDUH reports before 2007. See Section B.4.8 in Appendix B of
the Results from the 2008 NSDUH.
vi. Estimates of misuse of psychotherapeutics and stimulants do not include data from new methamphetamine items added in
2005 and 2006.
vii. Diagnostic criteria for a substance use disorder is based on definitions found in the Fourth Edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV).
Source: Center for Behavioral Health Statistics and Quality, (2016).3

PAGE | 1-9

INTRODUCTION

Figure 1.2: Trends in Binge Drinking and Past 30-Day Use of Illicit Drugs among Persons Aged
12 Years or Older, 2014 National Survey on Drug Use and Health (NSDUH)

Notes: *Difference between this estimate and the 2014 estimate is statistically significant at the .05 level. Illicit drugs include
marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescription psychotherapeutics used non-medically.
Nonmedical use of prescription psychotherapeutics includes the nonmedical use of pain relievers, tranquilizers, stimulants, or
sedatives. In 2015, changes were made to the NSDUH questionnaire and data collection procedures that do not allow comparisons
between 2015 and previous years for a number of outcomes.
Source: Center for Behavioral Health Statistics and Quality, (2015).13

Relevance of Substance Use and Misuse

It is sometimes thought that concern over substance use and misuse should be secondary to the real
issue of substance use disorders and especially their severest manifestation, addiction, which has
captured media headlines and has been linked to many health and social problems. This is an important
misconception. Individuals with substance use disorders have elevated rates of substance misuse
related health and social problems and costs, but as shown in the last columns of Table 1.2, Table 1.3, and
Table 1.4, many people who misuse substances do not meet the diagnostic criteria for a substance use
disorder. For example, binge drinking at least once during the past month was self-reported by over 66
million individuals. By definition, those episodes have the potential for producing harm to the user and/
or to those around them, through increases in motor vehicle crashes, violence, and alcohol-poisonings.33
Similarly, in 2015, 12.5 million individuals misused a pain reliever in the past yearsetting the stage
for a potential overdosebut only 2.9 million met diagnostic criteria for a prescription medication
disorder.3

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INTRODUCTION

Table 1.3: Past Year Alcohol Use, Past Month Binge Alcohol Use, and Met Diagnostic Criteria for
a Substance Use Disorder in the Past Year Among Persons Aged 12 Years or Older: Numbers in
Millions and Percentages, 2015 National Survey on Drug Use and Health (NSDUH)

Demographic Group

Past Year
Alcohol Use

Past Month
Binge Alcohol
Useii

Met Diagnostic Criteria

for a Substance Use
Disorder in Past Yeari

89.0

68.6

38.4

29.6

10.1

7.8

Female

86.9

62.9

28.3

20.5

5.6

4.1

White

119.9

70.3

44.4

26.0

10.4

6.1

Black or African American

18.6

58.0

7.5

23.4

1.6

4.9

American Indian or Alaska Native

0.7

51.4

0.3

24.1

0.1

9.7

Native Hawaiian or Other Pacific Islander

0.4

51.1

0.1

17.8

0.04

5.4

Asian

7.8

53.1

2.1

14.0

0.5

3.2

Two or More Races

2.7

57.8

1.1

22.9

0.3

6.2

Hispanic or Latino

25.7

59.0

11.2

25.7

2.8

6.4

Alcohol
Male

Table 1.4: Past Year Substance Use, Past 30-Day Illicit Drug Use, and Met Diagnostic Criteria for
a Substance Use Disorder in the Past Year Among Persons Aged 12 Years or Older: Numbers in
Millions and Percentages, 2015 National Survey on Drug Use and Health (NSDUH)

Demographic Group

Past Year Use

Past 30-Day Illicit

Drug Use

Met Diagnostic Criteria

for a Substance Use
Disorder in Past Yeari

Male

26.6

20.5

16.2

12.5

5.0

3.8

Female

21.2

15.3

10.9

7.9

2.8

2.0

White

30.5

17.9

17.4

10.2

4.8

2.8

Black or African American

6.6

20.7

4.0

12.5

1.1

3.5

American Indian or Alaska Native

0.3

22.9

0.2

14.2

0.06

4.1

Native Hawaiian or Other Pacific Islander

0.1

20.5

0.07

9.8

0.03

4.5

Asian

1.4

9.2

0.6

4.0

0.2

1.2

Two or More Races

1.3

27.1

0.8

17.2

0.2

4.9

Hispanic or Latino

7.4

17.2

4.0

9.2

1.3

3.0

Any Illicit Drug

iii

i. Diagnostic criteria for a substance use disorder is based on definitions found in the Fourth Edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV).
ii. Binge drinking, as defined by SAMHSA, are reported only for the period of 30 days before the interview date. SAMHSA
defines binge use of alcohol for males and females as drinking five (males)/four (females) or more drinks on the same
occasion (i.e., at the same time or within a couple of hours of each other) on at least 1 day in the past 30 days.
iii. Illicit drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or misuse of prescriptiontype psychotherapeutics, including data from original methamphetamine questions but not including new methamphetamine
items added in 2005 and 2006.
Source: Center for Behavioral Health Statistics and Quality, (2016).3

PAGE | 1-11

INTRODUCTION

The clear implications of these data are that a comprehensive

approach to reducing the misuse of alcohol and drugsone
that includes the implementation of effective prevention
See Chapter 2 - The Neurobiology of
programs and policy strategies as well as high-quality
Substance Use, Misuse, and Addiction.
treatment servicesis needed to reduce the problems and
costs of substance misuse in the United States. In fact, greater impact is likely to be achieved by reducing
substance misuse in the general populationthat is, among people who are not addictedthan among
those with severe substance use problems. Of course, efforts to reduce general population rates of
substance use and misuse are also likely to reduce rates of substance use disorders, because substance
use disorders typically develop over time following repeated episodes of misuse (often at escalating
rates) that result in the progressive changes to brain circuitry that underlie addiction.

