U.S. Department of Health & Human Services

The Surgeon General’s Report on 

Alcohol, Drugs, and Health

FACING ADDICTION

IN AMERICA

FACING ADDICTION

IN AMERICA

The Surgeon General’s Report on 

Alcohol, Drugs, and Health

2016

U.S. Department of Health & Human Services
Suggested Citation

U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: 

The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS, November 2016.

For More Information

For more information about the Surgeon General’s report or to download copies, visit Addiction.SurgeonGeneral.gov.

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MESSAGE FROM THE SECRETARY

PAGE | 

MESSAGE FROM THE SECRETARY, 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

All across the United States, individuals, families, communities, and health 

care systems are struggling to cope with substance use, misuse, and substance 

use disorders. Substance misuse and substance use disorders have devastating 

effects, disrupt the future plans of too many young people, and all too often, 

end lives prematurely and tragically. Substance misuse is a major public health 

challenge and a priority for our nation to address.

Fortunately, we have made considerable progress in recent years. First, 

decades of scientific research and technological advances have given us a 

better understanding of the functioning and neurobiology of the brain and 

how substance use affects brain chemistry and our capacity for self-control. 

One of the important findings of this research is that addiction is a chronic neurological disorder and 

needs to be treated as other chronic conditions are. Second, this Administration and others before it, 

as well as the private sector, have invested in research, development, and evaluation of programs to 

prevent and treat substance misuse, as well as support recovery. We now have many of the tools we 

need to protect children, young people, and adults from the negative health consequences of substance 

misuse; provide individuals with substance use disorders the treatment they need to lead healthy and 

productive lives; and help people stay substance-free. Finally, the enactment of the Paul Wellstone and 

Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 and the Affordable Care Act in 

2010 are helping increase access to prevention and treatment services.

The effects of substance use are cumulative and costly for our society, placing burdens on workplaces, 

the health care system, families, states, and communities. The Surgeon General’s Report on Alcohol, Drugs, 

and Health is another important step in our efforts to address the issue. This historic Report explains, in 

clear and understandable language, the effects on the brain of alcohol and drugs and how misuse can 

become a disorder. It describes the considerable evidence showing that prevention, treatment, and 

recovery policies and programs really do work. For example, minimum legal drinking age laws, funding 

for multi-sector community-based coalitions to plan and implement effective prevention interventions 

with fidelity, screening and brief intervention for alcohol use, needle/syringe exchange programs, 

behavioral counseling, pharmacologic interventions such as buprenorphine for opioid misuse, and 

mutual aid groups have all been shown effective in preventing, reducing, treating, and sustaining 

recovery from substance misuse and substance use disorders. 

The Report discusses opportunities to bring substance use disorder treatment and mainstream health care 

systems into alignment so that they can address a person’s overall health, rather than a substance misuse 

or a physical health condition alone or in isolation. It also provides suggestions and recommendations for 

action that everyone—individuals, families, community leaders, law enforcement, health care professionals, 

policymakers, and researchers—can take to prevent substance misuse and reduce its consequences.
MESSAGE FROM THE SECRETARY

PAGE | II

Throughout, the Report provides examples of how individuals, organizations, and communities can 

partner to lessen and eliminate substance misuse. These efforts have to start now. Change takes time 

and long-term commitment, as well as collaboration among key stakeholders. As the Secretary of the 

Department of Health and Human Services, I encourage you to use the information and findings in this 

Report to take action so that we can improve the health of those we love and make our communities 

healthier and stronger.

Sylvia Mathews Burwell 

Secretary 

U.S. Department of Health and Human Services
FOREWORD

PAGE | III

FOREWORD FROM THE PRINCIPAL DEPUTY 

ADMINISTRATOR, SUBSTANCE ABUSE AND 

MENTAL HEALTH SERVICES ADMINISTRATION

Substance misuse is one of the critical public health problems of our time. The 

most recent data on substance use, misuse, and substance use disorders reveal 

that the problem is deepening and the consequences are becoming more deadly 

than ever. There is an urgent need to raise awareness about the issue. At the 

same time, we need to spread the word that substance misuse and addiction are 

solvable problems. We can, and must, inspire and catalyze action on this crisis. 

That’s why I am so proud to support the Office of the Surgeon General in 

releasing this first report of its kind – The Surgeon General’s Report on Alcohol, 

Drugs, and Health.

This Report takes a comprehensive look at the problem; covering topics including misuse of alcohol, 

prescription drugs, and other substances, and bringing together the best available science on the adverse 

health consequences of substance misuse. It also summarizes what we know about what works in 

prevention, treatment, and recovery. Our goal: to equip health care providers, communities, policymakers, 

law enforcement, and others with the evidence, the tools, and the information they need to take action to 

address this growing epidemic.

Now is the time for this Report. The substance misuse problem in America won’t wait. Almost 22.5 

million people reported use of an illegal drug in the prior year. Over 20 million people have substance 

use disorders, and 12.5 million Americans reported misusing prescription pain relievers in the past year. 

Seventy-eight people die every day in the United States from an opioid overdose, and those numbers have 

nearly quadrupled since 1999. Despite the fact that we have treatments we know are effective, only one in 

five people who currently need treatment for opioid use disorders is actually receiving it. 

The addiction problem touches us all. We all need to play a part in solving it. The Surgeon General’s Report on 

Alcohol, Drugs, and Health provides a roadmap for working together to move our efforts forward. I hope all 

who read it will be inspired to take action to stem the rising tide of this public health crisis and reduce the 

impact of substance misuse and addiction on individuals, communities, and our nation.

Kana Enomoto 

Principal Deputy Administrator 

Substance Abuse and Mental Health Services Administration

U.S. Department of Health and Human Services
PAGE | IV
PREFACE

PAGE | 

PREFACE FROM THE SURGEON GENERAL, 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Before I assumed my position as U.S. Surgeon General, I stopped by the 

hospital where I had worked since my residency training to say goodbye to 

my colleagues. I wanted to thank them, especially the nurses, whose kindness 

and guidance had helped me on countless occasions. The nurses had one 

parting request for me. If you can only do one thing as Surgeon General, they 

said, please do something about the addiction crisis in America. 

I have not forgotten their words. As I have traveled across our extraordinary 

nation, meeting people struggling with substance use disorders and their 

families, I have come to appreciate even more deeply something I recognized 

through my own experience in patient care: that substance use disorders 

represent one of the most pressing public health crises of our time. 

Whether it is the rapid rise of prescription opioid addiction or the longstanding challenge of alcohol 

dependence, substance misuse and substance use disorders can—and do— prevent people from living 

healthy and productive lives. And, just as importantly, they have profound effects on families, friends, 

and entire communities.

I recognize there is no single solution. We need more policies and programs that increase access to 

proven treatment modalities. We need to invest more in expanding the scientific evidence base for 

prevention, treatment, and recovery. We also need a cultural shift in how we think about addiction. For 

far too long, too many in our country have viewed addiction as a moral failing. This unfortunate stigma 

has created an added burden of shame that has made people with substance use disorders less likely to 

come forward and seek help. It has also made it more challenging to marshal the necessary investments 

in prevention and treatment. We must help everyone see that addiction is not a character flaw – it is 

a chronic illness that we must approach with the same skill and compassion with which we approach 

heart disease, diabetes, and cancer. 

I am proud to release The Surgeon General’s Report on Alcohol, Drugs, and Health. As the first ever Surgeon 

General’s Report on this important topic, this Report aims to shift the way our society thinks about 

substance misuse and substance use disorders while defining actions we can take to prevent and treat 

these conditions. 

Over the past few decades, we have built a robust evidence base on this subject. We now know that there 

is a neurobiological basis for substance use disorders with potential for both recovery and recurrence. 

We have evidence-based interventions that prevent harmful substance use and related problems, 

particularly when started early. We also have proven interventions for treating substance use disorders, 

often involving a combination of medication, counseling, and social support. Additionally, we have 
PREFACE

PAGE | V I

learned that recovery has many pathways that should be tailored to fit the unique cultural values and 

psychological and behavioral health needs of each individual.

As Surgeon General, I care deeply about the health and well-being of all who are affected by substance 

misuse and substance use disorders. This Report offers a way forward through a public health approach 

that is firmly grounded in the best available science. Recognizing that we all have a role to play, 

the Report contains suggested actions that are intended for parents, families, educators, health care 

professionals, public policy makers, researchers, and all community members.

Above all, we can never forget that the faces of substance use disorders are real people. They are a 

beloved family member, a friend, a colleague, and ourselves. Despite the significant work that remains 

ahead of us, there are reasons to be hopeful. I find hope in the people I have met in recovery all across 

America who are now helping others with substance use disorders find their way. I draw strength 

from the communities I have visited that are coming together to work on prevention initiatives and to 

connect more people to treatment. And I am inspired by the countless family members who have lost 

loved ones to addiction and who have transformed their pain into a passion for helping others. These 

individuals and communities are rays of hope. It is now our collective duty to bring such light to all 

corners of our country. 

How we respond to this crisis is a moral test for America. Are we a nation willing to take on an 

epidemic that is causing great human suffering and economic loss? Are we able to live up to that most 

fundamental obligation we have as human beings: to care for one another?

Fifty years ago, the landmark Surgeon General’s report on the dangers of smoking began a half century 

of work to end the tobacco epidemic and saved millions of lives. With The Surgeon General’s Report on 

Alcohol, Drugs, and Health, I am issuing a new call to action to end the public health crisis of addiction. 

Please join me in taking the actions outlined in this Report and in helping ensure that all Americans can 

lead healthy and fulfilling lives.

Vivek H. Murthy, M.D., M.B.A.

Vice Admiral, U.S. Public Health Service

Surgeon General
ACKNOWLEDGMENTS

PAGE | VII

ACKNOWLEDGMENTS

This Report was prepared by the U.S. Department of Health and Human Services under the general 

direction of the Substance Abuse and Mental Health Services Administration. 

Vice Admiral Vivek H. Murthy, M.D., M.B.A., Surgeon General, U.S. Public Health Service, Office of the 

Surgeon General, Office of the Assistant Secretary for Health, Office of the Secretary, U.S. Department 

of Health and Human Services, Washington, D.C. 

Kana Enomoto, Principal Deputy Administrator, Substance Abuse and Mental Health Services 

Administration, Rockville, Maryland.

Science Editors 

A. Thomas McLellan, Ph.D., Senior Scientific Editor, Chair of the Board and Co-Founder, Treatment 

Research Institute, Philadelphia, Pennsylvania. 

Richard F. Catalano, Jr., Ph.D., M.A., Bartley Dobb Professor for the Study and Prevention of Violence; 

Co-Founder, Social Development Research Group, School of Social Work, University of Washington, 

Seattle, Washington. 

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM, Dean’s Executive Professor of Public Health, Santa 

Clara University, Santa Clara, California.

Keith Humphreys, Ph.D., Professor, Department of Psychiatry and Behavioral Science, Stanford 

University, Stanford, California; Research Career Scientist, VA Palo Alto Health Care System, Palo Alto, 

California. 

George F. Koob, Ph.D., Director, National Institute on Alcohol Abuse and Alcoholism, National 

Institutes of Health, Rockville, Maryland. 

Nora D. Volkow, M.D., Director, National Institute on Drug Abuse, National Institutes of Health, 

Rockville, Maryland. 

Constance M. Weisner, Dr.P.H., M.S.W., Associate Director, Behavioral Health, Aging, and Infectious 

Disease Section, Division of Research, Kaiser Permanente, Oakland, California; Professor of Psychiatry, 

Department of Psychiatry, Langley Porter Psychiatric Institute, University of California, San Francisco, 

California. 

Managing Editors 

Jinhee J. Lee, Pharm.D., Managing Editor, Senior Public Health Advisor, Division of Pharmacologic 

Therapies, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services 

Administration, Rockville, Maryland.
ACKNOWLEDGMENTS

PAGE | 

Jorielle Brown Houston, Ph.D., Associate Managing Editor, Director, Division of Systems Development, 

Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration, 

Rockville, Maryland.

Richard Lucey, Jr., M.A., Associate Managing Editor, Special Assistant to the Director, Center for Substance 

Abuse Prevention, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. 

