OVERVIEW: BUILD A STRONGER, HEALTHIER COMMUNITY

Statistics show that 22.5 million Americans aged 12 or over were classified with substance dependence or abuse in 2004.¹ Additionally, 17 million people under age 18 live in a household where a parent or other adult is a binge or heavy drinker, and more than 9 million live with a parent or other adult who uses illicit drugs.^{2, 3}

Drug addiction took over my life. By the time I was 21 years old, I was shooting up $300 to $400 a day of heroin, along with using cocaine and marijuana on a regular basis. I decided to call my mom and let her know, fully, the condition of my drug addiction. That's when we found a rehabilitation program and I finally admitted that I needed help. I quickly began to realize that there was a great possibility I would be able to live my life without drugs. I graduated on March 23, 2001, and have been completely clean and sober since then. Now, I am happily married with my first son. I work with a rehabilitation program to help others establish a solid future in recovery. Chris Red Graduate Officer

Yet there is hope, because like other chronic physical and mental disorders, substance use disorders are medical conditions that can be treated effectively.4, 5 People who are in recovery can spread a positive message to others, telling people what to expect from treatment and demonstrating that treatment is effective and recovery is possible. People in recovery can and do rejoin their families, their jobs, and their lives in their communities. Still, substance use disorders continue to be a major public health problem in the United States. In 2004: Among youths aged 12 to 17, an estimated 8.8 percent (2.2 million) were classified with substance dependence or abuse. 6 An estimated 7.9 percent of Americans aged 12 or older (19.1 million) were current users of illicit drugs, meaning they had used an illicit drug during the month prior to being interviewed.7 About 22.8 percent of Americans aged 12 or older (55 million) said they had participated in binge drinking (5 or more drinks on the same occasion) at least once in the last 30 days.8 A "drink" is defined as a can or bottle of beer, a glass of wine or a wine cooler, a shot of liquor, or a mixed drink with liquor in it. 9

Substance use disorders involve the dependence on or abuse of alcohol and/or drugs. Dependence on and abuse of alcohol and illicit drugs, which include the nonmedical use of prescription drugs, are defined using the American Psychiatric Association's criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Dependence indicates a more severe substance problem than abuse; individuals are classified with abuse of a certain substance only if they are not dependent on the substance.¹⁰ For more information on the criteria used in defining dependence and abuse, consult the 2004 National Survey on Drug Use and Health, which is available on the Web at www.oas.samhsa.gov/nsduh.htm.

Much has been written about substance abuse, dependence, and addiction; many studies have used different terminology to explain their findings. To foster greater understanding and avoid perpetuating the stigma associated with these conditions, the phrase "substance use disorders" is used as an umbrella term to encompass all of these concepts.

Before I decided to enter a rehabilitation program, I had no purpose or direction. The main ingredient in my life was methamphetamine. Eventually, my family encouraged me to get help, and finally I made the decision to go to rehab. The program taught me how to be happy with myself, and that I can achieve the things that I want in life! Now, I am happily married and I am working to help others on their path of recovery. Amanda Anzalone Public Contact Supervisor

People with substance use disorders often also have co-occurring disorders at the same time. This can include having serious psychological distress (SPD) while also suffering from a substance use disorder. Meeting the criteria for SPD indicates that a person exhibits high levels of distress due to any type of mental problem, which may include general symptoms related to phobia, anxiety, or depression.¹¹ For more information on these criteria, consult the 2004 National Survey on Drug Use and Health, which is available on the Web at www.oas.samhsa.gov/nsduh.htm.

Adults with SPD are more likely than those without to have a substance use disorder.¹² Among adults with SPD in 2004, 21.3 percent were dependent on or abused illicit drugs or alcohol, compared to only 7.9 percent of adults without SPD. ¹³

The National Mental Health Association (NMHA) goes into greater depth about the types of mental health problems that correlate with substance use disorders. Mental health problems often predate substance use disorders by four to six years; alcohol and/or drugs may be used as a form of self-medication to alleviate the symptoms of a mental disorder. In some cases, substance use disorders precede the development of mental health problems. For instance, anxiety and depression may be brought on as a response to stressors from broken relationships, lost employment, and other situations.¹⁴ For more information about mental illness and health, please visit the NMHA Web site at www.nmha.org.

To enable more people living with these disorders to get help, there is a need to raise awareness about the impact stigma and discrimination have on people in recovery and their family members. Stigma and discrimination are large barriers to accessing treatment. The following overview summarizes their impact and provides other basic information about these disorders. By educating others about substance use disorders and discussing ways to help people receive treatment or other services, we can help build stronger, healthier communities across the country.