Costs and Impact of Substance Use and Misuse

Alcohol misuse, illicit drug use, misuse of medications, and substance use disorders are estimated to
cost the United States more than $400 billion in lost workplace productivity (in part, due to premature
mortality), health care expenses, law enforcement and other criminal justice costs (e.g., drug-related
crimes), and losses from motor vehicle crashes.10,11 Furthermore, about three quarters of the costs
associated with alcohol use were due to binge drinking, and about 40 percent of those costs were paid
by government, emphasizing the huge cost of alcohol misuse to taxpayers.34
These costs are not unique to the United States. A 2010 study examined the global burden of disability
attributable to substance misuse problems and disorders, focusing particularly on lost ability to work
and years of life lost to premature mortality. Costs were calculated for 20 age groups and both sexes
in 187 countries.35 Mental and substance use disorders were the leading causes of years lived with
disability worldwide, largely because these problems strike individuals early in their lives and can
continueespecially if untreatedfor long periods.
In addition to the costs to society, substance misuse can have many direct and indirect health and
personal consequences for individuals. The direct effects on the user depend on the specific substances
used, how much and how often they are used, how they are taken (e.g., orally vs. injected), and other
factors. Acute effects can range from changes in mood and basic body functions, such as heart rate or
blood pressure, to overdose and death. Alcohol misuse and drug use can also have long-term effects on
physical and mental health and can lead to substance use disorders. For example, drug use is associated
with chronic pain conditions and cardiovascular and cardiopulmonary diseases.36,37 Alcohol misuse
is associated with liver and pancreatic diseases, hypertension, reproductive system disorders, trauma,
stroke, FASD, and cancers of the oral cavity, esophagus, larynx, pharynx, liver, colon, and rectum.26,28 For
breast cancer, studies have shown that even moderate drinking may increase the risk.25Although alcohol
consumption is associated with adverse health effects as noted above, the 2015-2020 Dietary Guidelines for

PAGE | 1-12

INTRODUCTION

Americans indicate that moderate alcohol use can be part of a healthy diet, but only when used by adults
of legal drinking age.i
In addition, alcohol and drug use by pregnant women can have profound effects on the developing fetus.
Alcohol use during pregnancy can lead to a wide range of disabilities in children, the most severe of
which is FASD, characterized by intellectual disabilities, speech and language delays, poor social skills,
and sometimes facial deformities. Use of drugs, such as opioids during pregnancy, can result in NAS, a
drug-withdrawal syndrome requiring medical intervention and extended hospital stay for newborns.
Use of some drugs, such as cocaine, during pregnancy may also lead to premature birth or miscarriage.
In addition, substance use during pregnancy may interfere with a childs brain development and result
in later consequences for mental functioning and behavior.
Substance misuse also can affect a users nutrition and sleep, as well as increase the risk for trauma,
violence, injury, and contraction of communicable diseases, such as HIV/AIDS and Hepatitis C. These
consequences can all contribute to the spectrum of public health consequences of substance misuse and
need to be considered both independently and collectively when developing and implementing clinical
and public health interventions.
Substance misuse problems can also result in other serious and sometimes fatal health problems and
extraordinary costs; they may also lead to unexpected death from other causes. Three examples of these
serious, sometimes lethal, problems related to substance misuse are highlighted below.

Driving Under the Influence

In 2014, 9,967 people were killed in motor vehicle crashes while driving under the influence of alcohol,
representing nearly one third (31 percent) of all traffic-related fatalities in the United States.38 DUI
continues to be among the most frequent causes for arrests every year.39 But at approximately 1.3
million per year, these arrests represent only about 1 percent of the actual alcohol-impaired driving
incidents reported in national surveys, suggesting that there are many more people who drive while
impaired that have not been arrested, putting themselves and others at high risk of being harmed.18,40
In addition to the deaths that result from DUI, the National Highway Traffic Safety Administration
(NHTSA) estimates that DUI costs the United States more than $44 billion each year in prosecution,
higher insurance rates, higher taxes, medical claims, and property damage.41
As important as they are, these statistics account for only alcohol-related driving impairment and fail to
measure other impairing substances. A study by NHTSA tested oral fluid and blood specimens from a
random sample of drivers at the roadside (during daytime on Friday or nighttime Friday to Sunday) and

Moderate alcohol use is defined by the 2015-2020 Dietary Guidelines for Americans as up to 1 drink per day for women
and up to 2 drinks per day for menand only by adults of legal drinking age. Many individuals should not
consume alcohol, including individuals who are taking certain over-the-counter or prescription medications or
who have certain medical conditions, those who are recovering from an alcohol use disorder or are unable to
control the amount they drink, and anyone younger than age 21 years. In addition, drinking during pregnancy
may result in negative behavioral or neurological consequences in the offspring.

