Drug and Alcohol Abuse in the United States

I. The Rise of Addiction. Drugs and Alcohol are nothing new to the United States. Commensurate with the first settlements, alcohol and drugs became an integral part of the American fabric. By many accounts, the Pilgrims landed at what is now Plymouth, Massachusetts, rather than continue sailing south because they were running out of supplies, foremost of which was alcohol.[1] In addition, what are now controlled and/or illicit (illegal) drugs were once readily available “over-the-counter” and quite pervasive. The early 1800's saw the rise of heroin and its derivatives with the max-influx of Chinese labor relative to the building of the American rail system. While it is commonplace to think of the “wild west” as a hot bed of saloons and cowboys “cutting the dust” with bottles of whisky, it was just as likely that they would frequent opium dens and spend countless days in dream-like trances amidst prostitutes and near-do-wells.[2] Opium derivatives such as Laudanum were produced by reputable companies and prospered in countless forms; soon becoming the elixir of choice for ailments including headaches, colds, tuberculosis, alcoholism, and even cancer. Morphine[3], another opium derivative, was heralded as a wonder drug due to its unparalleled ability to inhibit or eliminate severe pain.

It was not until the civil war that the darker side of opium was fully exposed. While both the North and the South depended upon morphine to treat the wounded, it soon became clear that this wonder drug was addictive. By the end of the war, tens of thousands of soldiers were chemically dependent. From there the addiction grew to epidemic proportions.[4]

It was not until 1920 that Congress addressed this burgeoning threat by controlling these substances with the Dangerous Drug Act. Said legislation prohibited the importation and exportation of various drugs (opium, morphine, cocaine, etc.) unless pursuant to a license granted by the Secretary of State. The law also provided a framework for future legislation which would later codify the manufacture, sale, possession and prescription of these dangerous drugs. Violation of the statute, and thus the illicit use of these drugs, was made for the first time, a criminal offence.[5] Nonetheless, by 1925, there were an estimated 200,000 opium addicts in the United States.

History fairs no better for alcoholism in America. While per capita consumption of alcohol in the United States was at its highest in colonial times (approximately three times current consumption)[6], the abuse of alcohol, the “loss of control” and thus alcoholism in America is far greater today. There are many hypotheses as to why there is less consumption of alcohol in present-day America but over twenty-fold the rate of alcoholism.

Many theorize that, in colonial times, alcohol consumption was a part of every-day life for all individuals despite age, sex, or social class. Alcohol was consumed from morning till night. That, coupled with the close-knit village society wherein everyone knew the goings-on of their neighbors, fostered an air of self-control. Social interaction was had in the local taverns wherein the news was discussed, business plans hatched and entire families gathered “drinks-in-hand”. Colonial America did not vilify alcohol, rather, alcohol, in all its forms, was venerated with even the Puritans proclaiming it the “good creature of God[7].” On those occasions wherein one did overindulge in his drinking, his “[d]runkenness was not so much seen as the cause of deviant social behavior—in particular crime and violence—as it was construed as a sign that an individual was willing to engage in such behavior."[8]

The rise of the industrial revolution and the expansion West saw the demise of Colonialism. Soon gone was the family-oriented tavern and in its wake came the saloons. Innovations in beer making and distillation markedly increased production and lowered costs. Between 1785 and 1835, the U.S. population nearly doubled, cities expanded and the “wild west” was born. Alcohol became less of an integral part of daily life and more of a sport; when one drank, they did so “all out”[9]. Binge drinking became more of the norm and alcohol itself, not the consumer, slowly became the object of scorn. Accordingly, the temperance movement, first established in 1826, soon grew to over a million members who had disavowed distilled spirits, and an additional 500,000 members that swore-off alcohol of any kind.[10] Despite its name, the temperance movement was little about temperance or moderation; it was about abstinence. Though some believed that beer and wine would not lead to the inexorable results of distilled spirits, the movement as a whole espoused zero-tolerance. Even though the temperance movement grew by leaps and bounds, it was far from diverse; consisting mainly of the white Protestant middle-class. As such, most European immigrants opted to retain their drinking traditions of the “old country” and tensions mounted between the “tea-toter” and the “drinking man”.