The Impact of Substance Use Disorders and the Effectiveness of Treatment

In 2001, the total expenditure for the treatment of substance use disorders in the United States was $18 billion. Another way of measuring costs is by calculating the total economic costs, including the costs of medical consequences of alcohol and drug use, lost earnings linked to premature death, lost productivity, motor vehicle crashes, crime, and other social consequences. In 1998, these costs were $184.6 billion for alcohol use disorders and $143.4 billion for drug use disorders.^{15, 16, 17, 18}

Additionally, more than 26,000 people died of drug-induced causes and nearly 20,000 died of alcohol-induced causes in the United States in 2002.¹⁹ Treatment can help offset these costs to society; it has a benefit-to-cost ratio of 7:1, with substance use disorder treatment costing $1,583 on average and having a monetary benefit to society of nearly $11,487.²⁰ Ensuring Solutions to Alcohol Problems has an online tool to determine the return on investment ratio for employers who invest in screening and treatment for employees with alcohol problems. The Alcohol Cost Calculator for Business is available at www.alcoholcostcalculator.org/roi/.

While cost is one way to measure the impact of substance use disorders, another way is by recognizing that substance use disorders affect more than just those in need of treatment. As many as 74 percent of Americans said in 2005 that addiction to alcohol has had some impact on them at some point in their lives, whether it was their own personal addiction, that of a friend or family member, or any other experience with addiction.²¹ Helping one person achieve recovery from a substance use disorder through effective treatment programs and other support services can improve many lives.

In fact, research shows that substance use disorders are medical conditions that can be effectively treated, just as many disorders are treatable.^{22, 23} A major study published in the Journal of the American Medical Association in 2000 is one of several studies that demonstrate the effectiveness of treatment for substance use disorders. The study found that treatments for drug use disorders are just as effective as treatments for other chronic conditions, such as high blood pressure, asthma, and diabetes.²⁴

The distinction between treatment and recovery is important. Recovery from alcohol and drug problems is a process of change through which an individual achieves abstinence and improved health, wellness, and quality of life. Individuals from the recovery community and treatment-related service providers developed this definition through the National Summit on Recovery process sponsored by the Substance Abuse and Mental Health Services Administration's (SAMHSA's) Center for Substance Abuse Treatment (CSAT).

For many people, treatment is a path toward recovery. It entails many interventions and attempts at abstinence and can occur in a variety of settings, in different forms, and for different periods of time.²⁵ According to SAMHSA's Report to Congress on the Prevention and Treatment of Co-occurring Substance Abuse Disorders and Mental Health Disorders in 2002, treatment of mental and substance use disorders together can help prevent the worsening of other health problems, such as cardiac and pulmonary diseases.²⁶

The Need to Overcome Stigma and Discrimination

The positive facts about the effectiveness of treatment are still not widely known, making it possible for stigma and discrimination to continue presenting a barrier for people with substance use disorders who wish to access treatment. They also inhibit the ongoing recovery process. Stigma detracts from the character or reputation of a person. For many people, stigma can be a mark of disgrace.²⁷ In 2004, 21.6 percent of the 1.2 million people who felt they needed treatment but did not receive it indicated it was because of reasons related to stigma.²⁸

Discrimination, on the other hand, is an act of prejudice. It can include denying someone employment, housing, accommodation, or other services based on the revelation that the person is receiving treatment or has previously been treated for a substance use disorder.²⁹ Discrimination ignores the fact that substance use disorders can strike people of any age, gender, race, ethnicity, education level, and geographic area.³⁰

Two surveys, published in 2001 and 2004 for Faces & Voices of Recovery, produced a wealth of information about the ongoing issues of stigma and discrimination. One survey of the general public found that:

• 67 percent of people surveyed thought that stigma exists toward people in recovery from an addiction to alcohol or other drugs.
• 27 percent of those surveyed said they believe it is acceptable that companies are less likely to hire people who are in recovery from an addiction to alcohol or other drugs.
• 53 percent of those surveyed believed that discrimination against people in recovery is a community problem.³¹

Another survey of people in recovery found that:

• 40 percent of people surveyed thought embarrassment or shame was their biggest obstacle to receiving treatment, and 19 percent were afraid of being fired or discriminated against if they entered treatment.
• 39 percent of people surveyed said they have experienced shame or embarrassment because they were in recovery from an alcohol or drug addiction.³²

Steps are being taken to fight stigma and discrimination. A new Institute of Medicine report, Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series, describes a comprehensive strategy for improving health care for mental health and substance use disorders. Among its recommendations is a call to ensure that "individual patient preferences, needs, and values prevail in the face of residual stigma, discrimination, and coercion into treatment." ³³

Build a Stronger, Healthier Community

Overcoming substance use disorders is possible and there are many ways to accomplish this, but people directly affected by substance use disorders need to learn about common misconceptions surrounding them. The general public also needs to be educated about stigma and discrimination in relation to substance use disorders and recovery. Stigma and discrimination can be tackled by public education about treatment effectiveness and stories about sustained recovery. Special training on strategies for reducing stigma and discrimination can also be helpful.

