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The impact of substance abuse
  1. Joseph A Califano Jr
  1. Center on Addiction and Substance Abuse at Columbia University, 152 W 57th Street, New York, NY 10019, USA
  1. Correspondence to: Joseph A Califano Jr

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The new Democrats and the Newt Republicans want to reform welfare, reduce crime, cut taxes, reshape Medicare, increase worker productivity and international competitiveness, house the homeless, and free state and federal budgets from the shackles of prison and Medicaid costs. The greatest obstacle to this proposed reinvention of America is abuse and addiction involving all substances: tobacco, alcohol, pills, and drugs. American leaders can soft-pedal the gravity of the addiction epidemic because so many individuals are content with their own self-denial. Yet, it is hard to find an American whom substance abuse has not touched directly.

The anecdotal evidence is everywhere, even among society’s most successful members; in the addiction to alcohol and pills of megastars like Elizabeth Taylor and Liza Minelli, in the death of Maryland college basketball star Len Bias from a cocaine overdose just as he was about to embark on a promising professional career, in the destructive cocaine and heroin dependence of Eugene Fodor, the first American to share top honours at the Tchaikovsky violin competition in Moscow, in the life threatening alcohol and drug addiction of Robin Williams, and the overdose death of Williams’ friend, John Belushi, in Cy Young Award winner Dwight Gooden’s cocaine abuse, and addiction-plagued pro football stars like Dexter Manley and Lawrence Taylor, and in the death of rock star Kurt Cobain.

Those who work the halls of national and state legislatures know how treacherous the lure of alcohol and pills can be in the corridors of political success. We have seen this in the political wives Kitty Dukakis and Betty Ford, and in the long line of alcohol abusing politicians, including at the peaks of their careers two of the most powerful congressional committee chairmen ever, Wilbur Mills and Russell Long.

And is there an American without a family member or friend who smoked themselves to premature disability or death from emphysema, lung cancer, or heart disease? The celebrity morbidity list here begins with Humphrey Bogart and Nat King Cole, and gets longer each day, just a couple of years ago claiming pop singer and two-pack-a-day smoker Mary Wells and Pat Nixon as cancer victims.

The statistical evidence gives substance abuse and addiction its sinister status as Public Health Enemy Number One. More than 50 million Americans are hooked on cigarettes, about 18 million are alcoholics or alcohol abusers, more than five million smoke marijuana at least once a week, two million snort cocaine, including half a million addicted to crack. As many as a million are hooked on heroin, eight million abuse psychotherapeutic drugs like tranquillizers, amphetamines, and sleeping pills. Up to a million regularly use hallucinogens like LSD and PCP, and some one million Americans, half of them teenagers, use black market steroids.

If illegal drug use is falling among affluent teenagers, binge drinking is still common among high school seniors and college students, and from 1977 to 1993, the percentage of college women who reported drinking to get drunk more than tripled from 10% to 35%. Princeton University president Howard Shapiro calls alcohol abuse “the greatest single threat to the university’s fulfilment of its mission”. The human misery caused by addiction and abuse cannot be calculated; the broken homes, the lives snuffed out in their twenties, the teenage mothers and absent fathers, women victimised by violence and rape, babies disabled by a mother’s smoking, drinking, or using drugs during pregnancy, children molested by a father hopped up on beer or marijuana or cocaine, old people locking themselves in apartments terrorised at the thought of grocery shopping even in daytime, children - yes, children committing suicide. We know that a child who smokes marijuana is twice as likely to commit suicide as one who doesn’t.

Substance abuse and addiction visit a special savagery on America’s poor and minorities, but they spawn tragedies far beyond the black and Hispanic ghettos of poverty. Heroin wrenched the life away from Ethel Kennedy’s son, David, in a luxurious Palm Beach hotel at the age of 28, and alcohol and drug addiction have touched many other members of that royal American family, including Robert Kennedy Jr, Matthew Kennedy, Patrick Kennedy, Joan Kennedy, Patricia Kennedy Lawford, and her son, Christopher, who chairs a special projects committee at the Center for Addiction and Substance Abuse (CASA) at Columbia University.