PAGE | 1-13

INTRODUCTION

found 12 to 15 percent had used one or more illegal substances.42 Drivers tested positive for drugs in
approximately 16 percent of all motor vehicle crashes.43

Overdose Deaths
Overdose deaths are typically caused by consuming substances at high intensity and/or by consuming
combinations of substances such as alcohol, sedatives, tranquilizers, and opioid pain relievers to the point
where critical areas in the brain that control breathing, heart rate, and body temperature stop functioning.

Alcohol Overdose (Alcohol Poisoning)

The CDC reports more than 2,200 alcohol overdose deaths in the United States each yearan average
of six deaths every day.44 More than three quarters (76 percent) of alcohol overdose deaths occur among
adults between ages 35 and 64, and 76 percent of those who die from alcohol overdose are men.

Drug Overdose (Illicit and Prescription Drugs)

Opioid analgesic pain relievers are now the most prescribed
class of medications in the United States, with more than 289
million prescriptions written each year.45,46 The increase in
The Opioid Crisis. Over-prescription of
powerful opioid pain relievers beginning
prescriptions of opioid pain relievers has been accompanied
in the 1990s led to a rapid escalation
by dramatic increases in misuse (Table 1.1) and by a more than
of use and misuse of these substances
200 percent increase in the number of emergency department
by a broad demographic of men and
visits from 2005 to 2011.47 In 2014, 47,055 drug overdose
women across the country.1 This led to
a resurgence of heroin use, as some
deaths occurred in the United States, and 61 percent of these
users transitioned to using this cheaper
deaths were the result of opioid use, including prescription
street cousin of expensive prescription
opioids and heroin.7 Heroin overdoses have more than
opioids. As a result, the number of
tripled from 2010 to 2014.7 Heroin overdoses were more
people dying from opioid overdoses
soaredincreasing nearly four-fold
than five times higher in 2014 (10,574) then ten years before
between 1999 and 2014.4
in 2004 (1,878). Additionally, rates of cocaine overdose were
higher in 2014 than in the previous six years (5,415 deaths
from cocaine overdose). In 2014, there were 17,465 overdoses from illicit drugs and 25,760 overdoses
from prescription drugs.48 Drug overdose deaths also occur as a result of the illicit manufacturing and
distribution of synthetic opioids, such as fentanyl, and the illegal diversion of prescription opioids. Illicit
fentanyl, for example, is often combined with heroin or counterfeit prescription drugs or sold as heroin,
and may be contributing to recent increases in drug overdose deaths.7,49

Intimate Partner Violence, Sexual Assault, and Rape

Intimate partner violence, sexual assault, and rape are crimes with long-lasting effects on victims and
great cost to society.50,51 These crimes happen to both women and men and are often associated with
substance use. A recent national survey found that 22 percent of women and 14 percent of men reported
experiencing severe physical violence from an intimate partner in their lifetimes.52 In this survey, 19.3
percent of women and 1.7 percent of men reported being raped in their lifetimes, while 43.9 percent
of women and 23.4 percent of men reported some other form of sexual violence in their lifetimes.52
Substance misuse is often related to these crimes.

PAGE | 1-14

INTRODUCTION

Numerous studies have found a high correlation between substance use and intimate partner
violence,53-56 although this does not mean that substance use causes intimate partner violence. In
addition to evidence from the criminal justice arena, recent systematic reviews have found that
substance use is both a risk factor for and a consequence of intimate partner violence.57-59
A recent survey of sexual assault and sexual misconduct on college campuses found that use of
alcohol and drugs are important risk factors for nonconsensual sexual contact among undergraduate,
graduate, and professional students.20 It is clear that substance use and intimate partner violence and
sexual assault are closely linked; however, more research is needed on the nature of the relationship
between substance use and these forms of violence to determine how substance use contributes to the
perpetration of violence and victimization and how violence contributes to subsequent substance use
among both perpetrators and victims.

Vulnerability to Substance Misuse Problems and

Disorders
Risk and Protective Factors: Keys to Vulnerability
Substance misuse problems and substance use disorders are not inevitable. An individuals vulnerability
may be partly predicted by assessing the nature and number of their community, caregiver/family, and
individual-level risk and protective factors.
Significant community-level risk factors for substance misuse
and use disorders include easy access to inexpensive alcohol
and other substances. Caregiver/family-level risk factors
See Chapter 3 - Prevention Programs
include low parental monitoring, a family history of substance
and Policies.
use or mental disorders, and high levels of family conflict or
violence. At the individual level, major risk factors include current mental disorders, low involvement in
school, a history of abuse and neglect, and a history of substance use during adolescence, among others.60
Community-level protective factors include higher cost for alcohol and other drugs (often achieved by
increasing taxes on these products); regulating the number and concentration of retailers selling various
substances (e.g., density of alcohol outlets or marijuana dispensaries); preventing illegal alcohol and
other drug sales by enforcing existing laws and holding retailers accountable for harms caused by illegal
sales (e.g., commercial host [dram shop] liability); availability of healthy recreational and social activities;
and other population-level policies and their enforcement.61 Caregiver/family-level protective factors
include support and regular monitoring by parents.60 Some important individual-level protective
factors include involvement in school, engagement in healthy recreational and social activities, and good
coping skills.60
Three important points about vulnerability should be highlighted. First, no single individual or
community-level factor determines whether an individual will develop a substance misuse problem or
disorder. Second, most risk and protective factors can be modified through preventive programs and