Embarking on a recovery path can reduce the stigma and discrimination toward people with substance use disorders. For example, 80 percent of the general public believes there is a stigma toward people with a dependence on alcohol. This number drops to 51 percent when a person dependent on alcohol is in recovery.³⁴

I started to drink at age 18 to fit in with my friends. I thought it was drinking that gave me a personality and I never thought I had anything to offer without it. Eventually, I realized I was being laughed at by my "friends," so I retreated and drank alone. You stop growing when you enter addiction. I was stuck at age 18 and never learned how to live in a grown-up world. I just did what I did best-drank and hid from life. At age 45, something in me snapped and I decided I wanted to live. I entered a treatment program and found a counselor who helped me learn how to love myself. I tell you if I knew life could be this good and this real after three short years in recovery, I would have done this long ago. Recovery had taught me to live my life passionately. Maureen Schaefer Recovery Advocate

Being aware of how we talk about substance use disorders and people who have them can also help. Stigmatizing words can discourage, isolate, misinform, shame, and embarrass those needing help as well as people who have successfully sustained long-term recovery from addiction. For example, according to the Institute of Medicine, the use of the word "abuse" in referring to substance abuse-as opposed to "use" or "dependence"-has been identified as derogatory, implying that substance use disorders indicate a willful commission of an abhorrent or sinful act, thus misrepresenting the nature of substance use disorders.³⁵ Therefore, it is important to be positive and respond to people with substance use disorders as individuals. Learn about them and do not make assumptions.³⁶

One positive example of other steps to take is the National Council on Alcoholism and Drug Dependence-New Jersey's (NCADD-NJ's) policy recommendations outlined in Overcoming Addiction Discrimination. This document outlines remedies suggested by a panel of legal, medical, and policy experts to combat stigma and discrimination. One suggestion is to launch an ongoing public awareness campaign to educate the public and change attitudes and perceptions to de-stigmatize substance use disorders and ensure their place in the public health realm.³⁷ The report can be found at NCADD-NJ's Web site at www.ncaddnj.org.

In addition to overcoming stigma and discrimination, other barriers to treatment must be addressed. President Bush's Access to Recovery (ATR) program, administered by SAMHSA, is working to increase each person's access to treatment. The program gives recipient states, territories, the District of Columbia, and tribal organizations broad discretion to design and execute federally supported voucher programs to pay for a wide range of effective, community-based substance use disorder clinical treatment and recovery support services. By offering vouchers to people in need of treatment services, the grant program promotes people's ability to choose the treatment and recovery services best suited for them. It also expands access to care, by including faith- and community-based programming, and increases substance use disorder treatment capacity.

When people with substance use disorders enter treatment, the healing can be significant. One year after treatment, people report a significant reduction in their alcohol and drug use, increases in employment and income, improvements in mental and physical health, decreases in homelessness, and decreases in risky behavior that puts them at risk for HIV/AIDS infections.³⁸ Helping people with substance use disorders get into treatment and confronting the stigma and discrimination against those who suffer from these disorders are the first steps toward building a stronger, healthier community.

For additional National Alcohol and Drug Addiction Recovery Month (Recovery Month) materials, visit the Recovery Month Web site at www.recoverymonth.gov or call 1-800-662-HELP.

For additional information about substance use disorders, treatment, and recovery, please visit SAMHSA's Web site at www.samhsa.gov.

