Public Health Enemy No. 1

Almost half of US citizens contribute to this problem.

Posted Nov 13, 2012

A recent report from the National Center on Addiction and Substance Abuse at Columbia University convincingly demonstrates that the unspoken elephant in the healthcare room involves risky use of addictive substances and addiction to these substances. Thirty-two percent of the US population 12 years of age and older report patterns of substance use that put them at risk for adverse outcomes, and another 16% report being addicted to legal or illicit substances.

Risky users are defined as “those who currently [in the past 30 days] use tobacco products, exceed the US Department of Agriculture (USDA) Dietary Guidelines for safe alcohol use, misuse controlled prescription drugs, use illicit drugs, or engage in some combination of these forms of substance use, but do not meet clinical diagnostic criteria for addiction.” Addiction is defined as meeting the criteria for substance abuse or dependence outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Substance abuse and dependence result in a continuum of behaviors, ranging from interference with work, school, or everyday activities to overwhelming preoccupation with obtaining and using the drug.

When we think about risky or addictive drugs, cocaine, methamphetamine, and heroin often come to mind. Although these drugs cause substantial health problems and account for many societal problems and emergency room visits, their public health impact pales in comparison to the consequences of nicotine (tobacco) and/or alcohol. Why? 

The answer is relatively simple from a statistical point of view. The risky use or abuse of tobacco and alcohol is much more common than the use of the illicit drugs, and thus these drugs contribute much more to societal costs. Risky use or addiction to nicotine (tobacco) occurs in about 27% of the population 12 years old and older. Risky use or addiction to alcohol occurs in about 34% of the population, and many people use both nicotine and alcohol. In comparison, risky use or addiction to illicit drugs and prescription drugs occurs in 8% and 3% of the population, respectively, and these individuals overlap with those that use nicotine and alcohol.

Risky use or addiction to drugs results in a multitude of serious medical problems, including various cancers, heart disease, respiratory illnesses, and gastrointestinal disorders, and underlies about 579,000 of the nearly 2.5 million deaths that occur in the US each year. Tobacco alone contributes to about 443,000 of these deaths, and alcohol adds another 98,000. Other drugs contribute to the remaining 38,000 deaths. Thus, tobacco and alcohol, the two drugs that are legal and that can be purchased readily over-the-counter in most convenience stores, account for the large majority of drug-associated deaths and, in fact, are responsible for over 21% of all deaths.

The sheer prevalence of risky drug use and abuse indicates that many people who have common medical illnesses are actively using addictive drugs while they are undergoing care for their medical conditions. Despite this reality, education pertaining to addiction is minimal at most medical schools, and treatment for substance use, including nicotine dependence, is not readily available in most areas of the country. Treatment of addictive disorders can be effective, yet such treatments are not considered part of routine medical care. In fact, most treatment facilities for substance use and abuse are not even part of the established medical community.

This comprehensive report from Columbia University strongly and effectively argues for major changes in medical education and health care delivery systems. The authors urge that substance use disorders be recognized, diagnosed, and treated. The implementation of preventative measures would substantially decrease the destructiveness of these disorders by helping young people avoid the abyss of drug addiction and its consequences.

This column was co-written by Eugene Rubin MD, PhD and Charles Zorumski MD.