Contributing Editors 

Nazleen H. Bharmal, M.D., Ph.D., M.P.P., Director of Science and Policy, Office of the Surgeon General, Office 

of the Assistant Secretary of Health, U.S. Department of Health and Human Services, Washington, D.C. 

Christine A. Cichetti, Senior Behavioral Health Policy Advisor, Office of the Assistant Secretary for 

Health/Office of the Deputy Assistant Secretary for Health (Science and Medicine), Washington, D.C. 

Tom Coderre, Chief of Staff, Substance Abuse and Mental Health Services Administration, Rockville, 

Maryland.

Tom Hill, M.S.W., Senior Advisor for Addiction and Recovery, Substance Abuse and Mental Health 

Services Administration, Rockville, Maryland.

Marion Cornelius Pierce, Public Health Analyst, Division of Systems Development, Center for Substance 

Abuse Prevention, Substance Abuse and Mental Health Services Administration, Rockville, Maryland.

Contributing Authors 

Michael A. Arends, Senior Research Assistant in the Committee on the Neurobiology of Addictive 

Disorders, The Scripps Research Institute, La Jolla, California. 

Maureen Boyle, Ph.D., Chief, Science Policy Branch, Office of Science Policy and Communications, 

National Institute on Drug Abuse, National Institutes of Health, Rockville, Maryland. 

Felipe González Castro, Ph.D., M.S.W., Professor and Southwest Borderlands Scholar, Arizona State 

University, College of Nursing and Health Innovation, Phoenix, Arizona.

Mady Chalk, Ph.D., M.S.W., Managing Partner, The Chalk Group.

Laura J. Dunlap, Ph.D., Director, Behavioral Health Economics Program, RTI International, Research 

Triangle Park, North Carolina. 

Vivian B. Faden, Ph.D., Director, Office of Science Policy and Communications and Associate Director 

of Behavioral Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of 

Health, Rockville, Maryland.

Abigail A. Fagan, Ph.D., Associate Professor of Criminology & Law, Department of Sociology and 

Criminology & Law, University of Florida, Gainesville, Florida. 
ACKNOWLEDGMENTS

PAGE | i

Mark T. Greenberg, Ph.D., M.A., Edna Peterson Bennett Endowed Chair in Prevention Research, 

Professor of Human Development and Psychology, College of Health and Human Development, The 

Pennsylvania State University, State College, Pennsylvania. 

Kevin P. Haggerty, Ph.D., M.S.W., Associate Professor; Director of Research; Director, Social 

Development Research Group; School of Social Work, University of Washington, Seattle, Washington. 

Ralph W. Hingson, Sc.D., M.P.H., Director, Division of Epidemiology and Prevention Research, National 

Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Rockville, Maryland.

Jennifer A. Hobin, Ph.D., Senior Health Science Policy Analyst, Science Policy Branch, Office of Science 

Policy and Communications, National Institute on Alcohol Abuse and Alcoholism, National Institutes 

of Health, Rockville, Maryland.

John F. Kelly, Ph.D, Elizabeth R. Spallin Associate Professor of Psychiatry in the Field of Addiction 

Medicine, Harvard Medical School, Boston, Massachusetts; Director, Recovery Research Institute; 

Program Director, Addiction Recovery Management Service; Associate Director, Center for Addiction 

Medicine, Massachusetts General Hospital, Boston, Massachusetts.

Tami L. Mark, Ph.D., M.B.A., Vice President and Director, Center for Behavioral Health Services 

Research, Truven Health Analytics, Bethesda, Maryland.

Patrick O’Connor, M.D., M.P.H., F.A.C.P., Professor and Chief of General Internal Medicine, Yale 

University School of Medicine, New Haven, Connecticut.

Harold Pollack, Ph.D., M.P.P., Helen Ross Professor, School of Social Services Administration; Affiliate 

Professor, Biological Science Collegiate Divisions and the Department of Public Health Service; CoDirector, The University of Chicago Crime Lab, The University of Chicago, Chicago, Illinois. 

Patricia A. Powell, Ph.D., Acting Deputy Director, Associate Director for Scientific Initiatives, National 

Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Rockville, Maryland.

Stacy A. Sterling, Dr.P.H., M.S.W., Practice Leader, Division of Research, Kaiser Permanente, Oakland, 

California. 

Eric M. Wargo, Ph.D., Science Writer, Science Policy Branch, Office of Science Policy and 

Communications, National Institute on Drug Abuse, National Institutes of Health, Rockville, Maryland.

Deborah Klein Walker, Ed.D., Vice President & Senior Fellow, U.S. Health, Abt Associates, Cambridge, 

Massachusetts. 

Bridget D. Williams-Simmons, Ph.D., Chief, Science Policy Branch, Office of Science Policy and 

Communications, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, 

Rockville, Maryland.

Gary A. Zarkin, Ph.D., Vice President, Behavioral Health and Criminal Justice Research Division, RTI 

International, Research Triangle Park, North Carolina. 
ACKNOWLEDGMENTS

PAGE | x

Science Writer

Anne B. Rodgers, Science Writer, Falls Church, Virginia.

Reviewers

Hortensia Amaro, Ph.D., Dean’s Professor, School of Social Work; Professor, Department of Preventive 

Medicine, Keck School of Medicine; and Associate Vice Provost, Community Research Initiatives, 

University of Southern California, Los Angeles, California.

Trina Menden Anglin, M.D., Ph.D., Chief, Adolescent Health Branch, Maternal and Child Health 

Bureau, Health Resources and Services Administration, Rockville, Maryland.

Bethany Applebaum, M.P.H., M.A., Public Health Analyst, Office of Women’s Health, Health Resources 

and Services Administration, Rockville, Maryland. 

Marsha L. Baker, LCSW, Public Health Advisor, Center for Substance Abuse Treatment, Substance 

Abuse and Mental Health Services Administration, Rockville, Maryland.

David S. Barry, Psy.D., Public Health Advisor, Substance Abuse and Mental Health Services 

Administration, Rockville, Maryland.

Mirtha R. Beadle, Director, Office of Tribal Affairs and Policy, Office of Policy, Planning, and 

Innovation, Substance Abuse and Mental Health Services Administration, Rockville, Maryland. 

David J. Beckstead, Ph.D., A.P.B.B., Clinical Director, Desert Visions Youth Wellness Center, Indian 

Health Services, Sacaton, Arizona. 

B. Steven Bentsen, M.D., D.F.A.P.A., Regional Chief Medical Officer, Beacon Health Options, 

Morrisville, North Carolina. 

Mitchell Berger, Public Health Advisor, Office of Policy, Planning, and Innovation, Substance Abuse and 

Mental Health Services Administration, Rockville, Maryland.

Jonaki Bose, Branch Chief, Populations Survey Branch, Center for Behavioral Health Statistics and 

Quality, Substance Abuse and Mental Health Services Administration, Rockville, Maryland.

Cheryl A. Boyce, Ph.D., Division of Clinical Neuroscience and Behavioral Research, National Institute 

on Drug Abuse, National Institutes of Health, Rockville, Maryland. 

Katharine A. Bradley, M.D., M.P.H., Senior Investigator and Internal Medicine Physician, Group Health 

Research Institute, Seattle, Washington. 

Robert D. Brewer, M.D., M.S.P.H., Epidemiologist - Lead, Alcohol Program, Division of Population 

Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease 

Control and Prevention, Atlanta, Georgia.

Jeffrey A. Buck, Ph.D., Centers for Medicare & Medicaid Services, Washington, D.C. 
ACKNOWLEDGMENTS

PAGE | x

A. Kathleen Burlew, Ph.D., M.A., McMicken Professor, McMicken College of Arts and Sciences, 

University of Cincinnati, Cincinnati, Ohio. 

John Campbell, M.A., Chief, Performance Partnership Grant Branch, Division of State and Community 

Assistance, Chief Medical Officer, Office of the Director, Center for Substance Abuse Treatment, 

Substance Abuse and Mental Health Services Administration, Rockville, Maryland.

Melinda Campopiano, M.D., Chief Medical Officer, Office of the Director, Center for Substance Abuse 

Treatment, Substance Abuse and Mental Health Services Administration, Rockville, Maryland.

Christopher D. Carroll, M.Sc., Director of Health Care Financing and Systems Integration, Substance 

Abuse and Mental Health Services Administration, Rockville, Maryland.

Walter B. Castle, M.S.S.W., Senior Public Health Advisor, Division of Behavioral Health, Indian Health 

Service, Rockville, Maryland. 

Nancy Cheal, M.S., Ph.D., Health Scientist, Division of Congenital and Developmental Disorders, 

National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and 

Prevention, Atlanta, Georgia. 

Laura W. Cheever, M.D., Sc.M., Associate Administrator, HIV/AIDS Bureau, Health Resources and 

Services Administration, Rockville, Maryland. 

Dominic Chiapperino, Ph.D., Regulatory and Liaison Team Lead, Controlled Substance Staff, Center for 

Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland.

Wilson M. Compton, M.D., M.P.E., Deputy Director, National Institute on Drug Abuse, National 

Institutes of Health, Rockville, Maryland.

Jessica H. Cotto, Health Scientist Administrator, Science Policy Branch, National Institute on Drug 

Abuse, National Institutes of Health, Rockville, Maryland.

Don L. Coyhis, Mohican Nation, President and Founder, White Bison, Inc., Colorado Springs, Colorado.

Steven Dettwyler, Ph.D., Public Health Advisor, State Grants Western Branch, Division of State and 

Community Systems Development, Center for Mental Health Services, Substance Abuse and Mental 

Health Services Administration, Rockville, Maryland. 

Lori Ducharme, Ph.D., Program Director for Health Services Research, Division of Treatment and 

Recovery Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, 

Rockville, Maryland.

Marissa Esser, M.P.H., Ph.D., Heath Scientist, Division of Population Health, National Center for Chronic 

Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.

Monica Feit, Ph.D., Director of the Office of Policy, Planning, and Innovation, Substance Abuse and 

Mental Health Services Administration, Rockville, Maryland.

Corinne Ferdon, Ph.D., Deputy Associate Director for Science, Division of Violence Prevention, National 

Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia.
ACKNOWLEDGMENTS

PAGE | xI I

David A. Fiellin, M.D., Professor of Medicine (General Medicine) and Public Health (Health Policy), 

Institute for Social and Policy Studies; Director, Community Research and Implementation Core, 

Center for Interdisciplinary Research on AIDS, Yale School of Medicine, New Haven, Connecticut.

Pennie Foster-Fishman, Ph.D., Professor, Department of Psychology; Senior Outreach Fellow, 

University Outreach and Engagement, Michigan State University. East Lansing, Michigan. 

Henry L. Francis, M.D., Director for Data Mining and Informatics Evaluation and Research, Office of 

Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, 

Silver Spring, Maryland. 

Rebecca Freeman, Ph.D., R.N., P.M.P., Chief Nursing Officer, Office of the National Coordinator for 

Health IT, U.S. Department of Health and Human Services, Washington, D.C.

Peter Gaumond, Chief, Recovery Branch, Office of National Drug Control Policy, Executive Office of 

the President, Washington, D.C. 

Udi E. Ghitza, Ph.D., Health Scientist Administrator, Program Officer, Center for the Clinical Trials 

Network, National Institute on Drug Abuse, National Institutes of Health, Rockville, Maryland.

Gregory Goldstein, M.S.H.S., Deputy Director, Center for Substance Abuse Prevention, Substance 

Abuse and Mental Health Services Administration, Rockville, Maryland.

Althea M. Grant, M.P.H., Ph.D., Chief, Epidemiology and Surveillance Branch, Division of 

Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Office of 

Noncommunicable Diseases, Injury and Environmental Health, Centers for Disease Control and 

Prevention, Atlanta, Georgia. 

Stephen J. Gumbley, M.A., Independent Consultant; Former Director, New England Addiction 

Technology Transfer Center, Providence, Rhode Island. 

Susan Marsiglia Gray, M.P.H., Senior Public Health Advisor, Center for Substance Abuse Prevention, 

Substance Abuse and Mental Health Services Administration, Rockville, Maryland.

Frances M. Harding, Director, Center for Substance Abuse Prevention, Substance Abuse and Mental 

Health Services Administration, Rockville, Maryland.