Amidst the growing controversy, the temperance movement evolved by the 1880's into the outright prohibition movement, largely pitting the rural second or third generation Protestant against the city-dwelling, newly immigrated Catholic. Given that the vast majority of power lay in the hands of our first settlers, national prohibition was soon to follow. January 16, 1920 marked the effective date of the Eighteenth Amendment to the U.S. Constitution, prohibiting the manufacture, sale, transportation, import, and export of intoxicating liquors for beverage purposes. Alas, it was believed, demon rum, alcoholism and the destruction of the American family would be halted in their tracks.

Such was not the case. Prohibition, by all accounts, was a failure. While indeed it changed how America consumed alcohol, it did little if anything to curb overall consumption. Rather, alcohol consumption increased in the U.S. during Prohibition. Only the lower middle-class - working folk - found it much harder to obtain alcohol, and thus alcohol related disorders declined in that segment alone. The lower class, rural citizens, however, not only supplied their own desires via home production/moonshine, but they also served, in part, the growing demands for alcohol of the middle and upper-classes.[11] What was once the tavern, then later the saloon, became, with Prohibition, the illegal clubs or “speakeasies”. This was the new underground. No more a place for family, friends and common discussions; no longer even a venue to rant, rave, argue or “let loose” after a long day herding cows, the American speakeasy was an odd amalgam of flamboyance, secrecy, decadence and just plain irreverence. In addition to the moonshine produced by rural Americans, a whole black market industry was born as the “bootleggers”[12] ran liquor, mostly from Canada, to the speakeasies in towns and cities across America. The most noted of these “Prohibition-made” outlaws was, of course, Al Capone.

It was not long after 1920 that Prohibition was seen as a complete failure. The traditional American family was not restored, a majority of the populous simply disregarded the Prohibition laws, organized crime ran amuck and, most of all, the overall consumption of alcohol was little affected. On December 5, 1933, Prohibition was repealed with the passage of the Twenty-First Amendment. The end of Prohibition, however, did little to affect the collective mind set toward alcohol. The general sentiment of prescribing “evil” characteristics to alcohol, which began with the temperance movement, continues to this day. The belief that alcohol, itself, is a corruptive, demonic substance over which we have little or no control, lent quite well with the then growing proposition that alcoholism is a disease; a model that was embraced by the then fledgling group of Alcoholics Anonymous. The first of the “12 steps” sets forth this philosophy:

“We admitted we were powerless over alcohol - that our lives had become unmanageable.”[13]

With a mere 400 members by the end of 1939, A.A. is now an international organization with estimated membership in excess of 2,160,000; of which more than 1,130,000 are in the U.S. and Canada.[14] The first edition of Alcoholics Anonymous, The Big Book, as it is commonly referred to, was first printed in 1939. It has had three subsequent editions, the latest being published in 2001. In all, more than 30 Million copies of the Big Book have been sold to date.

Modern science was slow to follow A.A.’s lead. In1951 The World Health Organization recognized alcoholism as a serious medical problem and the American Medical Association (AMA) declared alcoholism as a treatable illness in 1956. Following E.M. Jellinek’s 1960 comprehensive disease model of alcoholism, the American Psychiatric Association began in 1965 to use the term “disease” to describe alcoholism, and the AMA followed suit in 1966. The disease model has expanded to include not only alcohol, but addictions in general such as drug, gambling, sex, shopping, etc. Pursuant to the disease model, addiction is a primary disease; it exists in and of itself and is not secondary to or a result of some other ailment or condition.[15] The primary disease model is in direct contrast to the psychological model of Dual Diagnosis in which addictive behavior is seen as secondary to some psychological condition (eg. one suffers from depression and, as a partial result, abuses alcohol.[16] In any event, the current model embraced by the allopathic field is that drug and alcohol addiction is a primary disease.

