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Healthy People 2010 -
with Annotations (Edited to Reflect Injury Prevention Focus)

Chapter 26

Substance Abuse
Co-Lead Agencies:
National Institutes of Health;
Substance Abuse and Mental Health Services Administration

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


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

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

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

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

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

Alcohol use has been linked with a substantial proportion of injuries and deaths from traffic crashes, falls, fires, and drownings.(11) It also is a factor in homicide, suicide, marital violence, and child abuse(14) and has been associated with high-risk sexual behavior.(11, 15, 16) Persons who drink even relatively small amounts of alcoholic beverages may contribute to alcohol-related death and injury in occupational incidents or if they drink before operating a vehicle.(11) In 1996, alcohol use was associated with 41 percent of all motor vehicle crash fatalities, a significantly lower percentage than in the 1980s.(17)

Although there has been a long-term drop in overall use, many Americans still use illicit drugs. In 1997, there were 13.9 million current users of any illicit drug in the total household population aged 12 years and older, representing 6.4 percent of the total population.(18) Marijuana is the most commonly used illicit drug, and 60 percent of users abuse marijuana only.(18) Thirty-six percent of persons aged 12 years and older have used an illegal drug in their lifetime. Of these, more than 90 percent used marijuana or hashish, and approximately 30 percent tried cocaine.(18) Relatively rare in 1996, methamphetamine use began spreading in 1997.(18, 19)

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

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

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

Illegal use of drugs, such as heroin, marijuana, cocaine, and methamphetamine is associated with other serious consequences, including injury, illness, disability, and death as well as crime, domestic violence, and lost workplace productivity.

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

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

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

  • Whites and Hispanics are more likely than African Americans to use alcohol.
  • Whites are more likely than African Americans and Hispanics to use tobacco.
  • Whites are more likely than African Americans and Hispanics to use illicit drugs.
Source: National Household Survey on Drug Abuse: Population Estimates 1997, SAMHSA

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

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

Raising the minimum legal drinking age to 21 years was accompanied by reduced alcohol consumption, traffic crashes, and related fatalities among young persons under age 21 years.(38) Reductions in alcohol-related traffic crashes are associated with many policy and program measures (39) -- among them, administrative revocation of licenses for drinking and driving (40) and lower legal blood alcohol limits for youth41 and adults.(42) Community programs involving multiple city departments and private citizens have reduced driving after drinking and traffic deaths and injuries.(43) In addition, a combination of community mobilization, media advocacy, and enhanced law enforcement has been shown to reduce alcohol-related traffic crashes and sales of alcohol to minors.(44)

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

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

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

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Last modified: 15-Mar-2000.