Nor Is It A Bright Line

Nor Is It A Bright Line

Gene Gilchrist

Louisville, KY

Recently we wrote that the popular view of addiction in America is misinformed.  A well-intentioned media creates the false impression that addiction to alcohol and drugs is a problem isolated to the young, often minority individual living in poverty or, perhaps, living in homeless encampments.  Our discussion showed that while this image is often the “bottom” of the addiction curve, it portrays only a fraction of alcohol and drug use, abuse and addiction in America.  So what does substance use, abuse and addiction look like?  We suggest that rather than a bright line between “normal” drinking and drug use on the one hand, and the individuals who have “hit bottom” on the other, drug use, abuse and addiction in America occurs over a continuum. There isn’t a bright line; it isn’t that simple. 

The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that there were 40 million Americans suffering substance use disorder (SUD) from alcohol or drugs in 2020[1].  SUD describes behaviors including abuse and addiction.  The Department of Housing and Urban Development (HUD) reports that there were 580,466 homeless Americans (yes, that seems low to us too)[2].  HUD estimates that 38% of the homeless suffer from alcohol abuse and 26% abuse drugs.  Given these estimates, 371,498 people are those depicted in the general image of addiction – less than 1% of SUD in America.

We can assume that people who do not drink or use narcotics are not those with active substance use disorder (allowing there are some abstaining in recovery). The Centers for Disease Control estimates that 33% of adults in America do not use alcohol[3].  The CDC reports that 80.6% of Americans do not use schedule I or “street drugs” or abuse prescription drugs[4]. This leaves us with 220 million Americans who use alcohol and 60 million who use drugs (including marijuana).  Our point is that among these are those who drink to excess, use and abuse drugs, and have problems stemming from those behaviors on an occasional and on a regular basis.  They are not homeless, but they have problems in their lives related to their alcohol and drug use.*

The Centers for Disease Control (CDC) defines binge drinking as the consumption of 5 or more drinks in a two hour period for men and 4 in a two hour period for women.  The CDC reports that 1 in 6 American adults binge drinks and does so 4 times a month; approximately 43 million Americans[5].  Heavy drinking is defined as 15 drinks per week for men and 8 for women. 5.1% of Americans heavy drink once per month totaling 13.4 million Americans[6].

The issue of schedule 1 and 2 narcotics is somewhat more complex.  Except for the evolving issue with marijuana, and the use of schedule 2 narcotics “as prescribed”, all of these drugs are sold and used illegally.  There is also the relatively unresearched issue of a “safe” use of these drugs.  Noting these issues, the CDC estimates that Americans used drugs in these proportions in the past year[7]:

·        Marijuana                           15.9%

·        Heroin                                   3.0%

·        Methamphetamines             .7%

·        Cocaine                                 2.0%

Americans also abuse prescription drugs in these proportions according to the CDC:

·        Opioids                               3.7%

·        Tranquilizers                      2.1%

·        Benzodiazepines               2.0%

·        Stimulants                          1.9%

·        Sedatives                              .4%

The 21.6% of all Americans who use schedule 1 narcotics and the 10.1% who abuse schedule 2 narcotics totaling 100.6 million Americans (this is certainly overstated due to duplication of usage between schedule 1 and schedule 2 narcotics) adults are all candidates for substance use disorder and strictly speaking meet the definition since they are consuming illegals drugs or abusing prescription drugs.   The evolving policy of marijuana clouds this discussion.

For our purposes, and to be conservative, let us assume that there are more than 100 million American adults who binge drink, heavy drink, use schedule I narcotics and/or abuse schedule 2 narcotics – at least 30% of Americans.  Certainly, these Americans are not all suffering from substance use disorder.  Our point is that there are among them those who on occasion or regularly abuse alcohol and/or drugs.  Of these, the NIH estimates that there are 40 million people with a substance use disorder[8].  A small fraction of these numbers (<1% as noted above) fit the common, public vision. Our point is that harmful behaviors occur across the spectrum of more than 100 million American adults exhibiting the alcohol and drug use noted in this article.  Among those Americans their behavior costs America through:

 Self-Harm

Suicides totaled 44,834 in 2020 in the U.S. and ranked 10th among the causes of death reported by the CDC[9].  The CDC estimates that 60% of these deaths are attributable to alcohol and/or drug abuse[10]