While the repeal of Prohibition turned the matter of alcoholism back from the Federal Government to the private sector (A.A., etc.), such was not the case with illicit drugs. Beginning in 1954, then President Eisenhower formed a 5-member Cabinet committee to “stamp out narcotic addiction”[17]. Although not officially coined “the war on drugs” until President Nixon created the Drug Enforcement Agency in 1973 declaring “an all-out global war on the drug menace”, it was clear that illicit drugs (in keeping with public sentiment) would not get the stamp of “legality” afforded alcohol. To the contrary, in the past 40 years, the United States has spent over $2.5 trillion dollars combating the war on drug. In addition, in 2008, President Bush signed the Mérida Initiative whereby America would provide some $1.4 billion to Mexico and other countries to help fight illicit drug smuggling and the resulting violence.[18]

II. The Current State of Addiction.

A) Alcohol. The National Survey on Drug Use and Health (NSDUH) classifies alcohol consumption into three classes:

  1. Current (past month) use - At least one during in the past 30 days;
  2. Binge use - Five or more drinks on the same occasion on at lease 1 day in the past 30 days; and
  3. Heavy use - Five or more drinks on the same occasion on each of 5 or more days in the past 30 days.[19]

The above classifications are not mutually exclusive, as heavy use entails and includes both current use and binge use, and binge use includes current use. Further, the study focused on alcohol consumption in persons age 12 and older, and thus all figures and percentages cited below are premised upon the population consisting of such persons 12 and older.

B) Illicit Drugs. NSDHU tracks illicit drug use in nine categories: marijuana, cocaine, heroin, hallucinogens, inhalants; and nonmedical use of prescription pain relievers, tranquilizers, stimulants, and sedatives. Several of the many illicit drugs are grouped together within these nine categories, such as hashish within marijuana and crack within the cocaine category, etc. Over-the-counter drugs and the legitimate use of prescription drugs are not included in the findings below.[23] Further, like alcohol, all figures and percentages cited are for 2008, unless otherwise designated, and are premised upon the population consisting of persons 12 and older.

Past Month Use of Selected Illicit Drugs: 2002-2008


 

Age 50 & Older: Past Year
Illicit Drug Use

As one might expect, illicit drug use varies greatly with age. Not only do the categories of drug use differ with age but also the percentage of the populous using for a given age group. For instance, past-month illicit drug use among persons 18-25 years of age was 19.6% while such use was 4.6% for those aged 50-59[25]. Nonetheless, illicit drug use soared among those aged 50-59 from 2.7% in 2002 to the present figure. Moreover, the nonmedical use of prescription drugs was double that of marijuana (0.8% vs. 0.4%) among those aged 65 and older.[26] As illustrated in the adjacent chart, illicit drug use by those over 50 is far greater when viewed as “past year” versus “past month” usage.

C) Substance Abuse and Treatment. In 2008, some 22.2 million Americans (age 12 and older) were classified with substance abuse or dependence in the past year (8.9% of the population).[27] Of these 22.2 million persons:

As of March 30, 2007, there were an estimated 14,000 facilities in the U.S. which provided substance abuse treatment and/or detoxification, including outpatient, non-hospital residential, hospital inpatient, and methadone/buprenorphine clinics.[28] In 2008, approximately 4 million persons (age 12 and over) received treatment for alcohol and/or illicit drug use. Most (2.2 million) utilized self-help groups such as A.A., while the smallest number reported treatment while in prison or jail (343,000). The following figure sets forth the range of treatment modalities and the number of persons utilizing them:

Location where Substance Abuse Treatment was Received: 2008[29]