R. Adron Harris, Ph.D., M. June & J. Virgil Waggoner Chair in Molecular Biology; Director, Waggoner 

Center for Alcohol and Addiction Research, University of Texas at Austin, Austin, Texas. 

Marla Hendriksson, M.P.M., Director, Office of Communications, Substance Abuse and Mental Health 

Services Administration, Rockville, Maryland.

Anne M. Herron, M.S., Director, Division of Regional and National Policy Liaison, and Agency Lead, 

SAMHSA Workforce Development Strategic Initiative, Substance Abuse and Mental Health Services 

Administration, Rockville, Maryland.

Sharon Hertz, M.D., Director, Division of Anesthesia, Analgesia, and Addiction Products, Center for 

Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland.
ACKNOWLEDGMENTS

PAGE | xIII

Kevin C. Heslin, Ph.D., Staff Research Fellow, Agency for Healthcare Research and Quality, U.S. 

Department of Health and Human Services, Rockville, Maryland. 

Donna Hillman, M.A., Lead Public Health Advisor, Center for Substance Abuse Treatment, Substance 

Abuse and Mental Health Services Administration, Rockville, Maryland.

Margaret (Peggy) Honein, Ph.D., M.P.H., Chief, Birth Defects Branch, National Center on Birth Defects 

and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia.

Alexis G. Horan, M.P.P., Expert Consultant, Addiction Policy, Office of the Assistant Secretary for 

Planning and Evaluation, U.S. Department of Health and Human Services, Washington, D.C.

Constance M. Horgan, M.A., Sc.D., Professor; Director, Institute for Behavioral Health, The Heller 

School for Social Policy and Management, Brandeis University, Waltham, Massachusetts. 

Larke N. Huang, Ph.D., Director, Office of Behavioral Health Equity, Office of Policy, Planning, and 

Innovation, Substance Abuse and Mental Health Services Administration, Rockville, Maryland.

Robert B. Huebner, Ph.D., Acting Director, Division of Treatment and Recovery Research, National 

Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Rockville, Maryland.

Kristen V. Huntley Ph.D., Health Science Administrator, Center for the Clinical Trials Network, 

National Institute on Drug Abuse, National Institutes of Health, Rockville, Maryland.

Corinne G. Husten, M.D., M.P.H., Senior Medical Advisor, Office of the Center Director, Center for 

Tobacco Products, U.S. Food and Drug Administration, Silver Spring, Maryland.

Linda Hutchings, M.S.J., Special Assistant to the Director, Center for Substance Abuse Treatment, 

Substance Abuse and Mental Health Services Administration, Rockville, Maryland.

Pamela S. Hyde, J.D., Former Administrator, Substance Abuse and Mental Health Services 

Administration, Rockville, Maryland.

Carrie L. Jeffries, A.N.P.-B.C., M.S., M.P.H., R.N., A.A.C.R.N., Chief Nursing Officer, HIV/AIDS Bureau, 

Health Resources and Services Administration, Rockville, Maryland. 

Amelia (Amy) Jewett, M.P.H., Epidemiologist, Transportation Safety Team, Division of Unintentional 

Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and 

Prevention, Atlanta, Georgia.

Kimberly A. Johnson, Ph.D., Director, Center for Substance Abuse Treatment, Substance Abuse and 

Mental Health Services Administration, Rockville, Maryland.

Wanda K. Jones, Dr.P.H., M.P.H., Principal Deputy Assistant Secretary for Health, U.S. Department of 

Health and Human Services, Washington, D.C.

Elliot Kennedy, J.D., Special Expert, LGBT Affairs, Substance Abuse and Mental Health Services 

Administration, Rockville, Maryland.
ACKNOWLEDGMENTS

PAGE | xIV

Paul J. Kenny, Ph.D., Ward-Coleman Professor; Chair, Dorothy H. and Lewis Rosentiel Department of 

Pharmacology and Systems Therapeutics; Director, Experimental Therapeutics Institute, Mount Sinai 

Hospital, New York, New York. 

Thomas Kresina, Ph.D., Senior Public Health Advisor, Center for Substance Abuse Treatment, 

Substance Abuse and Mental Health Services Administration, Rockville, Maryland.

Alexandre B. Laudet, Ph.D., Director, Center for the Study of Addictions and Recovery, National 

Development and Research Institutes, Inc. (NDRI), New York, New York. 

Jennifer LeClercq, M.P.H., C.H.E.S., Public Health Analyst, Division of Population Health, National 

Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and 

Prevention, Atlanta, Georgia.

Raye Z. Litten, Ph.D., Acting Director, Division of Medications Development, National Institute on 

Alcohol Abuse and Alcoholism, National Institutes of Health, Rockville, Maryland.

Xiang Sharon Liu, Statistician, Treatment Service Branch, Center for Behavioral Health Statistics and 

Quality, Substance Abuse and Mental Health Services Administration, Rockville, Maryland.

Jacqueline J. Lloyd, Ph.D., M.S.W., Deputy Branch Chief and Health Scientist Administrator, Prevention 

Research Branch, Division of Epidemiology, Services, and Prevention Research, National Institute on 

Drug Abuse, National Institutes of Health, Rockville, Maryland. 

Joshua Lloyd, M.D., Lead Medical Officer, Division of Anesthesia, Analgesia, and Addiction Products, 

Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland.

Peter G. Lurie, M.D., M.P.H., Associate Commissioner for Public Health Strategy and Analysis, U.S. 

Food and Drug Administration, Silver Spring, Maryland. 

Robert Lyerla, Ph.D., Research Officer, Center for Behavioral Health Statistics and Quality, Substance 

Abuse and Mental Health Services Administration, Rockville, Maryland.

Spero M. Manson, Ph.D., Distinguished Professor of Public Health and Psychiatry; Director, Centers 

for American Indian and Alaska Native Health; The Colorado Trust Chair in American Indian Health; 

Associate Dean of Research, Colorado School of Public Health, Aurora, Colorado. 

Tim McAfee, Director, Medical Officer, Office on Smoking and Health, National Center for Chronic 

Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.

Dennis McCarty, Ph.D., M.A., Professor; Division Head, Health Services Research; OHSU-PSU School 

of Public Health, Oregon Health & Science University, Portland, Oregon. 

David K. Mineta, M.S.W., President and CEO, Momentum for Mental Health, San Jose, California. 

Ivan D. Montoya, M.D., M.P.H., Deputy Director, Division of Therapeutics and Medical Consequences, 

National Institute on Drug Abuse, National Institutes of Health, Rockville, Maryland. 

Michele LaTour Monroe, Senior Communications Specialist, Office of Communications, Substance 

Abuse and Mental Health Services Administration, Rockville, Maryland.
ACKNOWLEDGMENTS

PAGE | xV

Jon Morgenstern, Ph.D., Director of Addiction Services, Northwell Health, Great Neck, New York. 

Charlotte A. Mullican, M.P.H., Senior Advisor for Mental Health Research, Center for Evidence and 

Practice Improvement, Agency for Healthcare Research and Quality, Rockville, Maryland. 

Lisa M. Najavits, Ph.D., Professor, Department of Psychiatry, Boston University School of Medicine, 

Boston, Massachusetts; Director, Treatment Innovations, Newton Centre, Massachusetts. 

Jon P. Nelson, Ph.D., Professor Emeritus of Economics, The Pennsylvania State University, State 

College, Pennsylvania. 

Phyllis Holditch Niolon, Ph.D., Behavioral Scientist, Division of Violence Prevention, National Center 

for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia.

Antonio Noronha, Ph.D., Director, Division of Neuroscience and Behavior, National Institute on 

Alcohol Abuse and Alcoholism, National Institutes of Health, Rockville, Maryland.

Thomas E. Novotny, M.D., M.P.H., Deputy Assistant Secretary for Health (Science and Medicine), U.S. 

Department of Health and Human Services, Washington, D.C. 

John P. O’Brien, Senior Policy Advisor, Disabled and Elderly Health Programs Group, Centers for 

Medicare & Medicaid Services, Baltimore, Maryland. 

David L. Olds, Ph.D., Professor of Pediatrics; Director, Prevention Research Center for Family and 

Child Health; Department of Pediatrics, University of Colorado, Aurora, Colorado. 

Dee S. Owens, M.P.A., Special Assistant to the Director, Center for Behavioral Health Statistics and 

Quality, Substance Abuse and Mental Health Services Administration, Rockville, Maryland.

Derek W. Patton, M.S., M.B.A., Division Director, Integrated Behavioral Health, Office of Health 

Programs, Indian Health Service, Phoenix, Arizona. 

Len Paulozzi, M.D., Medical Officer, Division of Unintentional Injury Prevention, National Center for 

Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia.

Adolf Pfefferbaum, M.D., Senior Program Director and Distinguished Scientist, Center for Health 

Sciences, SRI International, Menlo Park, California. 

Kathryn Piscopo, Ph.D., Survey Statistician, Populations Survey Branch, Center for Behavioral Health 

Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, Maryland.

Jean O. Plascke, M.S.W., Youth Programs Officer, Office of Indian Alcohol and Substance Abuse, 

Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration, 

Rockville, Maryland.

Richard A. Rawson, Ph.D., Research Professor, Department of Psychiatry, University of Vermont, 

Burlington, Vermont; Professor Emeritus Department of Psychiatry; Geffen School of Medicine, 

University of California, Los Angeles, California. 
ACKNOWLEDGMENTS

PAGE | xVI

Kenneth W. Robertson, Lead Public Health Advisor, Criminal Justice Grants, Targeted Populations 

Branch, Division of Systems Improvement, Center for Substance Abuse Treatment, Substance Abuse 

and Mental Health Services Administration, Rockville, Maryland.

Susan Robilotto, D.O., Clinical Advisor/Medical Officer, HIV/AIDS Bureau, Health Resources and 

Services Administration, Rockville, Maryland.

Letitia B. Robinson, Ph.D., R.N., Senior Advisor, HIV/AIDS Bureau, Health Resources and Services 

Administration, Rockville, Maryland. 

Alexander F. Ross, Sc.D., Senior Behavioral Health Advisor, Office of Planning, Evaluation, and Analysis, 

Health Resources and Services Administration, Rockville, Maryland.

Tyler Sadwith, Health Insurance Specialist, Center for Medicaid and CHIP Services, Centers for 

Medicare & Medicaid Services, San Francisco, California. 

Onaje M. Salim, M.A., Ed.D., Director, Division of State and Community Assistance, Center for Substance 

Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, Maryland.

David R. Shillcutt, J.D., Disabled and Elderly Health Programs Group, Center for Medicaid and CHIP 

Services, Centers for Medicare & Medicaid Services, Baltimore, Maryland.

Ruth Shults, Ph.D., M.P.H., Senior Epidemiologist, Division of Unintentional Injury Prevention, National 

Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia.

Belinda Sims, Ph.D., Health Scientist Administrator, Prevention Research Branch, Division of 

Epidemiology, Services and Prevention Research, National Institute on Drug Abuse, National Institutes 

of Health, Rockville, Maryland.

Geetha A. Subramaniam, M.D., Deputy Director, Center for Clinical Trials Network, National Institute 

on Drug Abuse, National Institutes of Health, Rockville, Maryland.

Tison Thomas, M.S.W., Chief, State Grants Eastern Branch, Division of State and Community Systems 

Development, Center for Mental Health Services, Substance Abuse and Mental Health Services 

Administration, Rockville, Maryland.

Christine Timko, Ph.D., Research Career Scientist, Health Services Research and Development, U.S. 

Department of Veterans Affairs, Menlo Park, California. 

Traci L. Toomey, Ph.D., Professor, Division of Epidemiology and Community Health, School of Public 

Health, University of Minnesota, Minneapolis, Minnesota. 

Paolo del Vecchio, M.S.W., Director, Center for Mental Health Services, Substance Abuse and Mental 

Health Services Administration, Rockville, Maryland.

Mary Kate Weber, M.P.H, Behavioral Scientist, Division of Congenital and Developmental Disorders, 

National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and 

Prevention, Atlanta, Georgia.

Aaron White, Ph.D., Senior Advisor to the Director, National Institute on Alcohol Abuse and 

Alcoholism, National Institutes of Health, Rockville, Maryland.
ACKNOWLEDGMENTS

PAGE | xVII

William L. White, M.A., Emeritus Senior Research Consultant, Chestnut Health Systems, Bloomington, 

Illinois. 

