By Joseph A. Califano, Jr.
There was a time in our history—not so long ago—when smoking was cool, when seat belts were for sissies and when AIDS was seen as a death sentence for gay sex. Today our attitudes are profoundly different—with powerful and beneficial consequences. Smoking has been cut sharply, and so have the related deaths from lung cancer and heart disease. Auto safety measures have curbed the highway death and injury rate. AIDS is recognized as a serious illness rather than a social curse.
In all three cases, we fundamentally changed our attitudes and, as a result, took actions that greatly improved the quality of life for millions of people.
The time has come for a fundamental change in our attitude about the pervasive and pernicious role drug and alcohol abuse play in our society and a revolution in the way we deal with it.
Americans, comprising only 4 % of the world’s population, consume 2/3 of the world’s illegal drugs. The number of illegal drug users, which had dropped from a high of 25.4 million in 1979 to a quarter century low of 12 million in 1992, rose to 20.4 million in 2006. The number of teen illegal drug users, which had dropped from its 1979 high of 3.3 million to a low of 1.1 million in 1992, more than doubled to 2.5 million in 2006.
All the huffing and puffing in the current war on drugs has not been able to blow down the nation’s house of substance abuse and addiction:
- 61 million Americans are hooked on cigarettes
- 16 to 20 million are addicted to alcohol or abuse it regularly
- More than 15 million abuse prescription drugs
- 15 million smoke marijuana
- 2.4 million use cocaine; 600,000 use crack
- Hundreds of thousands are hooked on heroin
- More than 750,000 are methamphetamine users
- 1 million use ecstasy and hallucinogens
- Almost 2 million of our children have used steroids
- 4.5 million teens abuse controlled prescription drugs like OxyContin, Ritalin, and Adderall to get high
The human misery that addiction and abuse cause can’t be calculated. The consequences of this epidemic are severe.
Almost a quarter of a trillion dollars of the nation’s yearly health-care bill is attributable to substance abuse and addiction.
Alcohol and other drug abuse is involved in most violent and property crimes, with 80% of the nation’s adult inmates and juvenile arrestees either committing their offenses while high, stealing to buy drugs, violating alcohol or drug laws, having a history of substance abuse/addiction, or sharing some mix of these characteristics.
70% of abused and neglected children have alcohol or drug abusing parents.
90% of homeless are alcoholics or alcohol abusers; 60% abuse other drugs.
Half of the nation’s college students binge drink and/or abuse illegal and prescription drugs. Nearly a quarter of them meet the medical criteria for alcohol and drug abuse and addiction. Cruel courtesy of excessive drinking, each year—700,000 students are injured, 100,000 are raped or sexually assaulted, and 1,700 are killed by alcohol poisoning or alcohol related injuries.
Addiction and the Brain
Statistically we have known for some time that teens who abuse alcohol and smoke marijuana are likelier to use drugs like cocaine and heroin. Now biomedical research and the brain imaging work of Dr. Nora Volkow, Director of the National Institute on Drug Abuse (NIDA), help explain why teens who play with the fire of cigarettes, alcohol and marijuana increase the chance they will get burned by the flames of heroin, cocaine and hallucinogens. All of these substances cause an increase in dopamine levels in the brain. As dopamine levels increase, an individual’s feeling of pleasure increases. A growing body of science is finding that all these substances affect dopamine levels in the brain through similar pathways, and dopamine becomes less active in the brains of addicts who use drugs to trigger its release, a condition which in turn reinforces the need for the drug.
Studies by scientists in Italy reveal that marijuana affects levels of dopamine in the brain in a manner akin to heroin. Studies in the U.S. have found that nicotine and alcohol (as well as cocaine) have a similar effect on dopamine levels through common pathways to the brain. This may explain why some scientists believe that nicotine makes the brain more accommodating to other drugs.
In essence, whatever the substance, the brains of addicts are “rewired,” becoming predisposed to cravings. Dr. Joseph Frascella of NIDA points out that “in excessive behaviors such as compulsive drug abuse…the brain is changed, reward circuits are disrupted, and the behavior eventually becomes involuntary....”