If we cannot repair the broken hearts, we can at least put dollar signs on some costs. This year the financial bill will hit $400 billion in health care costs, lower productivity, disability, social welfare payments, fires, crime and punishment, and the expense of prisons, property damage from vandalism, and security systems to protect homes and offices. Almost one of every six of the trillion dollars we will spend on health care this year will be tribute paid to substance abuse and addiction. Half our hospital beds hold victims in auto and home accidents, cancer, heart disease, cirrhosis, kidney and respiratory illnesses, and violence, caused or exacerbated by tobacco, alcohol, and drugs. And the ripple impact on American society is becoming more apparent and frightening. Two thirds of illegal drug users work either part time or full time, and many businessmen are beginning to recognise that they can’t achieve world class levels of productivity and quality without reducing substance abuse among American workers.

Addiction and abuse have changed the way we educate millions of our children and even the way we graduate them from college. In many urban centres, teachers are terrorised by drug dealers, many of them students. Those who teach find it distracting and intimidating, to say the least, to be ushered in with their students through metal detectors as they enter the school building, and for their own protection in many urban centres, to be locked in the classroom while teaching. Michael Sovern, the recent president of Columbia University, told me that a few years ago he moved the graduation ceremony at Columbia from after-noon to morning in order to minimise rampant and unruly drunkenness. Surprised, I have mentioned this to several other university presidents. Most confessed they had done the same.

Cigarettes and alcohol and drug abuse have been pushing up taxes and raiding government coffers for years. Americans crippled by smoking and alcohol abuse will take home $5.6 billion in social security disability benefits in 1995-not welfare, just social security disability benefits - and $4.6 billion of that is due to cigarette smoking this year. At CASA, we have done a study of the cost of substance abuse to the Medicare programme, projected forward for 20 years. Medicare will pay $1 trillion to treat diseases as a result of substance abuse over the next 20 years; $800 billion of that will be due to cigarette smoking. As smoking among men has declined dramatically, smoking among women has fallen much less quickly, and women are beginning to move into that over 65 years bracket with the same smoking related diseases that men have.

Eighty per cent of state and local prison inmates are there for drug or alcohol related crimes; they are not necessarily addicts, but they were high at the time they committed the offence. Most mothers on long term welfare start with a teenage pregnancy, and there is no surer way of getting locked in poverty than becoming pregnant before you graduate from high school. Many of these pregnancies occur when one of the partners is high on booze or drugs. When the mother smokes, drinks, or uses drugs during pregnancy, the medical care to deliver her child jumps sharply. Ask your retail merchant why he left the downtown area, and he will probably respond “drugs.” Alcohol and drug abuse have fuelled a new $65 billion-a-year industry: security guards and devices to protect property from addicts who steal to feed their habits, and from marijuana and alcohol abusing vandals.

The abuse and addiction pandemic threatens our democratic institutions. For years, the criminal courts have been clogged with drug cases, but now the civil court system in many parts of the nation is simply not available to citizens angry enough to sue. So many judges have been diverted to criminal drug case duty that civil suits in many states languish for years, effectively denying plaintiffs any relief. In most parts of New Jersey, even family divorce cases and separation cases take three years to come to trial, leaving the spouses and the children in the nasty limbo of uncertainty.

America’s children are greatly at risk: from cigarette companies with their Joe Camel campaigns, to beer and alcohol advertisers who are the source of one third of all college newspaper revenue, to drug dealers who involve poor children in the drug trade and push drugs on teenagers and subteenagers. Most everyone addicted to nicotine and hard drugs is hooked before they are 21. The younger an individual becomes a smoker and regular drinker, the more likely he or she is to get hooked on alcohol or drugs. Half a million children in our country are in foster care, double the number of five years ago, an increase largely attributable to crack. Alcohol and drugs are the prime culprits in the spread of AIDS. Intravenous drug use is the conventional culprit, but abuse of beer, liquor, marijuana, and cocaine plays a role because young Americans, high on such substances, are far more likely to have sex and to have it without a condom. Every three years, substance abuse and addiction claims almost two million Americans, most of them cigarette smokers, more people than have died in all our wars and all our automobile accidents combined.

What can we do? First, we can end the denial, face the facts honestly and blow away the politically convenient myths. Most of our public energy and resources have been spent waging a limited war to keep illegal drugs out of the country. That war is important, but it has proved quixotic and too narrow minded. The root of the problem is not in faraway places like Turkey’s poppy fields, Southeast Asia’s golden triangle, or South America’s jungles, but within ourselves. Drugs are not invaders, but invitees to the homes and neighbourhoods of America. We are 5 % of the world’s population. We consume almost 50 % of the world’s illegal drugs. Most public policies guiding the nation’s various wars on drugs have fallen short. Yet one political leader after another orders up more of the same, more policemen, more prisons, more tough sentences. Let us recognise these leaders, Republican and Democrat alike, for what they are. They are a chorus of politicians pounding the table hard, and shouting louder and louder. If all the king’s horses and all the king’s men can’t put Humpty Dumpty back together again, then give us more horses and give us more men.

