Fall 1980

1. Nature and Extent of the Problem

A major objective of the drug and alcohol prevention policy is to reduce the adverse social and health consequences associated with the misuse of these substances, especially among adolescents, young adults, pregnant women and the elderly.

Alcohol and other drug problems have pervasive effects: biological, psychological and social consequences for the abuser; psychological and social effects on family members and others; increased risk of injury and death to self, family members and others (especially by accidents, fires or violence); and derivative social and economic consequences for society at large. Destructive drug and alcohol use shares many similarities with tobacco use and may respond to some of the same prevention strategies (see Smoking and Health).

Per capita alcohol consumption and use of other drugs for non-medical purposes decreases with older age groups, but the use of drugs for medical purposes, both over-the-counter and prescription drugs, increases. Since the aging process is accompanied by physiologic changes that after the body's response to both food and drugs, practices of self-medication, over-prescribing and the concurrent use of two or more drugs can create serious health problems for the elderly. Concurrent misuse of alcohol and drugs consumed for either non-medical or medical purposes increases risks to health and complicates the delivery and financing of preventive and treatment measures from both private and public sources.

*NOTE: For purposes of this report, the term "use of other drugs" refers to self-reported use of licit or illicit drugs for non-medical or self-defined purposes. It does not include inappropriate use of drugs consumed for medical purposes, nor the use of alcohol or tobacco. These are discussed separately.

2 Health implications

ALCOHOL

• In 1975, an estimated 36,000 deaths from cirrhosis, alcoholism or alcoholic psychosis could be directly attributed to alcohol use.

• In 1975, an additional 51,000 fatalities could be indirectly attributed to alcohol use.

• Alcohol has been identified as a risk factor for cancers of the oral cavity, esophagus and liver. • In 1977, about 45 percent of all motor vehicle fatalities involved drivers with blood alcohol

levels of .10 percent or more, a rate of 11.5 per 100,000 population.

In 1975, the costs of alcohol problems were estimated to be $43 billion in lost production, health and medical services, accidents, crime and other social consequences.

The Fetal Alcohol Syndrome is estimated to cause some 1,400 to 2,000 birth defects annually.

OTHER DRUGS

The vast majority of users of "other drugs" are marijuana users, but the category is not limited to this group.

The social cost of drug abuse, including law enforcement, has been estimated to be at least $10 billion per year, a figure which may be an underestimate considering the difficulties of measuring the aggregate health and social consequences of those behaviors.

• Between May 1976 and April 1977, there were an estimated 7,000 to 8,000 deaths and an estimated 275,000 to 300,000 medical emergencies related to misuse of drugs.

• An undetermined portion of deaths and medical emergencies relate to drug use for suicide and attempted suicide (see Control of Stress and Violent Behavior) and may be very difficult to prevent.

• Barbiturates were the class of drugs mentioned most frequently by medical examiners in connection with drug-related deaths reported to the Drug Abuse Warning Network between May 1977 and April 1978 (2 percent of drugs mentioned).

• Tranquilizers were the class of drugs mentioned most frequently by emergency rooms during the same period (24 percent of drugs mentioned). The proportion of barbiturate and tranquilizer misuse that is deliberate and the proportion that is accidental is not known.

DRUGS USED FOR MEDICAL PURPOSES • Use of high estrogen content oral contraceptives by women smokers increases risks of coronary and cerebrovascular disease.

counting for 30 percent of all medicines consumed.

• The risk of adverse drug reactions in elderly patients is almost twice that in patients between 30 and 40 years of age.

• Between 70 and 80 percent of reactions are predictable and preventable.

• Between 0.3 and 1.0 percent of the nation's total 35.5 million hospital admissions each year are due to adverse drug reactions.

• Improper use of drugs forces curtailment of normal activities, or contributes to such curtailment, in an unknown proportion of the disabled population.

b. Status and trends

ALCOHOL

• An estimated 10 percent of the adult population 18 years and over are frequent heavy drinkers (5 or more drinks per occasion at least once per week).

• Most problems indirectly attributable to alcohol (homicides, car crashes) have the highest rates among young adult males ages 18 to 24 years. • National surveys indicate no changes in peak quantity consumed by teenagers 12 to 17 (five or more beers at a time) or in regularity of their drinking, between 1974 and 1978. • Alcoholism mortality rates (2 per 100,000) and alcoholic psychosis rates (1 per 100,000) show little overall increase between 1950 and 1975. • Based on survey reports and tax-paid withdrawals, per capita consumption of absolute alcohol did not change significantly during the years 1971 to 1976. More recent data indicate that per capital consumption began to increase again after 1976, from 2.7 gallons to 2.82 gallons of absolute alcohol per capita in 1978. Whether the increase will continue is not yet known.