These statistical and biological findings are underscored by the fact that most addicts are poly-drug abusers. Alcoholics are likely to abuse tranquilizers, sleeping pills, or other psychotropic drugs. Older teens who abuse prescription drugs are often found to be to be abusing other drugs as well. There are also social elements to the relationship among smoking, drinking and using illegal and prescription drugs, as well as to polydrug use, particularly among children and teens. Kids who seek the high from marijuana may also want to look for “better” highs from other drugs. As kids start using drugs, they may tend to hang out and share experiences with others who use different drugs. In a sense, these teens end up encouraging each other to use various drugs.
Of special importance is the need to recognize that for many teens, smoking, drinking, or drug use is often a symptom of incipient depression, anxiety or some other (usually undiagnosed) mental illness that hikes the youngster’s risk of drug abuse.
Mental health problems go hand in hand with smoking, drinking and drug use for children and adults, and these problems can lead individuals to self-medicate with a variety of substances. Our current approach to substance abuse does not adequately recognize this.
Mounting a Revolution
We must recognize that substance abuse and addiction is a disease, not a moral failing or easily abandoned self-indulgence. We must recognize that it is a complex disease with neurological, physical, emotional and spiritual components. We must recognize its impact on the most intractable domestic problems we confront. With such acceptance and recognition, we will appreciate the benefits of a revolution.
In the Health-care System—The National Institutes of Health spend $13 billion a year on research for cancer, strokes, cardiovascular and respiratory diseases and AIDS, but only 1/10 of that amount to study substance abuse and addiction—the largest single cause and excacerbator of this quintet of killers and cripplers. It is time for a revolution in health-care: the creation of the National Institute on Addiction, with a budget of at least $3 billion a year to conduct a “Manhattan Project”-style research initiative identifying the causes and cures of substance abuse and addiction.
Courses in substance abuse and addiction should be a compulsory part of medical school curriculums. Physicians should be trained to diagnose the disease and refer patients for treatment. States and medical societies should establish professional standards for treatment counselors and accreditation systems to certify treatment facilities. Public and private health plans should cover substance abuse treatment and pay doctors to talk to patients.
Only through professionalizing the treatment system will we be able to bring it fully into the medical care system, which, in turn, is key to obtaining parity of coverage.
In the Justice System—Our nation’s prison system is as anachronistic as the debtor prisons in Charles Dickens’ day. Prosecutors, courts and prisons must seize the opportunity to reclaim hundreds of thousands of addicts by using the criminal justice system to offer effective treatment for all who need it and incentives for them to achieve and maintain sobriety. Successfully treating and training inmates could deliver the greatest reduction in criminal activity in the nation’s history. Experts estimate that the number of crimes committed by a drug addict range from 89 to 191 annually.
In the Social Service System—Parental substance abuse accounts for $23 billion in the nation’s child welfare spending, and most domestic violence involves alcohol or other drugs. The time has come for a complete overhaul of family court, adoption and foster care systems in order to better deal with alcohol and drug abusing parents and partners. The only way we will rehabilitate our nation’s homeless population is by investing in substance abuse and mental health treatment.
In the Education System—Schools, from elementary through college, should include age appropriate education about all substance abuse involving tobacco, alcohol, prescription and illegal drugs as they do about other health matters from hygiene to STDs.
Prevention should be “laser beamed” on children. 16 years of research at CASAColumbia finds that a child who gets through age 21 without smoking, using illegal drugs, or abusing alcohol is virtually certain never to do so.
It is time to end the denial and stamp out the stigma associated with substance abuse and addiction, and to finally commit the energy and resources to confront a plague that has maimed and killed more Americans than all our wars, natural catastrophes and traffic accidents combined.
In his monumental study of history, the brilliant British historian Arnold Toynbee found that the great civilizations were destroyed not by an external enemy, but from within. “Civilizations,” he said, “die from suicide, not by murder.” Of all the internal dangers our nation faces, none possess a greater threat to our children and families and none is complicit in more domestic ills than substance abuse and addiction.
This is our enemy within.
The judgment of history will be harsh if we fail to defeat that enemy—and deservedly so, when the stakes are our children and there is so much we can do to help them.
Appeared in On the Brain, Fall 2008, Vol. 14, No.