Second, we have got to recognise that substance abuse is a problem for all Americans, not just the poor and inner city ghettos and pockets of rural poverty. At least as many middle class affluent white youngsters experiment with drugs as do poor inner city black and Hispanic children. However, poor minority teenagers are more likely to stay the course long enough to get hooked. The middle class and affluent have more reliable support systems, families, economic security, and better schools and counselling, and they know how to tap these resources. The tenacity of alcohol and drug addiction increases as personal, social, financial, economic, and legal difficulties multiply, as they do for the poor.

Third, we have got to recognise that addiction is a chronic disease. In a medical treatment sense, addiction is more like diabetes and high blood pressure than like a broken arm or pneumonia, which can be fixed or cured in one round of treatment. Continuing care is as critical to treat the alcohol or drug addict, and perhaps the cigarette smoker, as taking insulin or antihypertension drugs is to the diabetic patient or the victim of high blood pressure.

Fourth, we have to shed our drug of the month mentality and recognise that there are very few abusers of just one substance. The enemy is substance abuse and addiction, not simply illegal drug addiction. Most alcoholics also use tranquillisers, sleeping pills, or other psychotropic drugs. For the very young, cigarettes and beer can be drugs of entry into a more dangerous world. Most cocaine and heroin addicts started on’ alcohol and marijuana, and continue on alcohol and marijuana. A 12 to 17 year old who smokes marijuana is 85 times more likely to use cocaine, based on the national household survey of drug abuse, conducted by the National Institute on Drug Abuse, than one who doesn’t. An adult who smoked as a child is three times more likely, who drank as a child is six times more likely, and who used marijuana as a child is 17 times more likely to use cocaine regularly than an adult who never used these substances as a child.

Ricocheting from drug to drug, without recognising the central problem of addiction, is the stuff of frenzy, not national policy. Alcohol topped the list of abused substances in the early sixties. By the end of the decade, marijuana was the most abused drug on college campuses, with a hefty dose of hallucinogens like LSD and PCP thrown in. In the 1970s, heroin turned our city streets into alleys of terror. A report I prepared in 1980 and 1981 on drug and alcohol abuse for the governor of New York is most notable because it hardly mentioned cocaine. That drug became the fashion of the well-to-do, and then the bane of the poor, in the mid-1980s. At the end of that decade, crack brought Wild West shootouts to urban streets. Today, heroin is returning as is the highly dangerous and addictive mixture of cocaine and heroin, and the drug of choice on America’s college campuses is once again alcohol.

Fifth, we can mount a united and system wide effort to deal with all aspects of substance abuse in America : research and practice, demand and supply, prevention and treatment. All the various wars on drugs have been subverted by fragmentation among professional disciplines, among federal, state, and local governments, and agencies within each level of government, among policy makers, researchers, and service providers, and among physicians, treatment counsellors, and social workers who often fail to work together in treating patients. Prosecutors, when they exercise their discretion, rarely consult public health officials to get the maximum public health impact from the indictments they issue. Biomedical researchers disdain behavioural scientists, keeping their distance, discouraging joint efforts, rarely sharing information and experience about tobacco, alcohol, and drug addiction. America will spend this year, at NIH, more than $4 billion to support basic research on cancer, cardiovascular disease, and AIDS. We shall spend less than 15% of that amount for basic research on substance abuse and addiction, the largest single cause and exacerbator of all three of those deadly ailments.

The national government, in my judgment, should invest at least a billion dollars a year in research to identify the most cost-effective treatments for those who are hooked on tobacco, alcohol, or other drugs, and to find the most persuasive causes of prevention for those who are not. With that level of consistent investment, we can attract our best minds to the antiabuse and addiction effort. It is no accident that we have such phenomenally intelligent doctors researching cancer and heart disease. Two presidents, Lyndon Johnson and Richard Nixon, in consecutive terms in office, said we would provide at least one billion dollars a year through NIH for research in this area; that is what drew so many of our great medical minds into those areas. They knew the resources would be there year after year if they decided to devote their lives to dealing with such intractable diseases. Stigma is another serious problem here. If a disease like cancer or diabetes afflicted as many Americans as tobacco, alcohol, and drug abuse and addiction do, this nation would mount a research effort on the scale of the Manhattan project to deal with it.