Gary B. Wilcox, M.A., Ph.D., John A. Beck Centennial Professor in Communication, Moody College of 

Communication, Stan Richards School of Advertising and Public Relations, The University of Texas at 

Austin, Austin, Texas. 

David Wilson, Public Affairs Specialist, Center for Substance Abuse Prevention, Substance Abuse and 

Mental Health Services Administration, Rockville, Maryland.

Ellen Witt, Ph.D., (retired) Deputy Director, Division of Neuroscience and Behavior, National Institute 

on Alcohol Abuse and Alcoholism, National Institutes of Health, Rockville, Maryland.

Amy Funk Wolkin, Dr.P.H., M.S.P.H. , Chief, Health Studies Branch, Division of Environmental Hazards 

and Health Effects, National Center for Environmental Health, Centers for Disease Control and 

Prevention, Atlanta, Georgia. 

Albert M. Woodward, Ph.D., Chief, Analysis and Services Research Branch, Division of Evaluation, 

Analysis and Quality, Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental 

Health Services Administration, Rockville, Maryland.

Marie Zeimetz, Ph.D., Writer-Editor, Office of the Director, Center for Substance Abuse Treatment, 

Substance Abuse and Mental Health Services Administration, Rockville, Maryland.

Terry S. Zobeck, Ph.D., Associate Director, Office of Research/Data Analysis, Office of National Drug 

Control Policy, Executive Office of the President, Washington, D.C. 

Other contributors were

Deepa Avula, M.P.H., Director, Office of Financial Resources, Substance Abuse and Mental Health Services 

Administration, Rockville, Maryland. 

Amy Berninger, M.P.H., Senior Analyst, Abt Associates, Cambridge, Massachusetts. 

Margaret K. Gwaltney, M.B.A., Principal Associate, Abt Associates, Bethesda, Maryland. 

Kevin Hennessy, Ph.D., Former Deputy Director, Center for Behavioral Health Statistics and Quality, 

Substance Abuse and Mental Health Services Administration, Rockville, Maryland. 

Janet Hightower, Digital Artist, Encinitas, California.

Mariel J. McLeod, Research Assistant, Abt Associates, Bethesda, Maryland.

Cori K. Sheedy, Ph.D., Senior Associate, Abt Associates, Cambridge, Massachusetts.

Daniel J. Smith, Senior Graphic Designer, Abt Associates, Bethesda, Maryland.

Alicia C. Sparks, Ph.D., Senior Analyst, Abt Associates, Bethesda, Maryland. 

Melanie Whitter, Principal Associate, Abt Associates, Bethesda, Maryland.
PAGE | xVIII
TABLE OF CONTENTS
 

TABLE OF CONTENTS
 

CHAPTER 1 - INTRODUCTION 

AND OVERVIEW OF THE 

REPORT 

Chapter 1 Preview 1-1
 

Substances Discussed in this Report 1-4
 

Prevalence of Substance Use, Misuse Problems, 


and Disorders 1-7
 

Costs and Impact of Substance Misuse 1-12
 

Vulnerability to Substance Misuse Problems 


and Disorders 1-15
 

Diagnosing a Substance Use Disorder 1-16
 

The Separation of Substance Use Treatment 


and General Health Care 1-19
 

Recent Changes in Health Care Policy and Law 1-20
 

Marijuana: A Changing Legal and Research 


Environment  1-21
 

Purpose, Focus, and Format of the Report 1-22
 

References 1-26
 

CHAPTER 2 - THE 

NEUROBIOLOGY OF 

SUBSTANCE USE, MISUSE, 

AND ADDICTION 

Chapter 2 Preview 2-1
 

Conducting Research on the Neurobiology of 


Substance Use, Misuse, and Addiction 2-3
 

The Primary Brain Regions Involved in Substance 


Use Disorders 2-5
 

The Addiction Cycle 2-6
 

Binge/Intoxication Stage: Basal Ganglia 2-8
 

Withdrawal/Negative Affect Stage: Extended
 

Amygdala 2-12
 

Factors that Increase Risk for Substance Use, 


Misuse, and Addiction 2-21
 

Use of Multiple Substances and Co-occurring 


Mental Health Conditions 2-22
 

Biological Factors Contributing to Population-based 


Differences in Substance Misuse and Substance Use 


Disorders 2-23
 

Recommendations for Research 2-24
 

References 2-27
 

PAGE | xIx 
TABLE OF CONTENTS
 

CHAPTER 3 - PREVENTION 

PROGRAMS AND POLICIES 

CHAPTER 4 - EARLY 

INTERVENTION, TREATMENT, 

AND MANAGEMENT OF 

SUBSTANCE USE DISORDERS 

Chapter 3 Preview 3-1
 

Why We Should Care About Prevention 3-3
 

Risk and Protective Factors 3-4
 

Types of Prevention Interventions 3-7
 

Evidence-Based Prevention Programs 3-8
 

Evidence-based Community Coalition-based 


Prevention Models 3-14
 

Evidence-Based Prevention Policies 3-17
 

Prevention Interventions for Specific Populations 3-27
 

Improving the Dissemination and Implementation 


of Evidence-based Programs 3-32
 

Recommendations for Research 3-35
 

References 3-37
 

Chapter 4 Preview 4-1
 

Continuum of Treatment Services 4-3
 

Early Intervention: Identifying and Engaging 


Individuals At Risk for Substance Misuse and 

Substance Use Disorders 4-5
 

Treatment Engagement: Reaching and Reducing 


Harm Among Those Who Need Treatment 4-8
 

Principles of Effective Treatment and Treatment 


Planning 4-13
 

Evidence-based Treatment: Components of Care 4-19
 

Emerging Treatment Technologies 4-32
 

Considerations for Specific Populations 4-36
 

Recommendations for Research 4-40
 

References 4-43
 

PAGE | xx
 
TABLE OF CONTENTS
 

CHAPTER 5 - RECOVERY: THE 

MANY PATHS TO WELLNESS 

CHAPTER 6 - HEALTH CARE 

SYSTEMS AND SUBSTANCE 

USE DISORDERS 

CHAPTER 7 - VISION FOR THE 

FUTURE: A PUBLIC HEALTH 

APPROACH 

Chapter 5 Preview 5-1
 

Definitions, Pathways, and Prevalence of Recovery 5-2
 

Perspectives of Those in Recovery 5-4
 

Estimating the Number of People “In Recovery” 5-5
 

Recovery-oriented Systems of Care 5-6
 

Recovery Supports 5-7
 

Social and Recreational Recovery Infrastructures 


and Social Media 5-16
 

Specific Populations and Recovery 5-16
 

Recommendations for Research 5-17
 

References 5-18
 

Chapter 6 Preview 6-1
 

Key Components of Health Care Systems 6-3
 

Substance Use Disorder Services Have Traditionally 


Been Separate From Mental Health and General 


Health Care 6-5
 

A Growing Impetus for Integration 6-6
 

Financing Systems for Substance Use Disorder 


Services 6-23
 

Challenges Facing the Integration of Substance 

Use Services and Health Care 6-27
 

Promising Innovations That Improve Access 


to Substance Use Disorder Treatment 6-34
 

Recommendations for Research 6-43
 

References 6-45
 

Time for a Change 7-2
 

Specific Suggestions for Key Stakeholders 7-7
 

Conclusion 7-16
 

References 7-18
 

PAGE | xxI 
 

 

 

 

 

 

 

TABLE OF CONTENTS
 

GLOSSARY OF TERMS 1 

LIST OF ABBREVIATIONS 7 

LIST OF TABLES AND FIGURES 11 

APPENDIX A - REVIEW 

PROCESS FOR PREVENTION 

PROGRAMS 15 

APPENDIX B - EVIDENCEBASED PREVENTION 

PROGRAMS AND POLICIES 17 

APPENDIX C - RESOURCE 

GUIDE 41 

APPENDIX D - IMPORTANT 

FACTS ABOUT ALCOHOL 

AND DRUGS 53 

PAGE | xxII 
PAGE | xxIII
INTRODUCTION

PAGE | 1-1

CHAPTER 1.

INTRODUCTION AND OVERVIEW 

OF THE REPORT

Chapter 1 Preview

The United States has a serious substance misuse problem. Substance misuse is the use of alcohol or 

drugs in a manner, situation, amount, or frequency that could cause harm to the user or to those around 

them. Alcohol and drug misuse and related substance use disorders affect millions of Americans and 

impose enormous costs on our society. In 2015, 66.7 million people in the United States reported 

binge drinking in the past month and 27.1 million people were current users of illicit drugs or misused 

prescription drugs.3 The accumulated costs to the individual, the family, and the community are 

staggering and arise as a consequence of many direct and indirect effects, including compromised 

physical and mental health, increased spread of infectious disease, loss of productivity, reduced quality 

of life, increased crime and violence, increased motor vehicle crashes, abuse and neglect of children, and 

health care costs. 

The most devastating consequences are seen in the tens of thousands of lives that are lost each year as a 

result of substance misuse. Alcohol misuse contributes to 88,000 deaths in the United States each year; 

1 in 10 deaths among working adults are due to alcohol misuse.6 In addition, in 2014 there were 47,055 

drug overdose deaths including 28,647 people who died from a drug overdose involving some type of 

opioid, including prescription pain relievers and heroin—more than in any previous year on record.7

Even though the United States spends more than any other country on health care, it ranks 27th in life 

expectancy, which has plateaued or decreased for some segments of the population at a time when life 

expectancy continues to increase in other developed countries—and the difference is largely due to 

substance misuse and associated physical and mental health problems. For example, recent research has 

shown an unprecedented increase in mortality among middle-aged White Americans between 1999 and 

2014 that was largely driven by alcohol and drug misuse and suicides, although this trend was not seen 

within other racial and ethnic populations such as Blacks and Hispanics.8 An analysis from the Centers 

for Disease Control and Prevention (CDC) demonstrated that alcohol and drug misuse accounted for 

a roughly 4-month decline in life expectancy among White Americans; no other cause of death had a 

larger negative impact in this population.9
INTRODUCTION

PAGE | 1-2

Substance misuse and substance use disorders also have serious economic consequences, costing 

more than $400 billion annually in crime, health, and lost productivity.10,11 These costs are of a similar 

order of magnitude to those associated with other serious health problems such as diabetes, which is 

estimated to cost the United States $245 billion each year.12 Alcohol misuse and alcohol use disorders 

alone costs the United States approximately $249 billion in lost productivity, health care expenses, law 

enforcement, and other criminal justice costs.10 The costs associated with drug use disorders and use of 

illegal drugs and non-prescribed medications were estimated to be more than $193 billion in 2007.11

Despite decades of expense and effort focused on a criminal justice–based model for addressing 

substance use-related problems, substance misuse remains a national public health crisis that continues 

to rob the United States of its most valuable asset: its people. In fact, high annual rates of past-month 

illicit drug use and binge drinking among people aged 12 years and older from 2002 through 2014 

(Figure 1.1) emphasize the importance of implementing evidence-based public-health-focused strategies 

to prevent and treat alcohol and drug problems in the United States.13A public health approach seeks 

to improve the health and safety of the population by addressing underlying social, environmental, and 

economic determinants of substance misuse and its consequences, to improve the health, safety, and 

well-being of the entire population.

Figure 1.1: Past Month Rates of Substance Use Among People Aged 12 or Older: 

Percentages, 2002-2014, 2014 National Survey on Drug Use and Health (NSDUH) 

Notes: The National Survey on Drug Use and Health (NSDUH) obtains information on nine categories of illicit drugs: marijuana 

(including hashish), cocaine (including crack), heroin, hallucinogens, and inhalants, as well as the nonmedical use of prescriptiontype pain relievers, tranquilizers, stimulants, and sedatives; see the section on nonmedical use of psychotherapeutic drugs for the 

definition of nonmedical use. Estimates of “illicit drug use” reported from NSDUH reflect the use of these nine drug categories. 

