Time for a Change

It is time to change how we as a society address alcohol and drug misuse and substance use disorders. A national opioid overdose epidemic has captured the attention of the public as well as federal, state, local, and tribal leaders across the country. Ongoing efforts to reform health care and criminal justice systems are creating new opportunities to increase access to prevention and treatment services. Health care reform and parity laws are providing significant opportunities and incentives to address substance misuse and related disorders more effectively in diverse health care settings. At the same time, many states are making changes to drug policies, ranging from mandating use of prescription drug monitoring programs (PDMPs) to eliminating mandatory minimum drug sentences. These changes represent new opportunities to create policies and practices that are more evidence-informed to address health and social problems related to substance misuse.

The moral obligation to address substance misuse and substance use disorders effectively for all Americans also aligns with a strong economic imperative. Substance misuse is estimated to cost society $442 billion each year in health care costs, lost productivity, and criminal justice costs.^1,2 However, numerous evidence-based prevention and treatment policies and programs can be implemented to reduce these costs while improving health and wellness. More than 10 million full-time workers in our nation have a substance use disorder—a leading cause of disability³—and studies have demonstrated that prevention and treatment programs for employees with substance use disorders are cost effective in improving worker productivity.^4,5 Prevention and treatment also reduce criminal-justice-related costs, and they are much less expensive than alternatives such as incarceration. Implementation of evidence-based interventions (EBIs) can have a benefit of more than $58 for every dollar spent; and studies show that every dollar spent on substance use disorder treatment saves $4 in health care costs and $7 in criminal justice costs.6 Yet, effective prevention interventions are highly underused. For example, only 8 to 10 percent of school administrators report using EBIs to prevent substance misuse,^7,8 and only about 11 percent of youth (aged 12 to 17) report participating in a substance use prevention program outside of school.⁹ Further, only 10.4 percent of individuals with a substance use disorder receive treatment,⁹ and only about a third of those individuals receives treatment that meets minimal standards of care.¹⁰

The public health-based approach called for in this Report aims to address the broad individual, environmental, and societal factors that influence substance misuse and its consequences, to improve the health, safety, and well-being of the entire population. It aims to understand and address the wide range of interacting factors that influence substance misuse and substance use disorders in different communities and coordinates efforts across diverse stakeholders to achieve reductions in both.

The following five general findings described within the Report have important implications for policy and practice. These are followed by specific evidence-based suggestions for the roles individuals, families, organizations, and communities can play in more effectively addressing this major health issue.

1. Both substance misuse and substance use disorders harm the health and well-being of individuals and communities. Addressing them requires implementation of effective strategies.

Substance misuse is the use of alcohol or illicit or prescription drugs in a manner that may cause harm to users or to those around them. Harms can include overdoses, interpersonal violence, motor vehicle crashes, as well as injuries, homicide, and suicide—the leading causes of death in adolescents and young adults (aged 12 to 25).¹¹ In 2015, 47.7 million Americans used an illicit drug or misused a prescription medication in the past year, 66.7 million binge drank in the past month, and 27.9 million self-reported driving under the influence (DUI) in the past year.⁹

Substance use disorders are medical illnesses that develop in some individuals who misuse substances—more than 20 million individuals in 2015.⁹ These disorders involve impaired control over substance use that results from disruption of specific brain circuits. Substance use disorders occur along a continuum from mild to severe; severe substance use disorders are also called addictions. Because substances have particularly powerful effects on the developing adolescent brain, young adults who misuse substances are at increased risk of developing a substance use disorder at some point in their lives.

Implications for Policy and Practice

Expanding access to effective, evidence-based treatments for those with addiction and also less severe substance use disorders is critical, but broader prevention programs and policies are also essential to reduce substance misuse and the pervasive health and social problems caused by it. Although they cannot address the chronic, severe impairments common among individuals with substance use disorders, education, regular monitoring, and even modest legal sanctions may significantly reduce substance misuse in the wider population. Additionally, these measures are cost-effective. Many policies at the federal, state, local, and tribal levels that aim to reduce the harms associated with substance use have proven very effective in preventing and reducing alcohol misuse (e.g., binge drinking) and its consequences. More than 300,000 deaths have been avoided over the past decade simply from the implementation and enforcement of effective policies to reduce underage drinking and DUI.¹² Needle/syringe exchange programs also represent effective and cost-effective prevention strategies that have been shown to reduce the transmission of HIV in communities implementing them, without increasing rates of injection drug use. These programs also provide the opportunity to engage people who inject drugs in treatment. These types of effective prevention policies can and should be adapted and extended to reduce the injuries, disabilities, and deaths caused by substance misuse.¹³