PAGE | 1-15

INTRODUCTION

policies to reduce vulnerability. Third, although substance

misuse problems and disorders may occur at any age,
adolescence and young adulthood are particularly critical atSee Chapter 2 - The Neurobiology of
risk periods. Research now indicates that the majority of those
Substance Use, Misuse, and Addiction.
who meet criteria for a substance use disorder in their lifetime
started using substances during adolescence and met the criteria by age 20 to 25.62-64 One likely reason
for this vulnerability in adolescence and young adulthood is that alcohol and other substances have
particularly potent effects on developing brain circuits, and recent scientific findings indicate that brain
development is not complete until approximately age 21 to 23 in women and 23 to 25 in men.65-67 Among
the last brain regions to reach maturity is the prefrontal cortex, the brain region primarily responsible
for adult abilities, such as delay of reward, extended reasoning, and impulse control. This area of the
brain is one of the most affected regions in a substance use disorder.
Substance misuse can begin at any age. Therefore, it is important to focus on prevention of substance
misuse across the lifespan as well as the prevention of substance use disorders.

Diagnosing a Substance Use Disorder

Changes in Understanding and Diagnosis of Substance Use
Disorders
Repeated, regular misuse of any of the substances listed in Figure 1.2 may lead to the development
of a substance use disorder. Severe substance use disorders are characterized by compulsive use of
substance(s) and impaired control of substance use. Substance
use disorder diagnoses are based on criteria specified in the
American Psychiatric Associations Diagnostic and Statistical
Misuse versus Abuse. This Report
Manual of Mental Disorders (DSM). Much of the substance use
uses the term substance misuse, a term
that is roughly equivalent to substance
disorder data included in this Report is based on definitions
abuse. Substance abuse, an older
included in the DSM-IV, which described two distinct
diagnostic term, was defined as use
disorders: substance abuse and substance dependence, with
that is unsafe (e.g., drunk or drugged
specific diagnostic criteria for each. Anyone meeting one
driving), use that leads a person to fail
to fulfill responsibilities or gets them
or more of the abuse criteriawhich focused largely on the
in legal trouble, or use that continues
negative consequences associated with substance misuse,
despite causing persistent interpersonal
such as being unable to fulfill family or work obligations,
problems like fights with a spouse.
experiencing legal trouble, or engaging in hazardous behavior
However, substance abuse is
as a result of drug usewould receive the abuse diagnosis.
increasingly avoided by professionals
Anyone with three or more of the dependence criteria,
because it can be shaming. Instead,
substance misuse is now the preferred
which included symptoms of drug tolerance, withdrawal,
term. Although misuse is not a
escalating and uncontrolled substance use, and the use of
diagnostic term, it generally suggests
the substance to the exclusion of other activities, would
use in a manner that could cause harm
receive the dependence diagnosis. Notably, addiction is not
to the user or those around them.
listed as a formal diagnosis in the DSM. However, substance

PAGE | 1-16

INTRODUCTION

dependence was often used interchangeably with addiction, and tolerance and withdrawal were
considered, by many, cardinal features of addiction.
The DSM-5, which is the fifth and current version of the
DSM, integrates the two DSM-IV disorders, substance
abuse and substance dependence, into a single disorder
called substance use disorder with mild, moderate, and severe
sub-classifications. Individuals are evaluated for a substance
use disorder based on 10 or 11 (depending on the substance)
equally weighted diagnostic criteria (Table 1.5). Most of these
overlap with those used to diagnose DSM-IV dependence and
abuse. Individuals exhibiting fewer than two of the symptoms
are not considered to have a substance use disorder. Those
exhibiting two or three symptoms are considered to have
a mild disorder, four or five symptoms constitutes a
moderate disorder, and six or more symptoms is considered
a severe substance use disorder.30 In this Report, addiction is
used to refer to substance use disorders at the severe end of
the spectrum and are characterized by compulsive substance
use and impaired control over use.

Tolerance. Alteration of the bodys

responsiveness to alcohol or a drug
such that higher doses are required
to produce the same effect achieved
during initial use.
Withdrawal. A set of symptoms that
are experienced when discontinuing
use of a substance to which a person
has become dependent or addicted,
which can include negative emotions
such as stress, anxiety, or depression,
as well as physical effects such as
nausea, vomiting, muscle aches, and
cramping, among others. Withdrawal
symptoms often lead a person to use
the substance again.