Difference between the Illicit Drug Use estimate for 2002-2013 and the 2014 estimate is statistically significant at the .05 level for 

all years against 2014. Binge drinking for NSDUH data collected in 2014 is defined as five or more drinks on the same occasion 

on at least one day in the past 30 days. There was no significant difference between 2002-2013 against 2014. In 2015, changes 

were made to the NSDUH questionnaire and data collection procedures that do not allow comparisons between 2015 and 

previous years for a number of outcomes.

Source: Center for Behavioral Health Statistics and Quality, (2015).13
INTRODUCTION

PAGE | 1-3

This Surgeon General’s Report has been created because of the 

important health and social problems associated with alcohol 

and drug misuse in America. As described in this Report, a 

comprehensive approach is needed to address substance 

use problems in the United States that includes several key 

components: 

$ Enhanced public education to improve awareness 

about substance use problems and demand for more 

effective policies and practices to address them; 

$ Widespread implementation of evidence-based 

prevention policies and programs to prevent 

substance misuse and related harms; 

$ Improved access to evidence-based treatment 

services, integrated with mainstream health care, 

for those at risk for or affected by substance use 

disorders; 

$ Recovery support services (RSS) to assist individuals 

in maintaining remission and preventing relapse; and 

$ Research-informed public policies and financing 

strategies to ensure that substance misuse and use 

disorder services are accessible, compassionate, 

efficient, and sustainable. 

Recognizing these needs, the Report explains the

neurobiological basis for substance use disorders and 

provides the biological, psychological, and social frameworks 

for improving diagnosis, prevention, and treatment of alcohol 

and drug misuse. It also describes evidence-based prevention 

strategies, such as public policies that can reduce substance misuse problems (e.g., driving under the 

influence [DUI]); effective treatment strategies, including medications and behavioral therapies for 

treating substance use disorders; and RSS for people who have completed treatment. Additionally, 

the Report describes recent changes in health care financing, including changes in health insurance 

regulations, which support the integration of clinical prevention and treatment services for substance 

use disorders into mainstream health care practice, and defines a research agenda for addressing alcohol 

and drug misuse as medical conditions.

Thus, this first Surgeon General’s Report on Alcohol, Drugs, and Health is not issued simply because of the 

prevalence of substance misuse or even the related devastating harms and costs, but also to help inform 

policymakers, health care professionals, and the general public about effective, practical, and sustainable 

strategies to address these problems. These strategies have the potential to substantially reduce substance 

misuse and related problems; promote early intervention for substance misuse and substance use disorders; 

and improve the availability of high-quality treatment and RSS for persons with substance use disorders.

The Public Health System. The 

Public Health System is defined as 

“all public, private, and voluntary 

entities that contribute to the delivery 

of essential public health services 

within a jurisdiction” and includes 

state and local public health agencies, 

public safety agencies, health care 

providers, human service and charity 

organizations, recreation and artsrelated organizations, economic and 

philanthropic organizations, and 

education and youth development 

organizations.2 

The Health Care System. The World 

Health Organization defines a health 

care system as (1) all the activities 

whose primary purpose is to promote, 

restore, and/or maintain health, and (2) 

the people, institutions, and resources, 

arranged together in accordance with 

established policies, to improve the 

health of the population they serve. 

The health care system is made up 

of diverse health care organizations 

ranging from primary care, specialty 

substance use disorder treatment 

(including residential and outpatient 

settings), mental health care, infectious 

disease clinics, school clinics, 

community health centers, hospitals, 

emergency departments, and others.5
PAGE | 1-4

A Public Health Model for Addressing Substance Misuse and Related 

Consequences

A public health systems approach to substance misuse and its consequences, including substance use disorders, 

aims to:

• Define the problem through the systematic collection of data on the scope, characteristics, and 

consequences of substance misuse; 

• Identify the risk and protective factors that increase or decrease the risk for substance misuse and its 

consequences, and the factors that could be modified through interventions;

• Work across the public and private sector to develop and test interventions that address social, 

environmental, or economic determinants of substance misuse and related health consequences;

• Support broad implementation of effective prevention and treatment interventions and recovery 

supports in a wide range of settings; and

• Monitor the impact of these interventions on substance misuse and related problems as well as on risk 

and protective factors.

A healthy community is one with not just a strong health care system but also a strong public health educational 

system, safe streets, effective public transportation and affordable, high quality food and housing – where 

all individuals have opportunities to thrive. Thus, community leaders should work together to mobilize the 

capacities of health care organizations, social service organizations, educational systems, community-based 

organizations, government health agencies, religious institutions, law enforcement, local businesses, researchers, 

and other public, private, and voluntary entities that can contribute to the above aims. Everyone has a role to 

play in addressing substance misuse and its consequences and thereby improving the public health.

Substances Discussed in this Report

This Report defines a substance as a psychoactive compound with the potential to cause health and social 

problems, including substance use disorders (and their most severe manifestation, addiction). These 

substances can be divided into three major categories: Alcohol, Illicit Drugs (a category that includes 

prescription drugs used nonmedically), and Over-the-Counter Drugs. Some specific examples of the 

substances included in each of these categories are included in Table 1.1. Over-the-Counter Drugs are 

not discussed in this Report, but are included in Appendix D – Important Facts about Alcohol and Drugs.

Although different in many respects, the substances discussed in this Report share three features that 

make them important to public health and safety. First, many people use and misuse these substances: 66.7 

million individuals in the United States aged 12 or older admitted to binge drinking in the past month 

and 27.1 million people aged 12 or older used an illicit drug in the past month.3
INTRODUCTION

PAGE | 1-5

Table 1.1: Categories and Examples of Substances

Substance Category Representative Examples

Alcohol • Beer

• Wine

• Malt liquor

• Distilled spirits

Illicit Drugs • Cocaine, including crack

• Heroin

• Hallucinogens, including LSD, PCP, ecstasy, peyote, mescaline, psilocybin

• Methamphetamines, including crystal meth 

• Marijuana, including hashish*

• Synthetic drugs, including K2, Spice, and “bath salts”**

• Prescription-type medications that are used for nonmedical purposes 

o Pain Relievers - Synthetic, semi-synthetic, and non-synthetic opioid 

medications, including fentanyl, codeine, oxycodone, hydrocodone, and 

tramadol products

o Tranquilizers, including benzodiazepines, meprobamate products, and muscle 

relaxants

o Stimulants and Methamphetamine, including amphetamine, 

dextroamphetamine, and phentermine products; mazindol products; and 

methylphenidate or dexmethylphenidate products

o Sedatives, including temazepam, flurazepam, or triazolam and any barbiturates

Over-the-Counter 

Drugs and Other 

Substances

• Cough and cold medicines** 

• Inhalants, including amyl nitrite, cleaning fluids, gasoline and lighter gases, 

anesthetics, solvents, spray paint, nitrous oxide

Notes: The Report discusses the substances known to have a significant public health impact. These substances are also included 

in NSDUH. Additionally, NSDUH includes tobacco products (cigarettes, smokeless tobacco, cigars, and pipe tobacco); however, 

tobacco products are not discussed in this Report at length because they have been covered extensively in other Surgeon 

General’s Reports.14-17

* As of June 2016, 25 states and the District of Columbia have legalized medical marijuana use, four states have legalized retail 

marijuana sales, and the District of Columbia has legalized personal use and home cultivation (both medical and recreational). It 

should be noted that none of the permitted uses under state laws alter the status of marijuana and its constituent compounds 

as illicit drugs under Schedule I of the federal Controlled Substances Act. See the section on Marijuana: A Changing Legal and 

Research Environment later in this chapter for more detail on this issue. 

** These substances are not included in NSDUH and are not discussed in this Report. However, important facts about these 

drugs are included in Appendix D - Important Facts about Alcohol and Drugs. 

Second, individuals can use these substances in a manner that causes harm to the user or those around them. This 

is called substance misuse and often results in health or social problems, referred to in this Report as

substance misuse problems. Misuse can be of low severity and temporary, but it can also result in serious, 

enduring, and costly consequences due to motor vehicle crashes,18,19 intimate partner and sexual 

violence,20 child abuse and neglect,21 suicide attempts and fatalities,22 overdose deaths,23 various forms of 

cancer24 (e.g., breast cancer in women),25 heart and liver diseases,26 HIV/AIDS,27 and problems related to 

drinking or using drugs during pregnancy, such as fetal alcohol spectrum disorders (FASDs) or neonatal 

abstinence syndrome (NAS).28

Third, prolonged, repeated misuse of any of these substances can 

produce changes to the brain that can lead to a substance use disorder,

an independent illness that significantly impairs health and function 

and may require specialty treatment. Disorders can range from 

mild to severe. Severe and chronic substance use disorders 

are commonly referred to as addictions. 

See the section on Diagnosing a 

Substance Use Disorder later in this 

chapter.
PAGE | 1-6

Key Terms Used in the Report 

Addiction: The most severe form of substance use disorder, associated with compulsive or uncontrolled use of 

one or more substances. Addiction is a chronic brain disease that has the potential for both recurrence (relapse) 

and recovery.

Substance: A psychoactive compound with the potential to cause health and social problems, including 

substance use disorders (and their most severe manifestation, addiction). For a list of substance categories 

included in this Report see Table 1.1. Note: Cigarettes and other tobacco products are only briefly discussed 

here due to extensive coverage in prior Surgeon General’s Reports.14-17

Substance Use: The use—even one time—of any of the substances in this Report.

Substance Misuse: The use of any substance in a manner, situation, amount, or frequency that can cause harm 

to users or to those around them. For some substances or individuals, any use would constitute misuse (e.g., 

underage drinking, injection drug use).

Binge Drinking: Binge drinking for men is drinking 5 or more standard alcoholic drinks, and for women, 4 or 

more standard alcoholic drinks on the same occasion on at least 1 day in the past 30 days. 

Heavy Drinking: Defined by the CDC as consuming 8 or more drinks per week for women, and 15 or more 

drinks per week for men, and by the Substance Abuse and Mental Health Services Administration (SAMHSA), for 

research purposes, as binge drinking on 5 or more days in the past 30 days.

Standard Drink: Based on the 2015-2020 Dietary Guidelines for Americans, a standard drink is defined as shown 

in the graphic below. All of these drinks contain 14 grams (0.6 ounces) of pure alcohol.

Source: U.S. Department of Health and Human Services and U.S. Department of Agriculture, (2015).29

Substance Misuse Problems or Consequences: Any health or social problem that results from substance 

misuse. Substance misuse problems or consequences may affect the substance user or those around them, 

and they may be acute (e.g., an argument or fight, a motor vehicle crash, an overdose) or chronic (e.g., a longterm substance-related medical, family, or employment problem, or chronic medical condition, such as various 

cancers, heart disease, and liver disease). These problems may occur at any age and are more likely to occur with 

greater frequency of substance misuse.

Substance Use Disorder: A medical illness caused by repeated misuse of a substance or substances. According 

to the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5),30 substance use 

disorders are characterized by clinically significant impairments in health, social function, and impaired control 

over substance use and are diagnosed through assessing cognitive, behavioral, and psychological symptoms. 

Substance use disorders range from mild to severe and from temporary to chronic. They typically develop 

gradually over time with repeated misuse, leading to changes in brain circuits governing incentive salience (the 
PAGE | 1-7

ability of substance-associated cues to trigger substance seeking), reward, stress, and executive functions like 

decision making and self-control. Multiple factors influence whether and how rapidly a person will develop a 

substance use disorder. These factors include the substance itself; the genetic vulnerability of the user; and the 

amount, frequency, and duration of the misuse. Note: A severe substance use disorder is commonly called an 

addiction. 

Relapse: The return to drug use after a significant period of abstinence.

Recovery: A process of change through which individuals improve their health and wellness, live a self-directed 

life, and strive to reach their full potential. Even individuals with severe and chronic substance use disorders can, 

with help, overcome their substance use disorder and regain health and social function. This is called remission. 

When those positive changes and values become part of a voluntarily adopted lifestyle, that is called “being in 

recovery.” Although abstinence from all substance misuse is a cardinal feature of a recovery lifestyle, it is not the 

only healthy, pro-social feature.