The lack of knowledge and scepticism about the efficacy of treatment programmes has helped convince Congress in recent years to appropriate even less money for treatment than Ronald Reagan, George Bush, or Bill Clinton had requested. Treatment works, but the only sure way not to get addicted is to stay away from drugs. We devote remarkably paltry resources to preventing our young from smoking, taking drugs, or drinking. At least among adults, America has moved from a society in which the smoker asks, “Would you like a cigarette?” to one in which the smoker sheepishly whispers, “Do you mind if I smoke?”. There is also a major role for research here, particularly to discover more about how to influence the behaviour of teenagers, for it is in the limbo of life between childhood and adulthood that individuals are most vulnerable to smoking, drinking, and drug abuse. We know that if an individual gets through the years from 10 to 20 without smoking, abusing alcohol, and using drugs, that individual is virtually certain never to do so in the future.

Sixth, we must place the responsibility of ridding the nation of substance abuse on all institutions. Each of us, as individuals in institutions, can do much more than we do at present to combat substance abuse. What little we know about this subject begins with two propositions: it can be prevented, and the earlier abuse or addiction is spotted, the more likely it can be ended. Parents particularly must be alert to signs of drug abuse in their children, and they must be willing to act promptly and aggressively when they suspect that a child has a problem. Each professional and institutional system, and those who work in them, should assume more responsibility to insist on smoke-free environments and to spot substance abuse and know how to act when it is spotted.

Seventh, we can take advantage of the captive audiences. Teachers in the classroom should learn how to detect substance abuse in children and parents and what the counselling and treatment options are. Physicians can identify substance abuse in patients, but they rarely take the responsibility of doing so. Ophthalmologists can spot drug and alcohol abuse during any routine eye examination. Dermatologists can spot smokers but they rarely do anything about it. Nurses could be particularly effective in emergency rooms. Most emergency visits - true emergencies - involve injuries or heart attacks in which cigarettes, alcohol, or drugs are implicated.

And nowhere is our failure to take advantage of captive audiences more costly than in the nation’s prison system. We broke the one million prisoners a year barrier in this country last year, and on the trajectory we are on, we will have more than two million prisoners in this country just beyond the year 2000. Eighty percent of the individuals in state and local prisons are there for drug or alcohol related crimes. Sixty percent of the individuals in federal prisons are there for violating the drug laws. Eighty percent of the people in prison have previously been convicted of a felony. We do virtually nothing to treat these individuals while they are in prison. In my judgment, instead of the mandatory sentences we have, we could provide treatment for anyone who is addicted to drugs or alcohol while they are in prison, and the mandatory sentence would be that they demonstrate a year’s sobriety before release.

Eighth, we can move the issues of substance abuse into the mainstream of America’s medical, social, economic, and political discourse, and accord work in the field the same respect and panache that we accord other professions. It should be as fashionable to search for a cure to addiction as it is to look for a vaccine for polio or seek a cure for multiple sclerosis. Parents should be as proud to say my son or my daughter, the addiction counsellor, as they are to say my son, the oncologist, or my daughter, the cardiologist. Family members should feel free to discuss a relative’s drug or alcohol problem, just the way they discuss the results of it, the cancer or heart disease.

In his epic A Study of History, Arnold Toynbee concluded that the great civilisations were destroyed by self inflicted wounds; not by enemies without, but within. As Toynbee put it, in all 16 cases reviewed, the most that an alien enemy has achieved has been to give an expiring suicide her coup de grace. The threat of destruction from substance abuse is not the only internal threat our nation faces, but it is the most pernicious and costly. The human nature of Americans is no different than that of the Greeks whose affluence ultimately led them to a decadent society, the Romans who came to believe that a people drenched in self indulgence did not endanger their empire, or the Chinese whose civilisation was destroyed by the widespread availability and use of opium. Americans are no more immune from the laws of history than those great civilisations were. It doesn’t take a Cassandra to see the fault lines within our own civilisation. The last 25 years have given us plenty of warning signals, but no sirens screech more insistently than these : the disintegration of the family, the decline of American education and child health, and the relentless plague of tobacco, alcohol, and drug abuse.

The most ominous dimension of these forces is that they goad each other, and that each has its sinister sights fixed on the same vulnerable and precious targets: our children and our teenagers, and that alone offers sufficient reason to act now on substance addiction and abuse.

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