Of the 4 million people who received treatment in 2008, 2.3 million received such treatment at a speciality facility, which included hospitals (inpatient only), drug or alcohol rehabilitation facilities (inpatient or outpatient), or mental health centers. Specialty facilities did not include treatment at an emergency room, private doctor's office, self-help groups, prison or jail, or hospital as an outpatient.[30] This figure represent roughly only 10% of the estimated 22.3 million in need of treatment. The said 2.3 million people sought specialty treatment as follows:

Remarkably, of the roughly 14,000 treatment centers (both speciality and otherwise), some 97% (.13,580) of the facilities are 12-step, A.A., based programs;[32] adhere to the primary disease concept of addiction, and comprise what is generally termed “conventional treatment”. However, it is all too evident that, as of 2007, 54.2% of persons seeking any form of treatment had been in treatment at least one time prior.[33] Moreover, according to the General Service Office of Alcoholic’s Anonymous, on average, sobriety for the total AA membership was 3.7% (first year) and 2.5% over five years.[34]

“After just one month in the [A.A.] fellowship, 81% of the new members have already dropped out. After three months, 90% have left, and a full 95% have disappeared in one year!”[35]

Nonetheless, the overwhelming majority of treatment facilities cling to the 12-step model despite the blatantly dismal results.

D) Economic Impact of Substance Abuse. Numerous studies have been done to estimate the overall economic cost of alcohol and illicit drug abuse. Most notable are those that not only factor the direct costs (i.e. treatment, law enforcement, etc.) but also the indirect costs such as lost productivity. According to a revised 1998 study, alcohol abuse alone in America costs $184.6 billion dollars annually with an average per annum increase of 3.8%.[36] Similarly, illicit drug abuse is estimated to cost $180.8 billion dollars annually with an average per annum increase of 5.3% from 1992-2002.[37]

As far back as 1999, $5.5 billion dollars was being spent annually by Americans as direct costs for specialty facilities (see page 8, ¶ 1, above) alone.[38] Presently, non-hospital residential treatment facilities range in costs from approximately $7,000 dollars per month, per client, to over $60,000 dollars per month. It is thus believed, since the costliest specialty facility in the 1999 study was approximately $18,500 dollars per client, per month, that the said $5.5 billion per year is vastly understated as of 2010.

III. Conclusion - Where Do We Go From Here? While the above data speaks for itself, certain conclusions can be logically inferred.


[1]. Eames, A.D. Secret Life of Beer: Legends, Lore and Little-Known Facts. Pownal, Vermont: Storey, 1995, p. 17.

[2]. Narconon Arrowhead, History of Heroin, Methadone & Heroin Addiction. Heroin Addiction Rehab, 2010.

[3]. Named by Dr. Friedrich Sertuerner after Morpheus, the Greek god of dreams.

[4]. http://www.naturalnews.com/023133_health_New_York_medicine.html, 1/28/2010.

[5]. http://www.the-shipman-inquiry.org.uk/images/fourthreport/chapter/ SHIP04_P003_1.pdf. 1/15/2010.

[6]. Peele, S. (1989, 1995), Diseasing of America: How we allowed recovery zealots and the treatment industry to convince us we are out of control. Lexington, MA/San Francisco: Lexington Books/Jossey-Bass.

[7]. H. G. Levine, "The alcohol problem in America: From temperance to alcoholism," British Journal of Addiction 79(1984):109-19.

[8]. H. G. Levine, "The good creature of God and the demon rum," in Alcohol and Disinhibition, eds. R. Room and G. Collins (National Institute on Alcohol Abuse and Alcoholism, 1983).

[9]. W. J. Rorabaugh, The Alcoholic Republic (Oxford University Press, 1979).

[10]. See, Peele, S., footnote #6, supra.

[11]. Id.

[12]. The term “bootlegger” originated from the white man hiding his liquor in his boots when trading with Indians.