 Crime

Alcohol is a large contributor to crime.  According to the Alcohol Rehab Guide, alcohol was involved in 15% of robberies, 37% of sexual assault, 27% of aggravated assault, and 40% of homicides. The relationship of drugs and crime is more complex given the issues created by the “war on drugs” that has made criminals of people with addiction.  However, 18% of incarcerated inmates reported that their violent crime was committed while using illegal drugs[11]

Driving Under the Influence

The CDC data includes 111,000,000 self-reported incidents of driving while impaired annually.  Car crashes in the U.S. where drugs other than alcohol are involved totaled 16% and marijuana is the largest contributor at 13%.  Individuals under the influence of marijuana are 25% more likely to be involved in car crashes[12]

Domestic Abuse

The NIH reports that 30-40% of domestic violence perpetrators were alcohol abusers, and NOVA Treatment Center estimates that 40-60% of domestic violence is committed under the influence of drugs[13] [14]

Workplace Absenteeism, Tardiness, Turnover and Accidents

NIH estimates that absenteeism due to alcohol and drug use alone costs business $225.8 billion annually. [15].

In recovery circles it is often said that a problem drinker/drug user is anyone who had a problem while drinking/using drugs.  We are not that strict.  Further, we are not H.L. Mencken’s puritan who has "the haunting fear that someone, somewhere, may be happy."  We do intend to say that the stereotype of an addict or alcoholic as destitute, homeless is misinformed and there is far more harm being done regularly and on occasion by Americans using and abusing alcohol and drugs.  Binge drinking, heavy drinking, driving under the influence, domestic abuse, self-harm, crime, and business costs are all serious problems caused in great part by alcohol and drug abuse that may not qualify as addiction.

It is time for us to abandon the thought that problem-drinking and drug use is only that among the homeless persons.  It is time for us to abandon a model that relegates treatment only to those who have “hit bottom”.  Without becoming Menken’s puritans, we need to recognize the ill effects of abusive alcohol and drug use and address those behaviors earlier in the cycle of abuse and addiction where it occurs.

On a personal level, whether you are worried for yourself or a loved one, it is important to stop thinking that it cannot be you/your loved one because “it is not that bad”.  Homelessness, incarceration, accidents, ill health, premature death are things that can and often do happen along the way to people who abuse alcohol and drugs but still have homes, jobs, families and do not live under the highway.

Gene Gilchrist

[1] See Substance Abuse and Mental Health Services Administration; “2020 National Survey on Drug Use and Health”

[2] See Department of Housing and Urban Development; “2020 Annual Homeless Assessment Report to Congress”

[3] Centers for Disease Control, National Center for Health Statistics, “Heavy Drinking Among U.S. Adults, 2018”, Peter Boersma, M.P.H., Maria A. Villarroel, Ph.D., and Anjel Vahratian, Ph.D., M.P.H.

[4] See Centers for Disease Control, “Annual Surveillance Report Drug-related Risks and Outcomes, 2019”

[5] See Center for Disease Control, “National Center for Chronic Disease Prevention and Health Promotion”, 11/21

*We will have more to say about non-problematic or “normal” use in a later article

[6] See Centers for Disease Control, “Alcohol Use and Your Health”, 12/21

 [7] Ibid footnote 4

[8] Ibid footnote 1

[9] See Centers for Disease Control, “National Vital Statistics Report” July 2021 by Jiaquan Xu, M.D., Sherry L. Murphy, B.S., Kenneth D. Kochanek, M.A., and Elizabeth Arias, Ph.D., Division of Vital Statistics

[10] See Substance Abuse and Mental Health Services Administration, “SUBSTANCE USE AND SUICIDE: A NEXUS REQUIRING A PUBLIC HEALTH APPROACH,” 2016

[11] See Alcohol Rehab Guide, “Alcohol Related Crimes”,  Carol Galbicsek, 2021 

[12] See Centers for Disease Control, “Impaired Driving: Get the Facts,” 2021

[13] See National Institutes for Health, “Alcohol-Related Intimate Partner Violence Among White, Black, and Hispanic Couples in the United States,” Raul Caetano, M.D., Ph.D.; John Schafer, Ph.D.; and Carol B. Cunradi, M.P.H., Ph.D.

[14] See NOVA Treatment Center, “Substance Abuse and Domestic Violence: A Toxic Duo, 2019

[15] See National Institutes for Health, “Alcohol consumption and workplace absenteeism: The moderating effect of social support”,  Samuel B. Bacharach, Peter Bamberger, and Michal Biron, 2010