SOURCES

¹  Overview of Findings from the 2004 National Survey on Drug Use and Health. DHHS Publication No. (SMA) 05-4061. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, September 2005, p. 7.
²  Grant, B. F. "Estimates of US children exposed to alcohol abuse and dependence in the family." American Journal of Public Health, 90(1), 2000, pp. 112-115.
³  CASA Analysis of the National Survey on Drug Use and Health [Data file]. New York: The National Center on Addiction and Substance Abuse at Columbia University, 2005.
⁴  Kleber, H.D., O'Brien, C.P., Lewis, D.C., McLellan, A.T. "Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation." Journal of the American Medical Association, 284 (13), Chicago, IL: American Medical Association, October 4, 2000, p. 1689.
⁵  Pathways of Addiction: Opportunities in Drug Abuse Research. National Academy Press.Washington, D.C.: Institute of Medicine, 1996.
⁶  Results From the 2004 National Survey on Drug Use and Health: National Findings. DHHS Publication No. (SMA) 05-4062. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, September 2005, pp. 70, 268.
⁷  Overview of Findings from the 2004 National Survey on Drug Use and Health, p. 3.
⁸  Ibid, p. 4.
⁹  Results From the 2004 National Survey on Drug Use and Health: National Findings, p. 23.
¹⁰  Ibid, pp. 155, 160.
¹¹  Ibid, p. 83.
¹²  Ibid, pp. 86, 91.
¹³  Ibid, p. 86.
¹⁴  "Alcohol and Drug Abuse, Addiction and Co-Occurring Disorders: Factsheet." National Mental Health Association Web site: www.nmha.org/substance/factsheet.cfm. Accessed December 9, 2005.
¹⁵  Mark, Tami, Ph.D., M.B.A., et al. National Expenditures for Mental Health Services and Substance Abuse Treatment 1991-2001. DHHS Publication No. (SMA) 05-3999. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 2005, p. 27.
¹⁶  Fitzgerald, H.E., Sullivan, L.A., Ham, H.P., Zucker, R.A., Bruckel, S., et al. Predictors of behavior problems in three-year-old sons of alcoholics: Early evidence for the onset of risk. Child Development, 64, 1993, pp. 110-123.
¹⁷  Harwood H, Fountain D, and Livermore G. The Economic Costs of Alcohol and Drug Abuse in the United States 1992. Report prepared for the National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism. NIH Publication No. 98-4327. Rockville, MD: National Institutes of Health, 1998.
¹⁸  The Economic Costs of Drug Abuse in the United States, 1992-1998. Pub. No. NCJ-190636. Washington, DC: Executive Office of the President, Office of National Drug Control Policy (ONDCP). 2001.
¹⁹  Kochanek, Kenneth D., M.A., Murphy, Sherry L., B.S., Anderson, Robert N., Ph.D., Scott, Chester. "Deaths: Final Data for 2002." National Vital Statistics Reports, 53(5), October 12, 2004, p. 11.
²⁰  Ettner, S., Huang, D., Evans, E., Ash, D.R., Hardy, M., Jourabchi, M., Hser, Y. "Benefit-Cost in the California Treatment Outcome Project: Does Substance Abuse Treatment Pay for Itself?" Health Services Research Journal. online early edition: www.blackwell-synergy.com/doi/abs/10.1111/j.1475-6773.2005.00466.x. Accessed December 1, 2005.
²¹  Rivlin, A., presentation at Community Anti-Drug Coalitions of America Science Writers' Briefing, Pittsburgh, PA, September 29, 2005, slide #4. Survey data collected August 2005 by Peter D. Hart Research Associates.
²²  Pathways of Addiction: Opportunities in Drug Abuse Research, p. 9.
²³  Kleber, H.D., et. al. "Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation." Journal of the American Medical Association, p. 1689
²⁴  Ibid, p. 1689.
²⁵  Daley, D.C., Marlatt, G.A. "Relapse prevention: Cognitive and behavioral interventions." Substance abuse: A comprehensive textbook, Lowinson, Ruiz, Millman, Langrod (eds), 1992, pp. 533-542.
²⁶  Report to Congress on the Prevention and Treatment of Co-occurring Substance Abuse Disorders and Mental Disorders. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2002, p. ix.
²⁷  Faces & Voices of Recovery Public Survey, p. 2.
²⁸  Results From the 2004 National Survey on Drug Use and Health: National Findings, pp. 78-79.
²⁹  Concurrent Disorders: Beyond the Label, An Educational Kit to Promote Awareness and Understanding of the Impact of Stigma on People Living with Concurrent Mental Health and Substance Use ProblemsToronto, ON: Centre for Addiction and Mental Health, 2005, slide #7.
³⁰  Results From the 2004 National Survey on Drug Use and Health: National Findings, pp. 67-72.
³¹  Faces & Voices of Recovery Public Survey, pp. 2, 3.
³²  The Face of Recovery. Washington, D.C.: Peter D. Hart Research Associates, Inc., October, 2001, p. 10.
³³  Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, D.C.: Institutes of Medicine of the National Academies, 2006, p. 1.
³⁴  Rivlin, A., presentation at Community Anti-Drug Coalitions of America Science Writers' Briefing, slide #8.
³⁵  Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, D.C.: Institutes of Medicine of the National Academies, 2006, p. 80.
³⁶  "Take Action." OpenMindsOpenDoors Web site: www.openmindsopendoors.com/action.htm. Accessed December 7, 2005.
³⁷  Overcoming Addiction Discrimination. Hamilton, NJ: National Council on Alcoholism and Drug Dependence-New Jersey, 2005, p. 3.
³⁸  Gerstein, Dean R., et. al. The National Treatment Improvement Evaluation Survey: Final Report. Chicago, IL: National Opinion Research Center, University of Chicago, March 1997, section entitled "Conclusion."