Health care challenges created by substance abuse: the whole is definitely bigger than the sum of its parts.

THE ENORMITY OF THE CHALLENGE What do a six-week-old infant, her 19-year-old mother, an 83-year-old nursing home resident, a 47-year-old landscape designer, and a high school sophomore have in common? The thread that ties-or the rope that binds--is frequently the pervasive challenge of substance misuse. As anyone working in the field of health care and social work can attest, mind-altering substances are so much a part of daily life that few individuals remain untouched by their influence; and few social workers can remain isolated from their daunting challenges (Abbott, 2000). Substance abuse creates a major drain on our personal, social, economic, and professional resources. The burdens on the health care delivery system, to say nothing of the social services system, are immense. In 2001 Alan Leshner, then-Director of the National Institute on Drug Abuse (NIDA), deemed substance abuse as the "most destructive health and social problem facing our Nation today" (Leshner, 2001b, p. 3). According to former Secretary of Health and Human Services, Donna Shalala, in the preface to the Tenth Special Report to the U.S. Congress on Alcohol and Health, "alcohol problems, both those of individuals and those that affect society at large, continue to impose a staggering burden on our Nation. Domestic violence, child abuse, fires and other accidents, falls, rape, and other crimes such as robbery and assault, all are linked to alcohol misuse" (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2000, p. ix). Estimates presented by Kirschstein in the Tenth Special Report indicate that more than 100,000 lives are lost each year because of alcohol misuse. Nearly $184.6 billion, or about $638 for every man, woman, and child in the United States, is spent annually because of alcohol misuse (NIAAA, 2000). Alcohol is third only to tobacco and unhealthy diet or exercise patterns as the leading cause of death in the United States (NIAAA Strategic Plan, 2001-2005, available at ). Startl ing statistics support the reported concerns: 14 million Americans or 7.4 percent of the population meet the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, American Psychiatric Association, 2000) criteria for alcohol abuse or alcoholism; in almost one of four instances of violent crime, the offender had been drinking before committing the crime; in 1997, traffic accidents involving alcohol resulted in more than 16,000 individual deaths (NIAAA, 2000). The data are equally staggering for drug abuse. Data from the National Household Survey on Drug Abuse, an annual survey funded by the Substance Abuse and Mental Health Service Administration (SAMHSA, 1999), indicated that nearly 15 million Americans reported using illicit drugs at least once in the month before being surveyed; 3.5 million of them were identified as being dependent on illicit drugs. Alarmingly, these figures did not include misuse or dependence on prescription or legal drugs. A recent study combining the economic cost of drug and alcohol abuse estimated that the combined costs were almost $250 billion or nearly $1,000 for every man, woman, and child in the United States. The study estimated that 60 percent was spent on alcohol-related activities, with the remaining 40 percent used on other drug abuse activities. These figures include the full spectrum of costs: health care, motor vehicles accidents, lost productivity, and property damage. It was estimated that only 12.7 percent of the total was spent of alcohol-related health care costs and only 10.2 percent on health care costs related to other drugs (National Institutes of Health, 1998). The Community Epidemiology Work Group (CEWG) of NIDA, which has monitored drug use patterns for more than 25 years, bases its annual reports on a number of indicators, including the National Household Survey on Drug Abuse mentioned earlier, the Drug Abuse Warning Network (based on emergency room statistics), Uniform Crime Reports by the Federal Bureau of Investigation, and data from the National Institute of Justice and the Drug Enforcement Administration (Hatem, 2001). …