Alcohol and drug use burdens individuals and society the world over through its association with acute and chronic illnesses such as overdose, trauma, liver disease, and human immunodeficiency virus (HIV) infection, and its connection to social problems, such as family violence, homelessness, and poverty. Neuropsychiatric illnesses are the largest contributors to the global burden of disease, with substance use second only to depression as a specific causative factor.¹ The contribution of substance use to mortality and morbidity varies by country (for country-by-country statistics, see WHO interactive maps at ) and by state in the United States (http://nccd.cdc.gov/DPH_ARDI/default/default.aspx).

Stigmatization of people who use substances by society in general and the health-care system in particular compounds these burdens. An estimated 22.2 million US citizens suffer from alcohol and drug use disorders.² The annual economic cost of alcohol use disorders in the United States alone has been estimated at greater than $223.5 billion dollars.³ Although tobacco use is the leading cause of preventable death in the United States, the nature of addiction to alcohol and drugs reduces patients’ ability to function and reduces providers’ desire to provide care, making alcohol and drug use disorders a vulnerability in a way that smoking is not. Hence, this chapter focuses primarily on addictions other than smoking, although much of what is presented here can be used to address cigarette use as well (see Chapter 40). This chapter describes the individual and societal burdens of alcohol and drug use with a focus on substance use in the United States, and provides specific strategies to address substance use disorders and advocate for patients.

People often begin using alcohol or drugs because they believe it will make them feel better. Those who are physically dependent on alcohol or drugs use them to avoid withdrawal. Others with underlying disorders such as chronic pain, schizophrenia, and posttraumatic stress disorder may use substances to cope with the symptoms of these conditions.⁴ Clarifying the nature and consequences of use for each patient and then diagnosing substance use disorders will guide clinicians’ prevention and treatment efforts.

Limited use of alcohol is associated with health benefits such as decreased risk of heart disease. However, recommending alcohol for its potential health benefits is controversial because it is very difficult to determine whether the potential benefits exceed the concomitant risks. Studies, other than randomized controlled trials, which have not been done, are limited by issues of bias and confounding.

AT-RISK ALCOHOL USE

To distinguish between safer and hazardous or harmful alcohol use, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) has defined moderate drinking (i.e., safe) as two drinks or fewer (12 oz. of beer, 4 oz. of wine, or 1.5 oz. of liquor) per day for men younger than 65 years, and one drink or fewer per day for women and people older than 65 years. The NIAAA defines at-risk drinking as more than 14 drinks per week or 4 drinks on any one occasion for men, and more than 7 drinks per week or 3 drinks on any one occasion for women. Patients in the at-risk drinking category are at greater risk for all-cause mortality and have a greater risk for developing a use disorder.

There are no similar “at-risk” definitions for drug use, perhaps because of the wide number and types of illicit drugs and the many ways they are used and abused.

MEDICAL MARIJUANA

An increasing number of states are permitting the distribution and use of medical marijuana for the relief of symptoms from chronic conditions, such as anorexia, nausea, anxiety, and chronic pain. Washington and Colorado have fully legalized and regulated the sale of recreational marijuana. Use of medical marijuana typically requires approval by a physician that permits patients to either grow it themselves or obtain it from a state-regulated dispensary. Marijuana users and medical providers prescribing or sanctioning its use are operating in a space of legal limbo between the federal government and approving states, because marijuana remains classified at the federal level as a substance with no medical benefits. There is some evidence for the symptom-relieving benefits of marijuana, yet there are substantial concerns about the adverse effects of chronic marijuana exposure, particularly for the developing brains of adolescents and young adults.⁵ Specifically, regular marijuana use during adolescence has been associated with worse cognitive function and development of addiction to marijuana and other substances. Acute marijuana use impairs driving ability and increases the risk of vehicle crashes.

The American Psychiatric Association (APA) updated its diagnostic criteria and definitions for substance use disorders in 2013 (Box 39-1). This update integrated two previous disorders—substance abuse and substance dependence—into one disorder with three subclassifications of mild, moderate, and severe, based on the number of the 11 criteria that a person meets in a 12-month period.