Table 1.5: Criteria for Diagnosing Substance Use Disorders

Diagnostic Criteria for Substance Use Disorders
Using in larger amounts or for longer than intended
Wanting to cut down or stop using, but not managing to
Spending a lot of time to get, use, or recover from use
Craving
Inability to manage commitments due to use
Continuing to use, even when it causes problems in relationships
Giving up important activities because of use
Continuing to use, even when it puts you in danger
Continuing to use, even when physical or psychological problems may be made worse by use
Increasing tolerance
Withdrawal symptoms
Notes: Fewer than 2 symptoms = no disorder; 2-3 = mild disorder; 4-5 = moderate disorder; 6 or more = severe disorder.
Source: American Psychiatric Association, (2013).30

Implications of the New Diagnostic Criteria

The new diagnostic criteria are likely to reduce the all or nothing thinking that has characterized the
substance use field. Tolerance and withdrawal remain major clinical symptoms, but they are no longer
the deciding factor in whether an individual has an addiction. Substance use disorders, including
addiction, can occur with all substances listed in Table 1.1, not just those that are able to produce

PAGE | 1-17

INTRODUCTION

What is an Intervention?
Intervention here and throughout this Report means a professionally delivered program, service, or policy
designed to prevent substance misuse or treat an individuals substance use disorder. It does not refer to an
arranged meeting or confrontation intended to persuade a friend or loved one to quit their substance misuse or
enter treatmentthe type of intervention sometimes depicted on television. Planned surprise confrontations
of the latter varietya model developed in the 1960s, sometimes called the Johnson Interventionhave
not been demonstrated to be an effective way to engage people in treatment.68 Confrontational approaches in
general, though once the norm even in many behavioral treatment settings, have not been found effective and
may backfire by heightening resistance and diminishing self-esteem on the part of the targeted individual.69

tolerance and withdrawal. It is also important to understand that substance use disorders do not occur
immediately but over time, with repeated misuse and development of more symptoms. This means
that it is both possible and highly advisable to identify emerging substance use disorders, and to use
evidence-based early interventions to stop the addiction process before the disorder becomes more
chronic, complex, and difficult to treat.
This type of proactive clinical monitoring and management
is already done within general health care settings to address
other potentially progressive illnesses that are brought about
See Chapter 6 - Health Care Systems
by unhealthy behaviors.70 For example, patients with high
and Substance Use Disorders.
blood pressure may be told to adjust their activity and stress
in order to reduce the progression of hypertension. Typically,
these individuals are also clinically monitored for key symptoms to ensure that symptoms do not worsen.
There are compelling reasons to apply similar procedures in emerging cases of substance misuse.
Routine screening for alcohol and other substance use should be conducted in primary care settings to
identify early symptoms of a substance use disorder (especially among those with known risk and few
protective factors). This should be followed by informed clinical guidance on reducing the frequency
and amount of substance use, family education to support lifestyle changes, and regular monitoring.
Research has shown that substance use disorders are similar
in course, management, and outcome to other chronic
illnesses, such as hypertension, diabetes, and asthma.71
See Chapter 4 - Early Intervention,
Unfortunately, substance use disorders have not been treated,
Treatment, and Management of
Substance Use Disorders and Chapter
monitored, or managed like other chronic illnesses, nor has
6 - Health Care Systems and Substance
care for these conditions been covered by insurance to the
Use Disorders.
same degree. Nonetheless, it is possible to adopt the same
type of chronic care management approach to the treatment
of substance use disorders as is now used to manage most other chronic illnesses.70-72 Evidence-based
behavioral interventions, medications, social support services, clinical monitoring, and RSS make this
type of chronic care management possible, often by the same health care teams that currently treat other
chronic illnesses.

PAGE | 1-18

INTRODUCTION

Evidence also shows that such an approach will improve the effectiveness of treatments for substance
use disorders. Remission of substance use and even full recovery can now be achieved if evidencebased care is provided for adequate periods of time, by properly trained health care professionals, and
augmented by supportive monitoring, RSS, and social services. This fact is supported by a national
survey showing that there are more than 25 million individuals who once had a problem with alcohol or
drugs who no longer do.73

The Separation of Substance Use Treatment and

General Health Care
Until quite recently, substance misuse problems and substance use disorders were viewed as social
problems, best managed at the individual and family levels, and sometimes through the existing social
infrastructuresuch as schools and places of worship, and, when necessary, through civil and criminal
justice interventions.74 In the 1970s, when rates of substance misuse increased, including by college
students and Vietnam War veterans, most families and traditional social services were not prepared to
handle this problem.75 Despite a compelling national need for treatment, the existing health care system
was neither trained to care for nor especially eager to accept patients with substance use disorders.
For these reasons, a new system of substance use disorder treatment programs was created, but with
administration, regulation, and financing placed outside mainstream health care.74,75 This meant that
with the exception of detoxification in hospital-based settings, virtually all treatment was delivered
by programs that were geographically, financially, culturally, and organizationally separate from
mainstream health care. Of equal historical importance was the decision to focus treatment only on
addiction. This left few provisions for detecting or intervening clinically with the far more prevalent
cases of early-onset, mild, or moderate substance use disorders.
Creating this system of substance use disorder treatment programs was a critical element in addressing
the burgeoning substance use disorder problems in our nation. However, that separation also created
unintended and enduring impediments to the quality and range of care options. For example, separate
systems for substance use disorder treatment and other health care needs may have exacerbated the
negative public attitudes toward people with substance use disorders. Additionally, the pharmaceutical
industry was hesitant to invest in the development of new medications for individuals with substance
use disorders, because they were not convinced that a market for these medications existed.
Consequently, until the 1990s, few U.S. Food and Drug Administration (FDA) approved medications
were available to treat addictions.76,77
Meanwhile, despite numerous research studies documenting high prevalence rates of substance use
disorders among patients in emergency departments, hospitals, and general medical care settings,
mainstream health care generally failed to recognize or address substance use disorders.78 In fact, a
recent study by the CDC found that in 2011, only 1 in 6 United States adults and 1 in 4 binge drinkers
had ever been asked by a health professional about their drinking behavior.79 Furthermore, the percent
of adult binge drinkers who had been asked about their drinking had not changed since 1997, reflecting
the challenges involved in fostering implementation of screening and counseling services for alcohol