Prevalence of Substance Use, Misuse Problems, and 

Disorders

How widespread are substance use, misuse, and substance use disorders in the United States? The annual 

National Survey on Drug Use and Health (NSDUH) gathers data on the scope and prevalence of substance 

use, misuse, and related disorders, as well as utilization of substance use disorder treatment, among 

Americans aged 12 and older, representing more than 265 million people. Table 1.2 provides selected 

findings from the 2015 NSDUH. The table provides only general statistics for the United States as a 

whole; readers are urged to consult NSDUH’s detailed tables3 for subpopulation estimates.

Over 175 million persons aged 12 and older (65.7 percent 

of this population) reported alcohol use in the past year, 

with over 66 million (24.9 percent) reporting binge drinking 

in the past month (Table 1.2). More than 36 million (13.5 

percent) reported using marijuana in the past year, 12.5 

million reported misusing prescription pain relievers, and 

over 300,000 reported using heroin in the past year. Almost 

8 percent of the population met diagnostic criteria for a 

substance use disorder for alcohol or illicit drugs, and another 1 percent met diagnostic criteria for both 

an alcohol and illicit drug use disorder. Although 20.8 million people (7.8 percent of the population) met 

the diagnostic criteria for a substance use disorder in 2015, only 2.2 million individuals (10.4 percent) 

received any type of treatment. Of those treated, 63.7 percent received treatment in specialty substance 

use disorder treatment programs.3

Prevalence. The proportion of a 

population who have (or had) a specific 

characteristic—for example, an illness, 

condition, behavior, or risk factor— in a 

given time period.
PAGE | 1-8

Several specific findings shown in Table 1.2 bear emphasis. Past year misuse of prescription 

psychotherapeutic drugs was reported by 18.9 million individuals in 2015 (7.1 percent of the 

population).3 Within this category, prescribed opioid pain relievers (e.g., OxyContin®, Vicodin®, 

Lortab®) accounted for 12.5 million people, followed by tranquilizers, such as Xanax®, reported by 6.1 

million people; stimulants, such as Adderall® or Ritalin®, reported by 5.3 million people; and sedatives, 

such as Valium®, reported by 1.5 million people.3

Substance Use Disorder Treatment Programs

Historically, treatment services were designed for people with severe substance use disorders (addictions), 

and programs were generally referred to as “specialty addiction treatment programs.” Today, individuals with 

mild to severe substance use disorders may receive treatment. These treatments are delivered by specialty 

programs, as well as by more generalist providers (e.g., primary care and general mental health providers). Not 

everyone with a substance use disorder will need ongoing treatment; many will require only a brief intervention 

and monitoring. Because treatments vary substantially in level of specialization, content, duration, and setting, 

and because those receiving services may differ substantially in the severity, duration, and complexity of their 

substance use disorder, this Report uses the phrase “substance use disorder treatment” as the generic term to 

capture the broad spectrum of advice, therapies, services, and monitoring provided to the group of individuals 

with mild to severe substance use disorders. The programs and services that provide specialty treatment are 

referred to as “substance use disorder treatment programs or services.”

The prevalence of past 30-day use of “any illicit drugs” (a broad category including marijuana/hashish, 

cocaine/crack, heroin, hallucinogens, inhalants, and prescription psychotherapeutic medications used 

nonmedically) rose from 9.4 percent in 2013 to 10.2 percent in 2014 among persons aged 12 and older 

(Figure 1.2). This 2014 prevalence rate for illicit drugs is significantly higher than it was in any year 

from 2002 to 2013. However, no significant changes were observed that year specifically in the use of 

prescription psychotherapeutic drugs, cocaine, or hallucinogens, suggesting that the observed increase 

was primarily related to increased use of marijuana. Marijuana was the most frequently used illicit drug 

(35.1 million past year users).31 The rate for past month marijuana use in 2014 was significantly higher 

than it was in any year from 2002 to 2013, with the prevalence of past 30-day marijuana use rising 

from 7.5 percent in 2013 to 8.4 percent in 2014.13 (Note: In 2015, changes were made to the NSDUH 

questionnaire and data collection procedures that do not allow for the presentation of trend data 

beyond 2014. For more information, see Summary of the Effects of the 2015 NSDUH Questionnaire Redesign: 

Implications for Data Users.32)

Demographics of Substance Use 

Table 1.3 and Table 1.4 show substance use by demographic characteristics. Prevalence of substance 

misuse and substance use disorders differs by race and ethnicity and gender, and these factors can 

also influence access to health care and substance use disorder treatment. Past year alcohol use for 

men was 68.6 percent and for women it was 62.9 percent. Past month binge alcohol use was 29.6 

percent for men and 20.5 percent for women. The prevalence of past month binge alcohol use was 24.1 

percent for American Indians or Alaska Natives, 25.7 percent for Hispanics or Latinos, and 26.0 for 

Whites. Prevalence of an alcohol use disorder was 7.8 percent for men and 4.1 percent for women. The 

prevalence of an illicit drug use disorder was 3.8 percent for men and 2.0 percent for women. 
PAGE | 1-9

Table 1.2: Past Year Substance Use, Past Year Initiation of Substance Use, and Met Diagnostic 

Criteria for a Substance Use Disorder in the Past Year Among Persons Aged 12 Years or Older 

for Specific Substances: Numbers in Millions and Percentages, 2015 National Survey on Drug 

Use and Health (NSDUH) 

Substance

Past Year Use or 

Misusev

Past Year 

Initiation Among 

Total Populationvi

Met Diagnostic 

Criteria for a 

Substance Use 

Disordervi,vii

# % # % # %

Alcohol 175.8 65.7 4.8 1.8 15.7 5.9

Drinking Pattern

Binge Drinkingi 66.7 24.9 da da da da 

Heavy Drinkingi 17.3 6.5 da da da da 

Any Illicit Drugii 47.7 17.8 nr nr 7.7 2.9

Cocaine/Crack 36.0 1.8 1.0 0.4 0.9 0.3

Heroin 0.8 0.3 0.1 0.1 0.6 0.2

Hallucinogens 4.7 1.8 1.2 0.4 0.3 0.1

Marijuanaiii 36.0 13.5 2.6 1.0 4.0 1.5

Inhalants 1.8 0.7 0.6 0.2 0.1 0.0

Misuse of Psychotherapeuticsiv 18.9 7.1 nr nr 2.7 1.0

Pain Relievers 12.5 4.7 2.1 0.8 2.0 0.8

Tranquilizers 6.1 2.3 1.4 0.5 0.7 0.3

Stimulants 5.3 2.0 1.3 0.5 0.4 0.2

Sedatives 1.5 0.6 0.4 0.2 0.2 0.1

Alcohol or Any Illicit Drugsii 182.3 68.1 nr nr 20.8 7.8

Alcohol and Any Illicit Drugsii 41.3 15.4 nr nr 2.7 1.0

Notes: Past year initiates are defined as persons who used the substance(s) for the first time in the 12 months before the date of 

interview. The “nr = not reported due to measurement issues” notation indicates that the estimate could be calculated based on 

available data but is not calculated due to potential measurement issues. The “da” indication means does not apply.

i. Binge and heavy drinking, as defined by SAMHSA, are reported only for the period of 30 days before the interview date. 

SAMHSA defines binge use of alcohol for males and females as “drinking five (males)/four (females) or more drinks on the 

same occasion (i.e., at the same time or within a couple of hours of each other) on at least 1 day in the past 30 days” and 

heavy use of alcohol for both males and females as “binge drinking on each of 5 or more days in the past 30 days.”

ii. Illicit drug use includes the misuse of prescription psychotherapeutics or the use of marijuana, cocaine (including crack), 

heroin, hallucinogens, inhalants, or methamphetamine. 

iii. As of June 2016, 25 states and the District of Columbia have legalized medical marijuana use. Four states have legalized 

retail marijuana sales; the District of Columbia has legalized personal use and home cultivation (both medical and 

recreational). It should be noted that none of the permitted uses under state laws alter the status of marijuana and its 

constituent compounds as illicit drugs under Schedule I of the federal Controlled Substances Act.

iv. Misuse of prescription-type psychotherapeutics includes the nonmedical use of pain relievers, tranquilizers, stimulants, or 

sedatives and does not include over-the-counter drugs.

v. Estimates of misuse of psychotherapeutics and stimulants include data from new methamphetamine items added in 2005 and 

2006 and are not comparable with estimates presented in NSDUH reports before 2007. See Section B.4.8 in Appendix B of 

the Results from the 2008 NSDUH.

vi. Estimates of misuse of psychotherapeutics and stimulants do not include data from new methamphetamine items added in 

2005 and 2006.

vii. Diagnostic criteria for a substance use disorder is based on definitions found in the Fourth Edition of the Diagnostic and 

Statistical Manual of Mental Disorders (DSM-IV).

Source: Center for Behavioral Health Statistics and Quality, (2016).3
PAGE | 1-10

Figure 1.2: Trends in Binge Drinking and Past 30-Day Use of Illicit Drugs among Persons Aged 

12 Years or Older, 2014 National Survey on Drug Use and Health (NSDUH) 

Notes: *Difference between this estimate and the 2014 estimate is statistically significant at the .05 level. Illicit drugs include 

marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescription psychotherapeutics used non-medically. 

Nonmedical use of prescription psychotherapeutics includes the nonmedical use of pain relievers, tranquilizers, stimulants, or 

sedatives. In 2015, changes were made to the NSDUH questionnaire and data collection procedures that do not allow comparisons 

between 2015 and previous years for a number of outcomes.

Source: Center for Behavioral Health Statistics and Quality, (2015).13

Relevance of Substance Use and Misuse 

It is sometimes thought that concern over substance use and misuse should be secondary to the real

issue of substance use disorders and especially their severest manifestation, addiction, which has 

captured media headlines and has been linked to many health and social problems. This is an important 

misconception. Individuals with substance use disorders have elevated rates of substance misuse–

related health and social problems and costs, but as shown in the last columns of Table 1.2, Table 1.3, and 

Table 1.4, many people who misuse substances do not meet the diagnostic criteria for a substance use 

disorder. For example, binge drinking at least once during the past month was self-reported by over 66 

million individuals. By definition, those episodes have the potential for producing harm to the user and/

or to those around them, through increases in motor vehicle crashes, violence, and alcohol-poisonings.33

Similarly, in 2015, 12.5 million individuals misused a pain reliever in the past year—setting the stage 

for a potential overdose—but only 2.9 million met diagnostic criteria for a prescription medication 

disorder.3
INTRODUCTION

PAGE | 1-11

Table 1.3: Past Year Alcohol Use, Past Month Binge Alcohol Use, and Met Diagnostic Criteria for 

a Substance Use Disorder in the Past Year Among Persons Aged 12 Years or Older: Numbers in 

Millions and Percentages, 2015 National Survey on Drug Use and Health (NSDUH) 

Demographic Group

Past Year 

Alcohol Use

Past Month 

Binge Alcohol 

Useii

Met Diagnostic Criteria 

for a Substance Use 

Disorder in Past Yeari

# % # % # %

Alcohol

Male 89.0 68.6 38.4 29.6 10.1 7.8

Female 86.9 62.9 28.3 20.5 5.6 4.1

White 119.9 70.3 44.4 26.0 10.4 6.1

Black or African American 18.6 58.0 7.5 23.4 1.6 4.9

American Indian or Alaska Native 0.7 51.4 0.3 24.1 0.1 9.7

Native Hawaiian or Other Pacific Islander 0.4 51.1 0.1 17.8 0.04 5.4

Asian 7.8 53.1 2.1 14.0 0.5 3.2

Two or More Races 2.7 57.8 1.1 22.9 0.3 6.2

Hispanic or Latino 25.7 59.0 11.2 25.7 2.8 6.4

Table 1.4: Past Year Substance Use, Past 30-Day Illicit Drug Use, and Met Diagnostic Criteria for 

a Substance Use Disorder in the Past Year Among Persons Aged 12 Years or Older: Numbers in 

Millions and Percentages, 2015 National Survey on Drug Use and Health (NSDUH) 

Demographic Group

Past Year Use Past 30-Day Illicit 

Drug Use

Met Diagnostic Criteria 

for a Substance Use 

Disorder in Past Yeari

# % # % # %

Any Illicit Drugiii

Male 26.6 20.5 16.2 12.5 5.0 3.8

Female 21.2 15.3 10.9 7.9 2.8 2.0

White 30.5 17.9 17.4 10.2 4.8 2.8

Black or African American 6.6 20.7 4.0 12.5 1.1 3.5

American Indian or Alaska Native 0.3 22.9 0.2 14.2 0.06 4.1

Native Hawaiian or Other Pacific Islander 0.1 20.5 0.07 9.8 0.03 4.5

Asian 1.4 9.2 0.6 4.0 0.2 1.2

Two or More Races 1.3 27.1 0.8 17.2 0.2 4.9

Hispanic or Latino 7.4 17.2 4.0 9.2 1.3 3.0

i. Diagnostic criteria for a substance use disorder is based on definitions found in the Fourth Edition of the Diagnostic and 

Statistical Manual of Mental Disorders (DSM-IV). 

ii. Binge drinking, as defined by SAMHSA, are reported only for the period of 30 days before the interview date. SAMHSA 

defines binge use of alcohol for males and females as “drinking five (males)/four (females) or more drinks on the same 

occasion (i.e., at the same time or within a couple of hours of each other) on at least 1 day in the past 30 days.

iii. Illicit drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or misuse of prescriptiontype psychotherapeutics, including data from original methamphetamine questions but not including new methamphetamine 

items added in 2005 and 2006. 