2. Highly effective community-based prevention programs and policies exist and should be widely implemented.

This Report describes the significant advances in prevention science over the past four decades, including the identification of major risk and protective factors and the development of more than two dozen research-tested prevention interventions that can be delivered in households, schools, clinical settings, and community centers. Three key findings from the Report are especially important in this regard. First, science has shown that adolescence and young adulthood are major “at risk” periods for substance misuse and related harms. Second, most of the major genetic, social, and environmental risk factors that predict substance misuse also predict many other serious adverse outcomes and risks. Third, several community-delivered prevention programs and policies have been shown to significantly reduce rates of substance-use initiation and misuse-related harms.

Prevention programs and interventions can have a strong impact and be cost-effective, but only if evidence-based components are used and if those components are delivered in a coordinated and consistent fashion throughout the at-risk period. Parents, schools, health care systems, faith communities, and social service organizations should be involved in delivering comprehensive, evidence-based community prevention programs that are sustained over time.

Additionally, research has demonstrated that policies and environmental strategies are highly effective in reducing alcohol-related problems by focusing on the social, political, and economic contexts in which these problems occur. These evidence-based policies include regulating alcohol outlet density, restricting hours and days of sale, and policies to increase the price of alcohol at the federal, state, or local level.

Implications for Policy and Practice

To be effective, prevention programs and policies should be designed to address the common risk and protective factors that influence the most common health threats affecting young people. They should be tested through research and should be delivered continuously throughout the entire at-risk period by those who have been properly trained and supervised to use them. Federal and state funding incentives could increase the number of properly organized community coalitions using effective prevention practices that adhere to commonly defined standards. The research reviewed in this Report suggests that such coordinated efforts could significantly improve the impact of existing prevention funding, programs, and policies, enhancing quality of life for American families and communities.

3. Full integration of the continuum of services for substance use disorders with the rest of health care could significantly improve the quality, effectiveness, and safety of all health care.

Individuals with substance use disorders at all levels of severity can benefit from treatment, and research shows that integrating substance use disorder treatment into mainstream health care can improve the quality of treatment services. Historically, however, only individuals with the most severe substance use disorders have received treatment, and only in independent “addiction treatment programs” that were originally designed in the early 1960s to treat addictions as personality or character disorders. Moreover, although 45 percent of patients seeking treatment for substance use disorders have a co-occurring mental disorder,¹⁴ most specialty substance use disorder treatment programs are not part of, or even affiliated with, mental or physical health care organizations. Similarly, most general health care organizations—even teaching hospitals—do not provide screening, diagnosis, or treatment for substance use disorders.

This separation of substance use disorder treatment from the rest of health care has contributed to the lack of understanding of the medical nature of these conditions, lack of awareness among affected individuals that they have a significant health problem, and slow adoption of scientifically supported medical treatments by addiction treatment providers. Additionally, mainstream health care has been inadequately prepared to address the prevalent substance misuse–related problems of patients in many clinical settings. This has contributed to incorrect diagnoses, inappropriate treatment plans, poor adherence to treatment plans by patients, and high rates of emergency department and hospital admissions.

The goals of substance use disorder treatment are very similar to the treatment goals for other chronic illnesses: to eliminate or reduce the primary symptoms (substance use), improve general health and function, and increase the motivation and skills of patients and their families to manage threats of relapse. Even serious substance use disorders can be treated effectively, with recurrence rates equivalent to those of other chronic illnesses such as diabetes, asthma, or hypertension.¹⁵ With comprehensive continuing care, recovery is an achievable outcome: More than 25 million individuals with a previous substance use disorder are estimated to be in remission.¹⁶ Integrated treatment can dramatically improve patient health and quality of life, reduce fatalities, address health disparities, and reduce societal costs that result from unrecognized, unaddressed substance use disorders among patients in the general health care system. However, most existing substance use disorder treatment programs lack the needed training, personnel, and infrastructure to provide treatment for co-occurring physical and mental illnesses. Similarly, most physicians, nurses, and other health care professionals working in general health care settings have not received training in screening, diagnosing, or addressing substance use disorders.

Implications for Policy and Practice

Policy changes, particularly at the state level, are needed to better integrate care for substance use disorders with the rest of health care. States have substantial power to shape the nature of care within these programs. State licensing and financing policies should be designed to better incentivize programs that offer the full continuum of care (residential, outpatient, continuing care, and recovery supports); offer a full range of evidence-based behavioral treatments and medications; and maintain working affiliations with general and mental health care professionals to integrate care. Within general health care, federal and state grants and development programs should make eligibility contingent on integrating care for mental and substance use disorders or provide incentives for organizations that support this type of integration.