PAGE | 1-19

INTRODUCTION

misuse in clinical settings. This has been a costly mistake, with often deadly consequences. A recent
study showed that the presence of a substance use disorder often doubles the odds for the subsequent
development of chronic and expensive medical illnesses, such as arthritis, chronic pain, heart disease,
stroke, hypertension, diabetes, and asthma.80
In this regard, fatal medication errors due to unforeseen interactions between a prescribed medication
for a diagnosed medical condition and unscreened, unaddressed patient substance use increased tenfold over the past 20 years.81 To address this problem, researchers suggested (1) screening patients
for useof alcohol and/or street drugs; (2) taking extra precautions when prescribing medicines with
known dangerous interactions with alcohol and/or street drugs; and (3) teaching the patient the risks of
mixing medicines with alcohol and/or street drugs.81 Similar recommendations focusing on prescribed
opioids have been issued by the CDC to curb the rise in opioid overdose deaths.82 Again, screening for
substance use and substance use disorders before and during the course of opioid prescribing, combined
with patient education, are recommended.82
Yet despite these and other indications of extreme threats to health care quality, safety, effectiveness, and
cost containment, as of this writing, few general health care organizations screen for, or offer services
for, the early identification and treatment of substance use disorders. Moreover, few medical, nursing,
dental, or pharmacy schools teach their students about substance use disorders;83-86 and, until recently,
few insurers offered adequate reimbursement for treatment of substance use disorders.87,88

Recent Changes in Health Care Policy and Law

The longstanding separation of substance use disorders from
the rest of health care began to change with enactment of the
Paul Wellstone and Pete Domenici Mental Health Parity and
See Chapter 6 - Health Care Systems
and Substance Use Disorders.
Addiction Equity Act of 2008 (MHPAEA) and the Affordable
89,90
Care Act in 2010.
MHPAEA requires that the financial
requirements and treatment limitations imposed by health plans and insurers for substance use disorders
be no more restrictive than the financial requirements and treatment limitations they impose for medical
and surgical conditions. The Affordable Care Act requires the majority of United States health plans and
insurers to offer prevention, screening, brief interventions, and other forms of treatment for substance use
disorders.89
It is difficult to overstate the importance of these two Acts for creating a public health-oriented
approach to reducing substance misuse and related disorders. These laws and related changes in health
care financing are creating incentives for health care organizations to integrate substance use disorder
treatment with general health care. Many questions remain, but those questions are no longer whether
but how this much-needed integration will occur. These changes combine to create a new, challenging
but exceptionally promising era for the prevention and treatment of substance use disorders and set the
context for this Report.

PAGE | 1-20

INTRODUCTION

Marijuana: A Changing Legal and Research

Environment
Although this Report does not examine the issue of marijuana legalization, its continually evolving
legal status is worth mentioning because of implications for both research and policy. As mentioned
elsewhere, marijuana is the most commonly used illicit drug in the United States, with 22.2 million
people aged 12 or older using it in the past year.3 In recent years marijuana use has become more
socially acceptable among both adults and youth, while perceptions of risk among adolescents of the
drugs harms have been declining over the past 13 years.91
As use of marijuana and its constituent components and derivatives becomes more widely accepted, it is
critical to strengthen understanding of the effects and consequences for individual users and for public
health and safety. Conducting such research can be complex as laws and policies vary significantly from
state to state. For example, some states use a decriminalization model, which means production and sale of
marijuana are still illegal and no legal marijuana farms, distributors, companies, stores, or advertising are
permitted. Through ballot initiatives, other states have legalized marijuana use, which means they allow
the production and sales of marijuana for personal [Link], some states have legalized marijuana
for medical purposes, and this group includes a wide variety of different models dictating how therapeutic
marijuana is dispensed. The impacts of state laws regarding therapeutic and recreational marijuana are
still being evaluated, although the differences make comparisons between states challenging.92
As of June 2016, 25 states and the District of Columbia have legalized medical marijuana use. Four states
have legalized retail sales; the District of Columbia has legalized personal use and home cultivation
(both medical and recreational), with more states expecting to do so. None of the permitted uses under
state laws alters the status of marijuana and its constituent compounds as illicit drugs under Schedule
I of the federal Controlled Substances Act.93 It should also be noted that use for recreational purposes
has not been legalized by any jurisdiction for people under age 21, and few jurisdictions have legalized
medical marijuana for young people. While laws are changing, so too is the drug itself with average
potency more than doubling over the past decade (1998 to 2008).94 The ways marijuana is used are
also changing in addition to smoking, consuming edible forms like baked goods and candies, using
vaporizing devices, and using high-potency extracts and oils (e.g., dabbing) are becoming increasingly
common.95 Because these products and methods are unregulated even in states that have legalized
marijuana use, users may not have accurate information about dosage or potency, which can lead and
has led to serious consequences such as hospitalizations for psychosis and other overdose-related
symptoms.95 Marijuana use can also impair driving skills and, while estimates vary, is linked to a roughly
two-fold increase in accident risk.96-98 The risk is compounded when marijuana is used with alcohol.96,99
There is a growing body of research suggesting the potential therapeutic value of marijuanas constituent
cannabinoid chemicals in numerous health conditions including pain, nausea, epilepsy, obesity, wasting
disease, addiction, autoimmune disorders, and other [Link] the possibilities around therapeutic
use, it is necessary to continue to explore ways of easing existing barriers to research. Marijuana has
more than 100 constituent cannabinoid compounds, with cannabidiol (CBD) and tetrahydrocannabinol
(THC, the chemical responsible for most of marijuanas intoxicating effects) being the most well-studied.
Evidence collected so far in clinical investigations of the marijuana plant is still insufficient to meet