For the year 2012, the National Survey on Drug Use and Health (NSDUH) estimated that 23.9 million people used illicit drugs and 125.5 million people drank alcohol in the previous month. Of the estimated 22.2 million Americans with a substance use disorder, 14.9 million have an alcohol disorder only, 4.5 million have a drug use disorder only, and 2.8 million have both alcohol and drug use disorder.² Only 2.5 million people receive specialty addiction treatment for substance use disorders. Surveys in primary care settings find rates of 2–29% for alcohol use disorders,⁶ 5–9% for current drug use disorders, and 20–25% for lifetime illicit drug use.⁷

Concomitant alcohol and drug disorders often go unnoticed in primary care and drug treatment programs, yet “polysubstance” users have greater physical and mental health problems and higher mortality than single substance users.^8,9

Substance use disorders exacerbate other vulnerabilities such as race and ethnicity, poverty, mental illness, and chronic disease. People who use alcohol or drugs are at significantly higher risk for death at a younger age than abstainers. These deaths result from accidental overdose, violence, and chronic diseases, and result in large numbers of years of life lost.^10,11

MEDICAL COMPLICATIONS

Medical complications of alcohol and drug use include both acute and chronic problems. Acute problems include overdose, seizures, psychosis, endocarditis, pulmonary edema, soft-tissue infections, osteomyelitis, hepatitis, pancreatitis, rhabdomyolysis, and sudden death. With chronic use, drug and alcohol addicts are at risk for chronic illnesses. Daily alcohol use of more than two drinks per day results in a twofold higher risk of hypertension; three- to fivefold higher likelihood of oral, esophageal, and liver cancer; and a ninefold higher risk of cirrhosis.¹² About half of all cirrhosis-related deaths are linked to alcohol.¹⁰ Cocaine is associated with accelerated atherosclerosis, dilated cardiomyopathy, and chronic pulmonary toxicity (including organizing pneumonia, interstitial pulmonary fibrosis, and bullous emphysema). Using injection drugs repeatedly such as heroin, cocaine, or methamphetamine is a major risk factor for HIV, and hepatitis B and C infections. Active alcohol and drug use also interferes with treatment of chronic diseases such as HIV infection.¹³

IMPACT ON THE FAMILY

The consequences of substance use extend from substance users to their families and neighbors. Non–drug using individuals living with drug users are 11 times more likely to be murdered than those not living with drug users (see Chapter 35).¹⁴ Estimates suggest that 60–75% of women who use substances suffer from partner violence, about three times the risk for women in general. The combination of sex, drugs, and violence brings increased risk for sexually transmitted infections and mental illnesses such as depression and posttraumatic stress disorder.¹⁵

Substance use disorders are family diseases both because of the profound burden they place on family function and because they are passed from one generation to the next through genetic and environmental means.^16,17 Children exposed to alcohol and drugs in utero risk problems such as fetal alcohol syndrome and low birth weight. In many families, alcohol use disorders, domestic violence, and child abuse are linked and lead to alcohol use disorders in offspring.¹⁸

IMPACT ON THE COMMUNITY

While the direct medical complications of substance use are tragic for users and their families, the burdens from trauma, violence, and crime affect entire communities.¹⁹ Because of several decades of “War on Drugs” policies, substance use is a fundamental thread woven into the blanket of crime in the United States. In metropolitan areas across the country, 63–83% of people arrested test positive for drugs.²⁰ In 2011, just under half of criminal sentences were for drug offenses.²¹ Yet fewer than 11% of the prison population receives drug treatment while incarcerated.²²

MENTAL ILLNESS

Links between substance use and mental illness abound (see Chapter 33). People who use substances are more than twice as likely to have a mental illness as people who do not use substances, and people with a mental illness are more than twice as likely to have substance use disorder. Teenage alcohol and drug use predicts both chronic substance use disorders and later development of adult mental illnesses.²³ One study among people who use drugs found that about half screen positive for depression.²⁴ People who use substances are more likely to commit suicide.²⁵ For example, the increased rates of suicide among American-Indian and Alaskan Native men are linked to increased rates of alcohol and drug use.¹²

Providers seem to derive little satisfaction from treating patients with substance use disorders,^26,27 and this is likely to result in poor care. For example, although validated tools are available to screen for alcohol use disorders, providers do not often use them. Furthermore, providers frequently avoid making referral to treatment even when they identify a substance use disorder.²⁸ Clinicians’ attitudes are not lost on substance using patients, who perceive that they receive poor access to care.²⁹ The alienation experienced by patients and providers can be explained by examining unrealistic expectations and mutual distrust.

HEALTH-CARE PROVIDERS’ EXPECTATIONS

Patients who use substances may not fit health-care providers’ expectations: they may be too intoxicated or substance dependent to have a clear presenting complaint; they may not permit testing or a thorough examination; a wide range of symptoms may reflect substance use and cloud diagnostic efforts; and they may refuse or be unable to follow treatment recommendations. In addition, providers may fear that patients will use prescribed pain relievers recreationally or sell them. Refusing to prescribe them, on the other hand, may lead to unnecessary suffering or even increased substance use. Finally, family or personal experiences with substance use may unconsciously influence the response to patients.

PATIENTS’ EXPECTATIONS

The patient who uses substances may have unrealistic expectations about clinicians (Box 39-2

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The Hidden Poor: Care of the Older Adult Advocacy Care of the Dying Patient Navigating Cross-Cultural Communication Intimate Partner Violence Trauma and Trauma-Informed Care

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