But integration of mental health and substance use disorder care into general health care will not be possible without a workforce that is competently cross-educated and trained in all these areas. Currently, only 8 percent of American medical schools offer a separate, required course on addiction medicine and 36 percent have an elective course; minimal or no professional education on substance use disorders is available for other health professionals.^17-19 Federal and state policies should require or incentivize medical, nursing, dental, pharmacy, and other clinical professional schools to provide mandatory courses to properly equip young health care professionals to address substance misuse and related health consequences. Similarly, associations of clinical professionals should continue to provide continuing education and training courses for those already in practice.

4. Coordination and implementation of recent health reform and parity laws will help ensure increased access to services for people with substance use disorders.

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and the 2010 Affordable Care Act increased access to coverage for mental health and substance use disorder treatment services for more than 161 million Americans. Even so, just 10.4 percent of people with substance use disorders who need treatment are accessing care.⁹ These pieces of legislation, besides promoting equity, make good long-term economic sense: Research reviewed in Chapter 6 - Health Care Systems and Substance Use Disorders (PDF | 1.3 MB) highlights the extraordinary costs to society from unaddressed substance misuse and from untreated or inappropriately treated substance use disorders—more than $422 billion annually (including more than $120 billion in health care costs). However, there remains great uncertainty on the part of affected individuals and their families, as well as among many health care professionals, about the nature and range of health care benefits and covered services available for prevention, early intervention, and treatment of substance use disorders.

Implications for Policy and Practice

Enhanced federal communication will help increase public understanding about individuals’ rights to appropriate care and services for substance use disorders. This communication could help eliminate confusion among patients, providers, and insurers. But, more will be needed to extend the reach of treatment and thereby reduce the prevalence, severity, and costs associated with substance use disorders. Within health care organizations, active screening for substance misuse and substance use disorders combined with effective communication around the availability of treatment programs could do much to engage untreated individuals in care. Screening and treatment must incorporate brief interventions for mildly affected individuals as well as the full range of evidence-based behavioral therapies and medications for more severe disorders, and must be provided by a fully trained complement of health care professionals.

5. A large body of research has clarified the biological, psychological, and social underpinnings of substance misuse and related disorders and described effective prevention, treatment, and recovery support services. Future research is needed to guide the new public health approach to substance misuse and substance use disorders.

Five decades ago, basic, pharmacological, epidemiological, clinical, and implementation research played important roles in informing a skeptical public about the harms of cigarette smoking and creating new and better prevention and treatment options. Similarly, research reviewed in this Report should eliminate many of the long-held, but incorrect, stereotypes about substance misuse and substance use disorders, such as that alcohol and drug problems are the product of faulty character or willful rejection of social norms.

Thanks to scientific research over the past two decades, we know far more about alcohol and drugs and their effects on health than we knew about the effects of smoking when the first Surgeon General’s Report on Smoking and Health was released in 1964. For instance, we now know that repeated substance misuse carries the greatest threat of developing into a substance use disorder when substance use begins in adolescence. We also know that substance use disorders involve persistent changes in specific brain circuits that control the perceived value of a substance as well as reward, stress, and executive functions, like decision making and self-control.

However, although this body of knowledge provides a firm foundation for developing effective prevention, early intervention, treatment, and recovery strategies, achieving the vision of this Report will require redoubled research efforts. We still do not fully understand how the brain changes involved in substance use disorders occur, how individual biological and environmental risk factors contribute to those changes, or the extent to which these brain changes reverse after long periods of abstinence from alcohol or drug use.

Implications for Policy and Practice

Future research should build upon our existing knowledge base to inform the development of prevention and treatment strategies that more directly target brain circuit abnormalities that underlie substance use disorders; identify which prevention and treatment interventions are most effective for which patients (personalizing medicine); clarify how the brain and body regain function and recover after chronic drug exposure; and inform the development of evidence-based strategies for supporting recovery. Also critically needed are long-term prospective studies of youth (particularly those deemed most at risk) that will concurrently study changes in personal and environmental risks; the nature, amount, and frequency of substance use; and changes in brain structure and function.

To guide the important system-wide changes recommended in this Report, research to optimize strategies for broadly and sustainably implementing evidence-based prevention, treatment, and recovery interventions across the community is necessary. Within traditional substance use disorder treatment programs, research is needed on how to use new insurance benefits and financing models to enhance service delivery most effectively, how to form working alliances with general physical and mental health providers, and how to integrate new technologies and information systems to enhance care without compromising patient confidentiality.