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The huge toll that substance use and misuse is having on individuals, families, and communities in the USA has culminated in a major public health crisis that shows few signs of abating. Last week, the US Surgeon General released Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health—the Surgeon General's first-ever statement on this topic. This 426-page report addresses the problem of substance use and the wide range of adverse health effects from alcohol and both legal and illegal drugs. It brings together evidence on prevention; treatment; and recovery interventions, policies, and programmes.
There are some alarming statistics. 20·8 million people in the USA have a substance use disorder, equivalent to the number of Americans with diabetes. In 2014, there were 47 055 drug overdose deaths, 28 647 of which involved prescription opioid drugs and heroin. Of the one in seven Americans (14·6% of the population) expected to develop a substance use disorder during their lives, only one in ten will receive treatment. More than 66·7 million people reported binge drinking in the past month. Alcohol misuse contributes to 88 000 deaths in the USA each year. These numbers do not include the millions of people misusing substances who will later develop a substance disorder.
The Surgeon General, Vivek Murthy, emphasises that addiction is a chronic neurological disorder that should be treated like other chronic illnesses. He calls for a cultural shift—from perceiving addiction as a “moral failing” to removing the stigma and shame that prevents addicted people from seeking help. The review of the science of substance abuse is thorough, and the argument for an evidenced-based and equitable public health approach to reducing the harms of both alcohol and drugs is a welcome advance. The report defends harm reduction and policies that reduce the imprisonment of drug users. It also advocates screening and early intervention in primary care and the integration of alcohol and drug use treatment into mainstream medical care. Endorsement of these effective approaches is a radical departure from the preceding US drug policy.
The challenge will be in implementing the report's recommendations. The call for more investment in scientific research should be heeded, but this report could have been more specific about what should be done over the next 5 years in expanding treatment capacity, for example. The report does not go far enough in acknowledging the major harms of past US drug policies of zero tolerance—namely, racial and ethnic discrimination in enforcement, leading to the mass incarceration of Black and Latino men, to the detriment of minority families and communities. The report does not even acknowledge that race has been at the centre of the war of the drugs. Nor does it see drug policy reform as an essential step in reducing the harms of substance use.
Despite the acknowledged severity of the US opioid problem, the report provides few details on how best to address it. It is a pity the report emphasises “brain disease” explanations at the expense of the socioeconomic factors that underlie addiction. For example, the chances of becoming addicted to opioid drugs increases if an individual is young, unemployed, or has co-occurring psychiatric disorders. This situation makes it critically important to have social policies that ensure people have job opportunities and affordable access to effective mental health services, rather than exclusively focusing on eliminating drugs from society.
It is unclear if Murthy's report will have the same impact as the 1964 landmark tobacco report from the Surgeon General, which galvanised several decades of work on the dangers of smoking and helped bring smoking rates down substantially. We already knew that substance use is a public health problem in the US. That fact still needed to be shown conclusively for tobacco in 1964. Also tobacco has been easier to address as a single legal substance that was culturally acceptable in the 1960s, unlike a mix of licit and illicit substances that are not all culturally acceptable. Clearly, different approaches will be required to gain traction. There is also a real danger that the incoming administration will oppose the approaches set out in this report, and return to the failed drug policies of the past. This would be disastrous given the evidence presented here. America's leaders must take a bipartisan stance on this issue. It would be a moral and political failure to allow the premature loss of lives from substance use to continue.
U.S. Surgeon General Vivek H. Murthy on Facing Addiction in America
By Dr. Vivek H. Murthy
When I became a doctor, I expected that most of my time would be spent seeing patients with chronic conditions like heart disease, diabetes, and cancer. When I became Surgeon General, I was eager to engage our nation in discussions about how to prevent those diseases and how to make sure everyone has a fair shot at living a healthy and productive life./.../