Source: Center for Behavioral Health Statistics and Quality, (2016).3
PAGE | 1-12

The clear implications of these data are that a comprehensive 

approach to reducing the misuse of alcohol and drugs—one 

that includes the implementation of effective prevention 

programs and policy strategies as well as high-quality 

treatment services—is needed to reduce the problems and 

costs of substance misuse in the United States. In fact, greater impact is likely to be achieved by reducing 

substance misuse in the general population—that is, among people who are not addicted—than among 

those with severe substance use problems. Of course, efforts to reduce general population rates of 

substance use and misuse are also likely to reduce rates of substance use disorders, because substance 

use disorders typically develop over time following repeated episodes of misuse (often at escalating 

rates) that result in the progressive changes to brain circuitry that underlie addiction. 

See Chapter 2 - The Neurobiology of 

Substance Use, Misuse, and Addiction.

Costs and Impact of Substance Use and Misuse

Alcohol misuse, illicit drug use, misuse of medications, and substance use disorders are estimated to 

cost the United States more than $400 billion in lost workplace productivity (in part, due to premature 

mortality), health care expenses, law enforcement and other criminal justice costs (e.g., drug-related 

crimes), and losses from motor vehicle crashes.10,11 Furthermore, about three quarters of the costs 

associated with alcohol use were due to binge drinking, and about 40 percent of those costs were paid 

by government, emphasizing the huge cost of alcohol misuse to taxpayers.34

These costs are not unique to the United States. A 2010 study examined the global burden of disability 

attributable to substance misuse problems and disorders, focusing particularly on lost ability to work 

and years of life lost to premature mortality. Costs were calculated for 20 age groups and both sexes 

in 187 countries.35 Mental and substance use disorders were the leading causes of years lived with 

disability worldwide, largely because these problems strike individuals early in their lives and can 

continue—especially if untreated—for long periods. 

In addition to the costs to society, substance misuse can have many direct and indirect health and 

personal consequences for individuals. The direct effects on the user depend on the specific substances 

used, how much and how often they are used, how they are taken (e.g., orally vs. injected), and other 

factors. Acute effects can range from changes in mood and basic body functions, such as heart rate or 

blood pressure, to overdose and death. Alcohol misuse and drug use can also have long-term effects on 

physical and mental health and can lead to substance use disorders. For example, drug use is associated 

with chronic pain conditions and cardiovascular and cardiopulmonary diseases.36,37 Alcohol misuse 

is associated with liver and pancreatic diseases, hypertension, reproductive system disorders, trauma, 

stroke, FASD, and cancers of the oral cavity, esophagus, larynx, pharynx, liver, colon, and rectum.26,28 For 

breast cancer, studies have shown that even moderate drinking may increase the risk.25Although alcohol 

consumption is associated with adverse health effects as noted above, the 2015-2020 Dietary Guidelines for 
PAGE | 1-13

Americans indicate that moderate alcohol use can be part of a healthy diet, but only when used by adults 

of legal drinking age.i

In addition, alcohol and drug use by pregnant women can have profound effects on the developing fetus. 

Alcohol use during pregnancy can lead to a wide range of disabilities in children, the most severe of 

which is FASD, characterized by intellectual disabilities, speech and language delays, poor social skills, 

and sometimes facial deformities. Use of drugs, such as opioids during pregnancy, can result in NAS, a 

drug-withdrawal syndrome requiring medical intervention and extended hospital stay for newborns. 

Use of some drugs, such as cocaine, during pregnancy may also lead to premature birth or miscarriage. 

In addition, substance use during pregnancy may interfere with a child’s brain development and result 

in later consequences for mental functioning and behavior. 

Substance misuse also can affect a user’s nutrition and sleep, as well as increase the risk for trauma, 

violence, injury, and contraction of communicable diseases, such as HIV/AIDS and Hepatitis C. These 

consequences can all contribute to the spectrum of public health consequences of substance misuse and 

need to be considered both independently and collectively when developing and implementing clinical 

and public health interventions. 

Substance misuse problems can also result in other serious and sometimes fatal health problems and 

extraordinary costs; they may also lead to unexpected death from other causes. Three examples of these 

serious, sometimes lethal, problems related to substance misuse are highlighted below. 

Driving Under the Influence

In 2014, 9,967 people were killed in motor vehicle crashes while driving under the influence of alcohol, 

representing nearly one third (31 percent) of all traffic-related fatalities in the United States.38 DUI 

continues to be among the most frequent causes for arrests every year.39 But at approximately 1.3 

million per year, these arrests represent only about 1 percent of the actual alcohol-impaired driving 

incidents reported in national surveys, suggesting that there are many more people who drive while 

impaired that have not been arrested, putting themselves and others at high risk of being harmed.18,40

In addition to the deaths that result from DUI, the National Highway Traffic Safety Administration 

(NHTSA) estimates that DUI costs the United States more than $44 billion each year in prosecution, 

higher insurance rates, higher taxes, medical claims, and property damage.41

As important as they are, these statistics account for only alcohol-related driving impairment and fail to 

measure other impairing substances. A study by NHTSA tested oral fluid and blood specimens from a 

random sample of drivers at the roadside (during daytime on Friday or nighttime Friday to Sunday) and 

i Moderate alcohol use is defined by the 2015-2020 Dietary Guidelines for Americans as up to 1 drink per day for women 

and up to 2 drinks per day for men—and only by adults of legal drinking age. Many individuals should not 

consume alcohol, including individuals who are taking certain over-the-counter or prescription medications or 

who have certain medical conditions, those who are recovering from an alcohol use disorder or are unable to 

control the amount they drink, and anyone younger than age 21 years. In addition, drinking during pregnancy 

may result in negative behavioral or neurological consequences in the offspring. 
PAGE | 1-14

found 12 to 15 percent had used one or more illegal substances.42 Drivers tested positive for drugs in 

approximately 16 percent of all motor vehicle crashes.43

Overdose Deaths 

Overdose deaths are typically caused by consuming substances at high intensity and/or by consuming 

combinations of substances such as alcohol, sedatives, tranquilizers, and opioid pain relievers to the point 

where critical areas in the brain that control breathing, heart rate, and body temperature stop functioning. 

Alcohol Overdose (Alcohol Poisoning)

The CDC reports more than 2,200 alcohol overdose deaths in the United States each year—an average 

of six deaths every day.44 More than three quarters (76 percent) of alcohol overdose deaths occur among 

adults between ages 35 and 64, and 76 percent of those who die from alcohol overdose are men. 

Drug Overdose (Illicit and Prescription Drugs)

Opioid analgesic pain relievers are now the most prescribed 

class of medications in the United States, with more than 289 

million prescriptions written each year.45,46 The increase in 

prescriptions of opioid pain relievers has been accompanied 

by dramatic increases in misuse (Table 1.1) and by a more than 

200 percent increase in the number of emergency department 

visits from 2005 to 2011.47 In 2014, 47,055 drug overdose 

deaths occurred in the United States, and 61 percent of these 

deaths were the result of opioid use, including prescription 

opioids and heroin.7 Heroin overdoses have more than 

tripled from 2010 to 2014.7 Heroin overdoses were more 

than five times higher in 2014 (10,574) then ten years before 

in 2004 (1,878). Additionally, rates of cocaine overdose were 

higher in 2014 than in the previous six years (5,415 deaths 

from cocaine overdose). In 2014, there were 17,465 overdoses from illicit drugs and 25,760 overdoses 

from prescription drugs.48 Drug overdose deaths also occur as a result of the illicit manufacturing and 

distribution of synthetic opioids, such as fentanyl, and the illegal diversion of prescription opioids. Illicit 

fentanyl, for example, is often combined with heroin or counterfeit prescription drugs or sold as heroin, 

and may be contributing to recent increases in drug overdose deaths.7,49

The Opioid Crisis. Over-prescription of 

powerful opioid pain relievers beginning 

in the 1990s led to a rapid escalation 

of use and misuse of these substances 

by a broad demographic of men and 

women across the country.1

 This led to 

a resurgence of heroin use, as some 

users transitioned to using this cheaper 

street cousin of expensive prescription 

opioids. As a result, the number of 

people dying from opioid overdoses 

soared—increasing nearly four-fold 

between 1999 and 2014.4

Intimate Partner Violence, Sexual Assault, and Rape

Intimate partner violence, sexual assault, and rape are crimes with long-lasting effects on victims and 

great cost to society.50,51 These crimes happen to both women and men and are often associated with 

substance use. A recent national survey found that 22 percent of women and 14 percent of men reported 

experiencing severe physical violence from an intimate partner in their lifetimes.52 In this survey, 19.3 

percent of women and 1.7 percent of men reported being raped in their lifetimes, while 43.9 percent 

of women and 23.4 percent of men reported some other form of sexual violence in their lifetimes.52

Substance misuse is often related to these crimes. 
PAGE | 1-15

Numerous studies have found a high correlation between substance use and intimate partner 

violence,53-56 although this does not mean that substance use causes intimate partner violence. In 

addition to evidence from the criminal justice arena, recent systematic reviews have found that 

substance use is both a risk factor for and a consequence of intimate partner violence.57-59

A recent survey of sexual assault and sexual misconduct on college campuses found that use of 

alcohol and drugs are important risk factors for nonconsensual sexual contact among undergraduate, 

graduate, and professional students.20 It is clear that substance use and intimate partner violence and 

sexual assault are closely linked; however, more research is needed on the nature of the relationship 

between substance use and these forms of violence to determine how substance use contributes to the 

perpetration of violence and victimization and how violence contributes to subsequent substance use 

among both perpetrators and victims. 

Vulnerability to Substance Misuse Problems and 

Disorders

Risk and Protective Factors: Keys to Vulnerability 

Substance misuse problems and substance use disorders are not inevitable. An individual’s vulnerability 

may be partly predicted by assessing the nature and number of their community, caregiver/family, and 

individual-level risk and protective factors. 

Significant community-level risk factors for substance misuse 

and use disorders include easy access to inexpensive alcohol 

and other substances. Caregiver/family-level risk factors 

include low parental monitoring, a family history of substance 

use or mental disorders, and high levels of family conflict or 

violence. At the individual level, major risk factors include current mental disorders, low involvement in 

school, a history of abuse and neglect, and a history of substance use during adolescence, among others.60

Community-level protective factors include higher cost for alcohol and other drugs (often achieved by 

increasing taxes on these products); regulating the number and concentration of retailers selling various 

substances (e.g., density of alcohol outlets or marijuana dispensaries); preventing illegal alcohol and 

other drug sales by enforcing existing laws and holding retailers accountable for harms caused by illegal 

sales (e.g., commercial host [dram shop] liability); availability of healthy recreational and social activities; 

and other population-level policies and their enforcement.61 Caregiver/family-level protective factors 

include support and regular monitoring by parents.60 Some important individual-level protective 

factors include involvement in school, engagement in healthy recreational and social activities, and good 

coping skills.60

Three important points about vulnerability should be highlighted. First, no single individual or 

community-level factor determines whether an individual will develop a substance misuse problem or 

disorder. Second, most risk and protective factors can be modified through preventive programs and 

See Chapter 3 - Prevention Programs 

and Policies.
PAGE | 1-16

policies to reduce vulnerability. Third, although substance 

misuse problems and disorders may occur at any age, 

adolescence and young adulthood are particularly critical atrisk periods. Research now indicates that the majority of those 

who meet criteria for a substance use disorder in their lifetime 

started using substances during adolescence and met the criteria by age 20 to 25.62-64 One likely reason 

for this vulnerability in adolescence and young adulthood is that alcohol and other substances have 

particularly potent effects on developing brain circuits, and recent scientific findings indicate that brain 

development is not complete until approximately age 21 to 23 in women and 23 to 25 in men.65-67 Among 

the last brain regions to reach maturity is the prefrontal cortex, the brain region primarily responsible 

for “adult” abilities, such as delay of reward, extended reasoning, and impulse control. This area of the 

brain is one of the most affected regions in a substance use disorder. 