[13]. http://www.aa.org/en_pdfs/smf-121_en.pdf

[14]. http://www.aa.org

[15]. http://www.yourdictionary.com/medical/primary-disease

[16]. Rassool, G. Hussein, Dual Diagnosis Nursing (Blackwell Publishing, 2006).

[17]. Claire Suddath, A Brief History of The War on Drugs, Time Magazine, (March 25, 2009). Retrieved 2/4/2010 from http://www.time.com/time/world/article/0,8599,1887488,00.html.

[18]. Id.

[19]. Substance Abuse and Mental Health Services Administration. (2009). Results from the 2008 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-36, HHS Publications No. SMA 09-4434). Rockville, MD.

[20]. Id. at p. 31.

[21i]. Id. at p. 33.

[22]. Treatment Episode Data Set (TEDS), Trends in Adult Femal Substance Abuse Treatment Admissions Reporting Primary Alcohol Abuse: 1992 to 2007. (January 7, 2010). Retrieved 1/29/2010 from: http://www.oas.samhsa.gov/samhda.htm.

[23]. Results from the 2008 National Survey on Drug Use and Health: National Findings (see footnote #17 for full cite) at p. 15.

[24]. Id. at p. 13-17.

[25]. Id. at p. 23.

[26]. The NSDUH Report, Illicit Drug Use Among Older Adults, December 29, 2009; retrieved 2/1/2010 from http://www.oas.samhsa.gov/2k9/168/168OlderAdults.htm.

[27]. Results from the 2008 National Survey on Drug Use and Health: National Findings (see footnote #17 for full cite) at p.73. Dependence or abuse was based on criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV)(American Psychiatric Association, 1994).

[28]. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. National Survey of Substance Abuse Treatment Services (N-SSATS): 2007. Data on Substance Abuse Treatment Facilities, DASIS Series: S-44, DHHS Publication No. (SMA) 08-4348, Rockville, MD, 2008.

[29]. Results from the 2008 National Survey on Drug Use and Health: National Findings (see footnote #17 for full cite) at p.81. Please note, the figures exceed the 4 million receiving treatment in 2008 implying that certain individuals utilized multiple treatment modalities in that year.

[30]. Id. at p.84.

[31]. Id. Please note, the roughly 100,000. discrepancy resulted from the decision to not count those individuals wherein it was not delineated for which substance(s) treatment was sought.

[32]. Saint Jude, The State of New York State Office of Alcoholism and Substance Abuse Services Certified Treatment Programs, at p.3.

[33]. United States Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Office of Applied Studies, Treatment Episode Data Sets - Discharge (TEDS-D), 2006 at p.50. Retrieved 1/30/2012 from http://www.icpsr.umich.edu/cgi-bin/bob/ archive2?study=24461&path=SAMHDA&dsopen=999999,1

[34]. Saint Jude, The State of New York State Office of Alcoholism and Substance Abuse Services Certified Treatment Programs, at p.3.

[35]. Kolenda, 2003, Golden Text Publishing Company. See also, Balla, John D., Is Alcoholics Anonymous Effective?, (2009). http://65.99.232.147/articles/articlesDetail.php?Is-Alcoholics -Anonymous-Effective-100

[36i]. National Institute on Alcohol Abuse and Alcoholism, Economic Costs of Alcohol Abuse in the United States. (December, 2000). Retrieved on 2/3/2010 from http://pubs.niaaa.nih.gov/ publications/economic-2000/.

[37]. Executive Office of the President, Office of National Drug Control Policy, The Economic Costs of Drug Abuse in the United States 1992-2002. (December, 2004). Retrieved on 2/3/2010 from http://www.ncjrs.gov/ondcppubs/publications/pdf/economic_costs.pdf.

[38]. United States Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Office of Applied Studies, The ADDS Cost Study, Costs of Substance Abuse Treatment in the Specialty Sector. (2003). Retrieved on 2/2/2010 from http://www.oas.samhsa.gov/adss/ADSSCostStudy.pdf.



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