On November 17, 2016, the Office of the Surgeon General released Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health.1 This is the first surgeon general’s report to focus on substance misuse, substance use disorders, and related harms, and it places substance abuse disorders in a public health framework rather than in a criminal justice framework. The report is a response to one of the most pressing public health issues in the United States.
Alcohol and drug misuse and related disorders exact an enormous toll on individuals, families, and communities. These disorders cause significant individual and public health consequences including more than 88 000 deaths related to alcohol misuse and more than 47 000 deaths due to drug overdoses each year.2,3 Misuse of alcohol and other drugs also contributes to crime and violence, abuse and neglect of children, lost productivity, and increased costs to the health care system.
Nearly 21 million people in the United States have a substance use disorder, comparable with the number of people diagnosed with diabetes and 1.5 times the prevalence of all cancers combined.4,5 This does not include the millions of people without a formal disorder who are engaged in substance misuse and who are therefore at greater risk of harm to themselves and others and the subsequent development of a substance use disorder. For example, one of the most common forms of misuse, binge drinking occurring during the previous month, was reported by more than 66 million people in the United States in 2015.6 Substance misuse and related disorders cost the United States more than $442 billion each year in health care, criminal justice, and lost productivity.1 Yet despite the scale of the problem, these health conditions receive disproportionately less research investment, coverage in clinical training, and public attention than do other chronic illnesses.
As daunting as these numbers may be, this is also a time of great opportunity. Reform efforts in the health care and criminal justice systems and advances in research are leading the way for increased access to effective prevention, treatment, and recovery services. The Surgeon General’s report seeks to mobilize families, policy makers, educators, law enforcement professionals, public health and social services agencies, and the health care system to make the most of these new opportunities to reduce the public health consequences associated with alcohol and drug use. The report builds the foundation for these approaches by establishing the neurobiological basis for substance use disorders; assembling the evidence base for prevention, treatment, and recovery services; and calling attention to policy and systems-level change that will enhance access to these services.
The neurobiological basis for substance use disorders has been established by a growing body of research that concludes addiction is a chronic disease of the brain and not simply a choice or personal failing as it has been viewed by many.7 New evidence suggests that substance use disorders result from changes in the brain that occur with repeated use of alcohol or drugs. The most severe expression of the disorder, addiction, is associated with changes in the basal ganglia, extended amygdala, and prefrontal cortex, which collectively affect pleasure (the reward system), learning, stress, decision making, and self-control. These changes help explain why individuals with addiction are unable to stop using drugs despite the negative effects on their health and well-being and why the risk of relapse persists for so long after discontinuation of drug use.
The report draws attention to the existence of highly effective community-based prevention programs and policies, and it calls for them to be widely implemented. Many of these programs are directed at reducing risk and enhancing protective factors. For example, preventing or even simply delaying young people from trying substances is important in reducing the likelihood of a substance use disorder later in life. Individuals who use alcohol before the age of 15 years are 4 times more likely to develop an alcohol use disorder later in life than those who have their first drink at age 21 years or older.8 Additionally, cultivating strong family ties, social connection, and emotional resilience reduce the risk of developing a substance use disorder. Prevention works. However, there is a need for more resources and infrastructure to ensure that evidence-based prevention interventions can be implemented with fidelity, sustainably, and at sufficient scale to reduce substance misuse and related disorders.
The report also recommends expanding access to treatment, in part through greater investment in services, training more clinicians to recognize and treat substance use disorders, and integration of treatment into the traditional medical care system. As with other chronic, relapsing medical conditions, evidence-based treatment can manage the symptoms of substance use disorders and prevent relapse. Rates of relapse following treatment for substance use disorders are comparable with those of other chronic illnesses such as diabetes, asthma, and hypertension. Recovery support programs offer a critical opportunity for people with substance use disorders and their loved ones to obtain the assistance they need to gradually return to a healthful and productive life away from the harmful effects of substance use. Recovery has many pathways that should be tailored to fit the unique cultural values and psychological and behavioral health needs of each individual. The challenge is that not enough people access the services they need. For example, only 1 in 10 people with a substance use disorder currently receives treatment.6
Noting recent developments in health policy, the report urges coordination and implementation of health reform and parity laws to ensure increased access to high-quality services for people with substance use disorders. The Affordable Care Act expanded insurance coverage to millions and has made services for substance use disorders an essential health benefit. Additionally, the Mental Health Parity and Addiction Equity Act of 2008 mandates that payers treat substance use disorders the same way they treat other medical conditions. Continued effort to implement and enforce these laws has the potential to improve health outcomes, reduce health disparities, and reduce health care costs for individuals, families, communities, and health care systems.
The report also recognizes that future research is essential to guide a public health approach to substance misuse and related disorders. A large body of research has already helped clarify the biological, psychological, and social underpinnings of substance use disorders and described effective prevention, treatment, and recovery support services. Continuing to expand understanding in these areas is essential.
Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health offers a way forward using a public health approach that is firmly grounded in the best available science, and is accompanied by a community-wide call to action to end the public health crisis of addiction. Families can talk to their children about alcohol and drugs and advocate for changes needed in their communities. Educators can implement evidence-based prevention programs in schools and colleges. Clinicians can screen patients for substance misuse and related disorders and connect them to treatment. Health care systems can integrate the treatment of substance use disorders with traditional medical services while also enhancing training of health care professionals. Each person has an important role in changing attitudes toward addiction and in ensuring that practices, programs, and policies are aligned to support the health of those affected by substance misuse and related disorders.
Addiction has been a challenge communities have faced long before the advent of modern medicine. But the opportunity and the tools to begin to address alcohol and drug use disorders are now available. Doing so can transform lives, rebuild families, and strengthen communities. Given the scale and cost of the epidemic, there could not be a more important time for action.