In the past several decades our understanding of addiction and its many aspects has increased at a tremendous rate. We now know that addiction is a complex disorder involving several chemical systems in the brain and that the brains of addicts function in an abnormal manner. We have seen that genes play an important role in a person’s vulnerability to addiction. We have also seen that social factors, conditioning, emotional elements, and the characteristics of the drugs themselves contribute to the disease of addiction.

Great strides have been made in the development of effective treatments for addiction. Until the mid-1960s, hospital treatment for alcoholism and drug dependence was almost nonexistent and often consisted simply of medical detoxification and advice that the person stop drinking or using drugs.

We now have more effective therapies and medications that help the addict recover.

But there is much work left to be done. Current research targets several different areas, including the following: (1) epidemiology - tracking the prevalence and types of addictions and who is affected, (2) genetics - identifying addiction genes to discover who is at risk, (3) pharmacology - understanding more fully how addictive drugs work and developing new medications to counteract the effects of addiction, and (4) treatment - devising and testing treatment strategies and measuring outcomes.

Epidemiology
The National Institutes of Health and its divisions on alcohol and drug abuse maintain numerous data collection vehicles concerning all aspects of addiction. (Most of these surveys can be readily obtained on the Web sites listed in

appendix B.) A few examples of data collected by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) are the National Hospital Discharge Survey (which tracks alcohol-related illness), information on traffic fatalities and blood alcohol levels provided by the National Highway Traffic Safety Administration and related agencies, alcohol consumption data from state alcohol agencies and the alcoholic beverage industry, and the National Longitudinal Alcohol Epidemiological Survey. A comprehensive listing of current survey reports and the reports themselves can be obtained directly from NIAAA.

The National Institute on Drug Abuse (NIDA) maintains several sources of surveillance data, including the Drug Abuse Warning Network (DAWN) composed of selected emergency rooms, medical examiners, crisis centers, and other agencies.

DAWN tracks illnesses and deaths believed to be the result of addiction and is often able to provide early indications of new trends in drug abuse such as the recent resurgence of heroin addiction. Prescription audits and recapture studies by the Drug Enforcement Administration also provide useful data. (Recapture studies were first done to gather information on wildlife. When an animal is captured, it is measured and tagged, and when recaptured it is measured again.) Identified contacts within the drug community are tracked, and their activities provide useful information about trends in substance abuse. The National Institute of Justice conducts an ongoing survey of arrestees at selected urban sites across the country called the Arrestee Drug Abuse Monitoring Program (ADAM). Data is collected quarterly and includes both an interview and a urine drug screen. The United Nations also tracks several sources of data through its various agencies, including WHO and UNESCO.

The Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services conducts the annual National Household Survey on Drug Abuse. Use of alcohol and drugs over the past month, past year, and person’s lifetime is tracked and analyzed. State and local agencies use this survey in order to design and implement more detailed surveillance. The Household Survey provides data relevant to community prevention groups, to legislatures, to agencies planning health care delivery systems, and to law enforcement.

Survey data in 1998 revealed that 13.6 million Americans were current users of illicit drugs (use within thirty days) and that 4.1 million met diagnostic criteria for drug addiction. Of those addicted, 1.1 million were between the ages of twelve and seventeen. One hundred thirteen million Americans had drunk alcohol within the past thirty days, and 10.5 million were between the ages of twelve and twenty. Twelve million were described as heavy drinkers. Survey data also confirmed the observation of addiction professionals that the use of heroin and hallucinogens is on the rise. First time use of heroin in youths has risen to levels not seen since the early 1970s. First time hallucinogen use by those between the ages of twelve and seventeen rose during the 1990s, with 1.1 million new users in 1997.

In 1994 and 1997 the Household Survey contained questions about drug and alcohol use in the workplace. It was noted that 70 percent of current drug users were employed, with 7.7 percent of full-time employees reporting current illicit drug use and about the same number reporting heavy drinking.

Data was also gathered on occupation, sex, ethnic group, workplace drug testing, and other variables.

Critical to those who plan and provide funding for prevention and treatment are studies that look at the costs of addiction to society. These cost-of-illness studies are complex and cover three main areas of inquiry: what the connection is between addiction and various adverse outcomes such as medical and social problems, to what degree addiction is directly responsible for these outcomes, and how to determine what the cost is to society. The studies draw upon the diverse surveillance data provided by the kinds of surveys mentioned above, using information from the health care industry and from death reports, workplace data, household surveys, correctional facilities, law enforcement, welfare agencies, transportation safety agencies, and fire departments. “Opportunity cost” determines the value of resources that are diverted from one use to another because of addiction problems. Costs of direct health care are measured and an estimate made of lost productivity resulting from addiction. Additional costs associated with crime, accidents, and other alcohol- and drug-related events are also measured.

A comprehensive cost-of-illness study released by the National Institutes of Health in 1998 placed the annual cost of alcohol and drug abuse at $246 billion, or $965 per capita.

Of these costs, roughly 60 percent had to do with alcohol and 40 percent with drugs. Compared to figures in the last costof-illness study done in the 1980s, costs had risen substantially, even when factors such as changes in methodology were considered, largely because of a higher level of drug abuse and addiction following the late 1970s. The crack cocaine epidemic of the 1980s and the sharp rise in drug-related crime were responsible for a substantial percentage of the increase in costs.

Elizabeth Connell Henderson, M.D.

Glossary

Appendix A: Regulation of Addictive Substances

Appendix B: Sources of Additional Information