OTHER DRUGS

• A dramatic decline in level of heroin-related medical problem indicators was seen from 1976 to 1977, suggesting a decline in heroin use. The proportion of adolescents (12 to 17 years old) reporting current use of marijuana has been rising continuously for the last decade and has increased significantly from 6 percent in 1971 to 16 percent in 1977.

• The proportion of young adults (18 to 25 years old) reporting that they had ever used marijuana rose from 39 percent in 1971 to 60 percent in 1977.

It has been estimated that there are approximately 2,500,000 persons (roughly 2 percent of the population age 18 and over) having serious drug problems.

• Epidemiological evidence suggests that the use of alcohol, tobacco and marijuana by adolescents is associated.

DRUGS USED FOR MEDICAL PURPOSES
• Barbiturate-related mortality accounted for less
than 1,300 deaths in 1976.

.2. Prevention/Promotion Measures
a. Potential measures

• Education and information measures include: general public information campaigns, and programs targeted to children and youth and to specific at-risk populations, with specific messages to facilitate problem recognition or reinforce desired behavior;

programs targeted at a wide array of service professions concerning the recognition of, and responses to, alcohol and other drug problems;

information on medicine labels on drug/ drug, drug/food and drug/alcohol interactions, with practical guidance on avoiding clinically significant interactions;

school and community-based health education programs, some using peer leaders and models;

special education programs emphasizing effective risk-management skills and alternatives to drug and alcohol use;

education of physicians, nursing home staff and patients about hazards surrounding the misuse of tranquilizers, hypnotics and other classes of prescription and nonprescription drugs;

· easily understandable information available to patients taking drugs for medical purposes.

• Service measures include:

-

programs which offer general social support (youth centers, recreation programs) and thereby provide alternatives to drug and alcohol use;

outreach and early intervention services at the worksite and in community settings for persons whose behavior indicates that they are at-risk for the development of alcohol or other drug problems;

anticipatory guidance, identification of children at high risk of alcoholism;

- a broad range of treatment services in employee assistance programs, in general health care delivery settings and in specialized alcohol and drug facilities; counseling by pharmacists to older people taking drugs for medical purposes; maintenance of computerized drug profiles; hotlines and drug information centers people can use to learn about drug effects and interactions.

• Technologic measures include:

- product safety changes which reduce the risk of injury and death in places associated with use of alcohol and other drugs (e.g., airbags

in motor vehicles and improved fireproofing in residences);

modification to alcoholic beverages themselves (e.g., reduction of alcohol content, reduction or elimination of nitrosamines); efforts by community institutions to modify social settings and contexts to reduce the risk associated with intoxication and to alter social reaction to some types of drinking or drug-using behavior.

• Legislative and regulatory measures include:

regulating the conditions of availability of alcoholic beverages (i.e., zoning regulations regarding hours of sale, numbers of outlets and numbers of licenses);

enforcing minimum drinking age laws and employing legal disincentives to discourage the dispensing of alcohol to obviously intoxicated persons;

enforcing laws prohibiting driving while intoxicated by alcohol or drugs and initiating stronger legal disincentives;

controlling advertising of alcoholic beverages;

enforcing laws related to production, distribution and use of "other drugs" that are proscribed except for medical and scientific purposes; special law enforcement agencies are responsible for enforcing such prohibitions and violations are punishable by criminal sanctions;

regulation of conditions under which these substances are available for authorized uses, such as measures relating to scheduling of "controlled substances' and limitations on prescriptions;

periodic re-examination of sanctions to ensure correspondence to the degree of severity of the health and social problems associated with the overuse of each particular substance or drug;

patient labeling for certain prescription drugs (estrogens, progestins);

drug information for patients in nursing homes and in other long-term care facilities.

• Economic measures include:

excise taxes on alcoholic beverages and other means of affecting the price of alcohol; -tax incentives or disincentives to control levels of advertising expenditures for alcoholic beverages.

b. Relative strength of the measures

• Systematic evaluation of the effects of education and yearly intervention programs targeted at children and youth and populations at special risk is at an early stage.

• Regulatory measures have been the Nation's primary tool of drug abuse prevention during most of the 20th century. There is much debate

about the overall cost-benefit assessment of the
current prohibitions. From a more limited per-
spective, however, some recent trends tend to
support claims that regulatory approaches have
had an impact on the extent of drug use.

• Heroin addiction in this country has been de-
clining in recent years, coincident with reduced
supplies on the illegal market and the extensive
availability of treatment services. Late in 1979,
however, the supply and incidence of heroin use
increased in several Eastern cities. Also, bar-
biturate-related mortality has been declining
steadily as a result of increased legal controls,
greater physician awareness of the most effica-
cious uses of these drugs, and improved public
awareness of the hazards associated with the
use of barbiturates in combination with other
depressants.

