Substance abuse: Unpacking a Public Health Crisis
In November 2016, a report by U.S. Surgeon General Dr. Vivek Murthy detailed a growing concern over the health implications of drug and alcohol addiction. Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health examines the pathology and classification of substance misuse painting a picture of a crisis that is taking a heavy toll on the nation, both financially and socially.
“Most Americans know someone who has been touched by an alcohol or a drug use disorder,” Murthy told the National Institute on Alcohol Abuse and Alcoholism. “Yet 90 percent of people with a substance use disorder are not getting treatment. That has to change.”
For public health experts, the crisis is likely to impact policy and treatment strategies for years to come. With the prompt from Murthy shaping the discourse, public health officials must seek effective means of treatment and prevention that harness the data we have available, while still navigating cultural conceptions — and misconceptions — about substance abuse.
The diversity of misuse
In the report, Murthy takes a broad, comprehensive approach, including a variety of substances and use disorders. In his preface, Murthy claims that “there is no single solution,” recognizing the use behaviors are influenced by a variety of factors, as well as acknowledging that the various substances have their own unique challenges.
The broadness of this approach is a double-edged sword for public health officials: On the one hand, the diversity of research analyzed by the surgeon general provides a strong baseline for future insight. On the other hand, it creates a challenge for public health officials to know where to start.
The picture of substance abuse detailed by the surgeon general is one of nearly epidemic proportion: In 2015, almost 48 million Americans used an illicit drug or misused a prescription medication. About 67 million also reported binge drinking in the last month — defined by the Centers for Disease Control and Prevention as a sustained pattern of drinking that brings a person’s blood alcohol concentration to 0.08 percent or over, and nearly 28 million people self-reported driving under the influence in the past year.
“Substance misuse is a major public health challenge and a priority for our nation to address,” wrote U.S. Department of Health and Human Services Secretary Sylvia Burwell in the report’s executive summary. “The effects of substance use are cumulative and costly for our society, placing burdens on workplaces, the health care system, families, states and communities.”
The economic impact of substance use
In an interview with NPR, Murthy spelled out the direct economic cost of substance abuse the nation has faced. Compared to other medical disorders like diabetes, substance abuse affects roughly the same amount of people — yet lacks the same level of comprehensive scientific research as similar disorders and costs the public much more.
“These substance use disorders cost over $420 billion a year in the form of health care costs, lost economic productivity and cost to the criminal justice system,” Murthy told NPR. “We measure numbers like this for other illnesses, too, and the cost for substance abuse disorders far exceeds the cost of diabetes.”
Yet even with this insight, Murthy recognizes that data related to the full impact and cost of substance abuse is lacking comparative to other diseases. In his recommendations to public health officials working in research and clinical settings, Murthy urges researchers to devote greater attention to measuring outcomes, as well as testing existing treatment methods for efficacy.
In addition to shaping treatment, this points to a potentially useful angle when it comes to lobbying for additional attention and financing being allocated to future research. By being able to quantify the direct economic impact of drug addiction, lawmakers can better rationalize spending to their constituents.
A ‘moral failing’ no more
Describing the crisis, Murthy points to historical parallels with the landmark surgeon general’s report on the dangers of cigarettes and smoking published in 1964. The report, authorized by Surgeon General Luther L. Terry, is credited with challenging and reshaping the way that public health officials and the federal government approached issues of health and welfare policy. Rather than focusing exclusively on distinct environmental hazards like radiation or infectious diseases like typhoid, the surgeon general’s report on smoking and tobacco took scientific data from the time and reframed the conversation to include issues previously relegated to private medicine or an individual’s behavior.
This set the groundwork for much of the current surgeon general’s thinking on the subject of addiction — namely, that substance abuse has for too long been considered by the public and even by some members of the medical community as a sort of “moral failure” rather than a disease. This idea, according to many experts, has inhibited the ability of the scientific and public health community to fully explore and create treatment plans.
“We underestimated how exposure to addictive substances can lead to full blown addiction,” Murthy told NPR.
This is guidance most pertinent to public health researchers and experts, though perhaps not as much a given as Murthy might think. While scientific fact may have currency in more academic circles, bridging the taboo on the community level could take alternative strategies.
Reshaping the brain
The stigma has been a challenging aspect to reshape in the public’s perception and one of the most essential places that public health officials can offer a call to action.
“Now we understand that these disorders actually change the circuitry in your brain,” Murthy went on to explain. “They affect your ability to make decisions, and change your reward system and your stress response. That tells us that addiction is a chronic disease of the brain, and we need to treat it with the same urgency and compassion that we do with any other illness.”
Burwell told the Tennessee Department of Mental Health & Substance Abuse Services that the battle for many Americans isn’t just against the disease — it’s against the stigma assigned to it.
How public health can curb the crisis
In the report and in speaking to NPR, Murthy lays out several ways that the nation can address the crisis. Citing data that shows teenagers who start drinking before the age of 15 are four times more likely to develop an alcohol use disorder later in life compared to those who have their first drink at age 20 or older, Murthy points to the power of early evidence-based interventions at several different levels.
“There are prevention strategies and treatment strategies that can address multiple substance use disorders. Some of these programs are school-based, college-campus-based, and community-based, some online and some in person.” Murthy told NPR.
Murthy claims that teaching strategies to help children deal with stress in healthy ways is particularly important. Stress, he describes, is one of the biggest motivating factors that causes children in vulnerable developmental stages to turn to substances like alcohol and drugs.
Research published in Frontiers in Psychology supports Murthy’s conclusions. New York University researchers looked at a variety of behaviors exhibited by juniors enrolled in two highly selective private secondary schools in the Northeast, including coping skills, academic engagement, family involvement and expectations, mental health symptoms and substance use. The study found that, even when armed with more familial resources and support from parents and schools, 49 percent of all students reported feeling a great deal of stress on a daily basis and 31 percent reported feeling somewhat stressed. Over a quarter of those studied also showed “clinically significant” levels of anxiety.
Substance use in this group was also prevalent: 38 percent of students reported drinking alcohol to the point of intoxication in the past 30 days, while 34 percent reported getting high on illegal substances. While less than 5 percent of those studied reported struggling with drugs or alcohol addiction, the self-reported nature of this may make this conclusion suspect. Even if accurate, this kind of early use, according to Murthy, may still leave these students vulnerable to addiction later in life.
Key public health recommendations from the surgeon general
In his report, Murthy outlines several specific ways that stakeholders can help fight the addiction crisis. Within public health, his breakdown follows a few distinct tracks that ultimately are dictated by the pathway of the public health official. For instance, Murthy urges public health researchers and epidemiologists to:
Murthy also calls for public health officials with ties to state and federal government to “improve coordination between social service systems and the health care system to address the social and environmental factors that contribute to the risk for substance use disorders.” This recommendation underpins the biggest insight the surgeon general’s report has to offer: that no single effort will curb substance misuse. Rather, public health officials must make a coordinated and dispersed effort to address the many root causes — cultural, biological and otherwise — of substance misuse and reshape policy to give future generations the skills to resist it.