PAGE | 1-21

INTRODUCTION

FDA standards for a finding of safety and efficacy for any therapeutic indications. However, the FDA
has approved three medications containing synthetically derived cannabinoids: Marinol capsules and
Syndros oral solution (both containing dronabinol, which is identical in chemical structure to THC),
and Cesamet capsules (containing nabilone, which is similar in structure to THC) for severe nausea and
wasting in certain circumstances, for instance in AIDS patients. Recognizing the potential therapeutic
importance of compounds found in marijuana, the FDA has granted Fast Track designation to four
development programs of products that contain marijuana constituents or their synthetic equivalents. The
therapeutic areas in which products are being developed granted Fast Track by FDA include the treatment
of pain in patients with advanced cancer; treatment of Dravet syndrome (two programs), a rare and
catastrophic treatment-resistant form of childhood epilepsy; and treatment of neonatal hypoxic ischemic
encephalopathy, brain injury resulting from oxygen deprivation during birth.
Additionally, there are clinical investigations for the treatment of refractory seizure syndromes, including
Lennox Gastaut Syndrome, and for treatment of post-traumatic stress disorder (PTSD). However, further
exploration of these issues always requires consideration of the serious health and safety risks associated with
marijuana use. Research shows that risks can include respiratory illnesses, dependence, mental health-related
problems, and other issues affecting public health such as impaired driving. Within this context of changing
marijuana policies at the state level, research is needed on the impact of different models of legalization and
how to minimize harm based on what has been learned from legal substances subject to misuse, such as
alcohol and tobacco. Continued assessment of barriers to research and surveillance will help build the best
scientific foundation to support good public policy while also protecting the public health.

Purpose, Focus, and Format of the Report

The Audience
This Report is intended for individuals, families, community members, educators, health care
professionals, public health practitioners, advocates, public policymakers, and researchers who are
looking for effective, sustainable solutions to the problems created by alcohol and other substances. To
meet those needs, the Report reviews and synthesizes the most important and reliable scientific findings
in key topic areas and distills those findings into recommendations for:
$$ Improving public awareness of substance misuse and related problems;
$$ Reducing negative attitudes related to substance use disorders;
$$ Closing the gap between what is known to reduce substance misuse at the population level and
within specific subgroups, and the implementation of these effective programs, policies, and
environmental strategies at the federal, state, and community levels;
$$ Understanding the need for and effectiveness of programs for high-risk populations;
$$ Expanding the capacity of health care systems to deliver evidence-based substance use disorder
treatment;
$$ Integrating financing and health care system models to facilitate access and affordability of care
for substance use disorders;

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INTRODUCTION

$$ Continuing to build the science base of effective prevention, treatment, and recovery practices
and policies; and
$$ Engaging stakeholders in reducing substance use and misuse problems and protecting the health
of all individuals across the lifespan.
Because of the broad audience, the Report is purposely written in accessible language without excessive
scientific jargon. The Report also focuses on current issues and practical questions that trouble so many people:
$$ What are the health and social impacts of alcohol and drug use and misuse in the United States?
What key factors influence these behaviors?
$$ What are the major substance misuse problems facing the United States?
$$ What causes substance use disorders and why do they change people so dramatically?
$$ Can substance misuse problems and disorders be prevented? How?
$$ What constitutes effective treatment?
$$ Can addicted individuals recover? What will it take to manage their disorders and sustain recovery?

Topics Covered in the Report

Individual chapters in the Report review the science associated with the major substance use, misuse,
and disorder issues for specific topics. Tobacco, also an addictive substance, is mentioned only briefly,
because problems associated with tobacco use and nicotine addiction have been covered extensively in
other Surgeon Generals Reports.14-16,100-103
Because of the broad audience and the practical emphasis, the Report is intentionally selective rather
than exhaustive, emphasizing findings that have the potential for the greatest public health impact
and the greatest potential for action. For readers wanting greater scientific detail or more specific
information, detailed research reports, as well as supplemental resource materials, are supplied in
references, in the Appendices, and in special emphasis boxes throughout the Report.

Scientific Standards Used to Develop the Report

Findings cited in all of the chapters came from electronic database searches of research articles
published in English. Within those searches, priority was given to systematic literature reviews and
to findings that were replicated by multiple controlled trials. However, many important issues in
prevention, treatment, recovery, and health care systems have not yet been examined in rigorous
controlled trials, or are not appropriate for such research designs. In these cases, the best available
evidence was cited and labeled according to the reporting conventions published by the CDC:104

$$ Well-supported: Evidence derived from multiple controlled trials or large-scale population studies.
$$ Supported: Evidence derived from rigorous but fewer or smaller trials or restricted samples.
$$ Promising: Findings that do not derive from rigorously controlled studies but that nonetheless
make practical or clinical sense and are widely practiced.