• Mass media campaigns that have focused public . attention upon alcohol use and abuse may have contributed to a period of relative stability in alcohol consumption during the seventies (although economic conditions were also a likely significant factor). Alcohol problems, as noted by several indicators (cirrhosis mortality rate decline, survey data on alcohol consumption among youth and adults), appear also to have leveled off during this period of apparent stability. While direct causal attribution is not possible, the creation of a National alcoholism treatment network and early intervention services in the workplace probably played a role in the stabilization of cirrhosis deaths.

• Alcoholic beverage regulation has not traditionally been focused on public health considerations, but data concerning the impact of regulatory initiatives on tobacco smoking may be transferable to the alcohol area. Research here and in other countries suggests that the availability of alcohol may affect the level and type of alcohol problems, particularly physical health problems consequent to long-term excessive drinking. Consumption, in turn, has been linked fairly conclusively to the relative price of alcohol, and less conclusively to such factors as the legal purchase age, number and dispersion of retail on-premise and off-premise outlets, and hours of sale. Also "Dram Shop" laws can offer powerful incentives for alcoholic beverage licensees to try to reduce the likelihood of intoxication among their patrons.

• In general, alcohol and drug education programs can increase information levels and modify attitudes. Their effect on drinking or drug-using behavior has not yet been demonstrated conclusively, although recent studies have yielded encouraging preliminary findings.

3. Specific Objectives for 1990

counting for 30 percent of all medicines con'sumed.

The risk of adverse drug reactions in elderly patients is almost twice that in patients between 30 and 40 years of age.

• Between 70 and 80 percent of reactions are predictable and preventable.

• Between 0.3 and 1.0 percent of the nation's total 35.5 million hospital admissions each year are due to adverse drug reactions.

Improper use of drugs forces curtailment of normal activities, or contributes to such curtailment, in an unknown proportion of the disabled population.

b. Status and trends

ALCOHOL

• An estimated 10 percent of the adult population 18 years and over are frequent heavy drinkers (5 or more drinks per occasion at least once per week).

• Most problems indirectly attributable to alcohol (homicides, car crashes) have the highest rates among young adult males ages 18 to 24 years. • National surveys indicate no changes in peak quantity consumed by teenagers 12 to 17 (five or more beers at a time) or in regularity of their drinking, between 1974 and 1978. • Alcoholism mortality rates (2 per 100,000) and alcoholic psychosis rates (1 per 100,000) show little overall increase between 1950 and 1975. • Based on survey reports and tax-paid withdrawals, per capita consumption of absolute alcohol did not change significantly during the years 1971 to 1976. More recent data indicate that per capital consumption began to increase again after 1976, from 2.7 gallons to 2.82 gallons of absolute alcohol per capita in 1978. Whether the increase will continue is not yet known.

OTHER DRUGS

A dramatic decline in level of heroin-related medical problem indicators was seen from 1976 to 1977, suggesting a decline in heroin use. The proportion of adolescents (12 to 17 years old) reporting current use of marijuana has been rising continuously for the last decade and has increased significantly from 6 percent in 1971 to 16 percent in 1977.

• The proportion of young adults (18 to 25 years old) reporting that they had ever used marijuana rose from 39 percent in 1971 to 60 percent in 1977.

It has been estimated that there are approximately 2,500,000 persons (roughly 2 percent of the population age 18 and over) having serious drug problems.

• Epidemiological evidence suggests that the use of alcohol, tobacco and marijuana by adolescents is associated.

DRUGS USED FOR MEDICAL PURPOSES
• Barbiturate-related mortality accounted for less
than 1,300 deaths in 1976.

2. Prevention/Promotion Measures
a. Potential measures

• Education and information measures include: general public information campaigns, and programs targeted to children and youth and to specific at-risk populations, with specific messages to facilitate problem recognition or reinforce desired behavior;

-

programs targeted at a wide array of service professions concerning the recognition of, and responses to, alcohol and other drug problems;

information on medicine labels on drug/ drug, drug/food and drug/alcohol interactions, with practical guidance on avoiding clinically significant interactions;

school and community-based health education programs, some using peer leaders and models;

special education programs emphasizing effective risk-management skills and alternatives to drug and alcohol use;

education of physicians, nursing home staff and patients about hazards surrounding the misuse of tranquilizers, hypnotics and other classes of prescription and nonprescription drugs;

easily understandable information available to patients taking drugs for medical purposes.

• Service measures include:

-

-

programs which offer general social support (youth centers, recreation programs) and thereby provide alternatives to drug and alcohol use;

outreach and early intervention services at the worksite and in community settings for persons whose behavior indicates that they are at-risk for the development of alcohol or other drug problems;

anticipatory guidance, identification of children at high risk of alcoholism;

- a broad range of treatment services in employee assistance programs, in general health care delivery settings and in specialized alcohol and drug facilities; counseling by pharmacists to older people taking drugs for medical purposes; maintenance of computerized drug profiles; hotlines and drug information centers people can use to learn about drug effects and interactions.

• Technologic measures include:

-

- product safety changes which reduce the risk of injury and death in places associated with use of alcohol and other drugs (e.g., airbags