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INTRODUCTION

In cases in which evidence was based on findings of neurobiological research, the CDC standards were
adapted.
A summary of the key findings appears at the beginning of each chapter. The key findings highlight
what is currently known from available research about the chapter topic, as well as the strength of
the evidence. As with the rest of the Report, the key findings are not intended to be exhaustive, but
are instead considered the important take-aways from each chapter. Readers interested in a fuller
discussion of the topics are encouraged to read the chapters in their entirety.

Addressing Substance Use in Specific Populations

As indicated, the chapters are designed to prioritize best available research findings that apply most
broadly across different substances and across various subgroups, while also identifying program and
policy interventions that have strong evidence for particular substances (e.g., alcohol), when available.
The rationale for this decision is that the available research suggests that the genetic, neurobiological,
and environmental processes underlying substance use, misuse, and disorders are largely similar across
most known substances and unrelated to the age, sex, race and ethnicity, gender identity, or culture of
the individual. The available research also clearly indicates that many of the interventions, including
population-level policies, focused programs, behavioral therapies, medications, and social services
shown to be effective in one subgroup are generally effective for other subgroups. Put differently, it is
reasonable to assume that the findings presented in this Report are relevant for many substance use types
and patterns; for most age, gender, racial and ethnic, and cultural subgroups; and for many special needs
subgroups (e.g., those with co-occurring mental or physical illnesses; those involved with the criminal
justice system).
However, this general statement has some important caveats. First, the statement depends heavily
on the phrase available research. There is insufficient research examining subgroup differences in
the neurobiology of substance use disorders and in interventions aimed at preventing, treating, and
promoting recovery from substance use disorders. Additional research designed to examine these
differences and to test interventions in specific populations is needed.
A second caveat is that individual variability in response to standard prevention, treatment, and
recovery support interventions is common throughout health care. Individuals with the same disease
often react quite differently to the same medicine or behavioral intervention. Accordingly, general
health care has moved toward personalized medicine, an individualized treatment regimen derived
from specific information about the individuals genetics and stage of illness, as well as lifestyle,
language, culture, and personal preferences. Personalized care is not common in the substance use
disorder field because many prevention, treatment, and recovery regimens were created as standardized
programs rather than individualized protocols.
The third caveat to the statement on general research findings is that even if research has shown that
certain medications, therapies, or recovery support services are likely to be effective, this does not mean
that they will be adequate, especially for groups with specific needs. For example, a medication that is
effective in blocking the rewarding effects of opioid use will not fully address the multiple, complex
problems of those with opioid use disorders, nor address any co-occurring health conditions such as
depression or HIV/AIDS.

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INTRODUCTION

Recognizing these limitations to the generalizability of research findings, each chapter has a dedicated
section on Specific Populations that focuses particularly on age, racial and ethnic subgroups, and
individuals with co-occurring mental and physical illnesses. Findings relevant to other important
groups (e.g., military veterans; lesbian, gay, bisexual, and transgender [LGBT] populations; those with
criminal justice involvement; those in rural areas) are referred to throughout the Report when available.

The Organization of the Report

This Report is divided into Chapters, highlighting the key issues and most important research findings
in those topics. The final chapter concludes with recommendations for key stakeholders, including
implications for practice and policy.
This Chapter 1 - Introduction and Overview describes the overall rationale for the Report, defines key
terms used throughout the Report, introduces the major issues covered in the topical chapters, and
describes the organization, format, and the scientific standards that dictated content and emphasis
within the Report.
Chapter 2 - The Neurobiology of Substance Use, Misuse, and Addiction reviews brain research on the
neurobiological processes that turn casual substance use into a compulsive disorder.
Chapter 3 - Prevention Program and Policies reviews the scientific evidence on preventing substance
misuse, substance use-related problems, and substance use disorders.
Chapter 4 - Early Intervention, Treatment, and Management of Substance Use Disorders describes the
goals, settings, and stages of treatment, and reviews the effectiveness of the major components of early
intervention and treatment approaches, including behavioral therapies, medications, and social services.
Chapter 5 - Recovery: The Many Paths to Wellness discusses perspectives on remission and recovery from
substance use disorders and reviews the types and effectiveness of RSS.
Chapter 6 - Health Care Systems and Substance Use Disorders reviews ongoing changes in organization,
delivery, and financing of care for substance use disorders in both specialty treatment programs and in
mainstream health care settings.
Chapter 7 - Vision for the Future: A Public Health Approach presents a realistic vision for a
comprehensive, effective, and humane public health approach to addressing substance misuse and
substance use disorders in our country, including actionable recommendations for parents, families,
communities, health care organizations, educators, researchers, and policymakers.
The Appendices provide additional detail about the topics covered in this Report. Appendix A - Review
Process for Prevention Programs details the review process for the prevention programs included in
Chapter 3 and the evidence on these programs; Appendix B - Evidence-Based Prevention Programs and
Policies provides detail on scientific evidence grounding the programs and policies discussed in Chapter
3; Appendix C - Resource Guide provides resources specific to those seeking information on preventing
and treating substance misuse or substance use disorders; and Appendix D - Important Facts about
Alcohol and Drugs contains facts about alcohol and specific drugs, including descriptions, uses and
possible health effects, treatment options, and statistics as of 2015.

PAGE | 1-25

INTRODUCTION

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