Substance misuse can begin at any age. Therefore, it is important to focus on prevention of substance 

misuse across the lifespan as well as the prevention of substance use disorders. 

See Chapter 2 - The Neurobiology of 

Substance Use, Misuse, and Addiction.

Diagnosing a Substance Use Disorder

Changes in Understanding and Diagnosis of Substance Use 

Disorders 

Repeated, regular misuse of any of the substances listed in Figure 1.2 may lead to the development 

of a substance use disorder. Severe substance use disorders are characterized by compulsive use of 

substance(s) and impaired control of substance use. Substance 

use disorder diagnoses are based on criteria specified in the 

American Psychiatric Association’s Diagnostic and Statistical 

Manual of Mental Disorders (DSM). Much of the substance use 

disorder data included in this Report is based on definitions 

included in the DSM-IV, which described two distinct 

disorders: substance abuse and substance dependence, with 

specific diagnostic criteria for each. Anyone meeting one 

or more of the abuse criteria—which focused largely on the 

negative consequences associated with substance misuse, 

such as being unable to fulfill family or work obligations, 

experiencing legal trouble, or engaging in hazardous behavior 

as a result of drug use—would receive the “abuse” diagnosis. 

Anyone with three or more of the dependence criteria, 

which included symptoms of drug tolerance, withdrawal, 

escalating and uncontrolled substance use, and the use of 

the substance to the exclusion of other activities, would 

receive the “dependence” diagnosis. Notably, addiction is not 

listed as a formal diagnosis in the DSM. However, substance 

Misuse versus Abuse. This Report

uses the term substance misuse, a term 

that is roughly equivalent to substance 

abuse. Substance abuse, an older 

diagnostic term, was defined as use 

that is unsafe (e.g., drunk or drugged 

driving), use that leads a person to fail 

to fulfill responsibilities or gets them 

in legal trouble, or use that continues 

despite causing persistent interpersonal 

problems like fights with a spouse.

However, “substance abuse” is 

increasingly avoided by professionals 

because it can be shaming. Instead, 

substance misuse is now the preferred 

term. Although misuse is not a 

diagnostic term, it generally suggests 

use in a manner that could cause harm 

to the user or those around them. 
PAGE | 1-17

dependence was often used interchangeably with addiction, and tolerance and withdrawal were 

considered, by many, cardinal features of addiction. 

The DSM-5, which is the fifth and current version of the 

DSM, integrates the two DSM-IV disorders, substance 

abuse and substance dependence, into a single disorder 

called substance use disorder with mild, moderate, and severe

sub-classifications. Individuals are evaluated for a substance 

use disorder based on 10 or 11 (depending on the substance) 

equally weighted diagnostic criteria (Table 1.5). Most of these 

overlap with those used to diagnose DSM-IV dependence and 

abuse. Individuals exhibiting fewer than two of the symptoms 

are not considered to have a substance use disorder. Those 

exhibiting two or three symptoms are considered to have 

a “mild” disorder, four or five symptoms constitutes a 

“moderate” disorder, and six or more symptoms is considered 

a “severe” substance use disorder.30 In this Report, addiction is 

used to refer to substance use disorders at the severe end of 

the spectrum and are characterized by compulsive substance 

use and impaired control over use.

Table 1.5: Criteria for Diagnosing Substance Use Disorders

Diagnostic Criteria for Substance Use Disorders

Tolerance. Alteration of the body’s 

responsiveness to alcohol or a drug 

such that higher doses are required 

to produce the same effect achieved 

during initial use.

Withdrawal. A set of symptoms that 

are experienced when discontinuing 

use of a substance to which a person 

has become dependent or addicted, 

which can include negative emotions 

such as stress, anxiety, or depression, 

as well as physical effects such as 

nausea, vomiting, muscle aches, and 

cramping, among others. Withdrawal 

symptoms often lead a person to use 

the substance again.

Using in larger amounts or for longer than intended

Wanting to cut down or stop using, but not managing to

Spending a lot of time to get, use, or recover from use

Craving

Inability to manage commitments due to use

Continuing to use, even when it causes problems in relationships

Giving up important activities because of use

Continuing to use, even when it puts you in danger

Continuing to use, even when physical or psychological problems may be made worse by use

Increasing tolerance

Withdrawal symptoms

Notes: Fewer than 2 symptoms = no disorder; 2-3 = mild disorder; 4-5 = moderate disorder; 6 or more = severe disorder.

Source: American Psychiatric Association, (2013).30

Implications of the New Diagnostic Criteria

The new diagnostic criteria are likely to reduce the “all or nothing” thinking that has characterized the 

substance use field. Tolerance and withdrawal remain major clinical symptoms, but they are no longer 

the deciding factor in whether an individual “has an addiction.” Substance use disorders, including 

addiction, can occur with all substances listed in Table 1.1, not just those that are able to produce 
PAGE | 1-18

What is an Intervention?

Intervention here and throughout this Report means a professionally delivered program, service, or policy 

designed to prevent substance misuse or treat an individual’s substance use disorder. It does not refer to an 

arranged meeting or confrontation intended to persuade a friend or loved one to quit their substance misuse or 

enter treatment—the type of “intervention” sometimes depicted on television. Planned surprise confrontations 

of the latter variety—a model developed in the 1960s, sometimes called the “Johnson Intervention”—have 

not been demonstrated to be an effective way to engage people in treatment.68 Confrontational approaches in 

general, though once the norm even in many behavioral treatment settings, have not been found effective and 

may backfire by heightening resistance and diminishing self-esteem on the part of the targeted individual.69 

tolerance and withdrawal. It is also important to understand that substance use disorders do not occur 

immediately but over time, with repeated misuse and development of more symptoms. This means 

that it is both possible and highly advisable to identify emerging substance use disorders, and to use 

evidence-based early interventions to stop the addiction process before the disorder becomes more 

chronic, complex, and difficult to treat. 

This type of proactive clinical monitoring and management 

is already done within general health care settings to address 

other potentially progressive illnesses that are brought about 

by unhealthy behaviors.70 For example, patients with high 

blood pressure may be told to adjust their activity and stress 

in order to reduce the progression of hypertension. Typically, 

these individuals are also clinically monitored for key symptoms to ensure that symptoms do not worsen. 

There are compelling reasons to apply similar procedures in emerging cases of substance misuse. 

Routine screening for alcohol and other substance use should be conducted in primary care settings to 

identify early symptoms of a substance use disorder (especially among those with known risk and few 

protective factors). This should be followed by informed clinical guidance on reducing the frequency 

and amount of substance use, family education to support lifestyle changes, and regular monitoring.

Research has shown that substance use disorders are similar 

in course, management, and outcome to other chronic 

illnesses, such as hypertension, diabetes, and asthma.71

Unfortunately, substance use disorders have not been treated, 

monitored, or managed like other chronic illnesses, nor has 

care for these conditions been covered by insurance to the 

same degree. Nonetheless, it is possible to adopt the same 

type of chronic care management approach to the treatment 

of substance use disorders as is now used to manage most other chronic illnesses.70-72 Evidence-based 

behavioral interventions, medications, social support services, clinical monitoring, and RSS make this 

type of chronic care management possible, often by the same health care teams that currently treat other 

chronic illnesses. 

See Chapter 6 - Health Care Systems 

and Substance Use Disorders.

See Chapter 4 - Early Intervention, 

Treatment, and Management of 

Substance Use Disorders and Chapter 

6 - Health Care Systems and Substance 

Use Disorders.
PAGE | 1-19

Evidence also shows that such an approach will improve the effectiveness of treatments for substance 

use disorders. Remission of substance use and even full recovery can now be achieved if evidencebased care is provided for adequate periods of time, by properly trained health care professionals, and 

augmented by supportive monitoring, RSS, and social services. This fact is supported by a national 

survey showing that there are more than 25 million individuals who once had a problem with alcohol or 

drugs who no longer do.

73

The Separation of Substance Use Treatment and 

General Health Care

Until quite recently, substance misuse problems and substance use disorders were viewed as social 

problems, best managed at the individual and family levels, and sometimes through the existing social 

infrastructure—such as schools and places of worship, and, when necessary, through civil and criminal 

justice interventions.74 In the 1970s, when rates of substance misuse increased, including by college 

students and Vietnam War veterans, most families and traditional social services were not prepared to 

handle this problem.75 Despite a compelling national need for treatment, the existing health care system 

was neither trained to care for nor especially eager to accept patients with substance use disorders. 

For these reasons, a new system of substance use disorder treatment programs was created, but with 

administration, regulation, and financing placed outside mainstream health care.74,75 This meant that 

with the exception of detoxification in hospital-based settings, virtually all treatment was delivered 

by programs that were geographically, financially, culturally, and organizationally separate from 

mainstream health care. Of equal historical importance was the decision to focus treatment only on 

addiction. This left few provisions for detecting or intervening clinically with the far more prevalent 

cases of early-onset, mild, or moderate substance use disorders. 

Creating this system of substance use disorder treatment programs was a critical element in addressing 

the burgeoning substance use disorder problems in our nation. However, that separation also created 

unintended and enduring impediments to the quality and range of care options. For example, separate 

systems for substance use disorder treatment and other health care needs may have exacerbated the 

negative public attitudes toward people with substance use disorders. Additionally, the pharmaceutical 

industry was hesitant to invest in the development of new medications for individuals with substance 

use disorders, because they were not convinced that a market for these medications existed. 

Consequently, until the 1990s, few U.S. Food and Drug Administration (FDA) approved medications 

were available to treat addictions.76,77

Meanwhile, despite numerous research studies documenting high prevalence rates of substance use 

disorders among patients in emergency departments, hospitals, and general medical care settings, 

mainstream health care generally failed to recognize or address substance use disorders.78 In fact, a 

recent study by the CDC found that in 2011, only 1 in 6 United States adults and 1 in 4 binge drinkers 

had ever been asked by a health professional about their drinking behavior.79 Furthermore, the percent 

of adult binge drinkers who had been asked about their drinking had not changed since 1997, reflecting 

the challenges involved in fostering implementation of screening and counseling services for alcohol 
PAGE | 1-20

misuse in clinical settings. This has been a costly mistake, with often deadly consequences. A recent 

study showed that the presence of a substance use disorder often doubles the odds for the subsequent 

development of chronic and expensive medical illnesses, such as arthritis, chronic pain, heart disease, 

stroke, hypertension, diabetes, and asthma.80

In this regard, fatal medication errors due to unforeseen interactions between a prescribed medication 

for a diagnosed medical condition and unscreened, unaddressed patient substance use increased tenfold over the past 20 years.81 To address this problem, researchers suggested “...(1) screening patients 

for use...of alcohol and/or street drugs; (2) taking extra precautions when prescribing medicines with 

known dangerous interactions with alcohol and/or street drugs; and (3) teaching the patient the risks of 

mixing medicines with alcohol and/or street drugs.”81 Similar recommendations focusing on prescribed 

opioids have been issued by the CDC to curb the rise in opioid overdose deaths.82 Again, screening for 

substance use and substance use disorders before and during the course of opioid prescribing, combined 

with patient education, are recommended.82

Yet despite these and other indications of extreme threats to health care quality, safety, effectiveness, and 

cost containment, as of this writing, few general health care organizations screen for, or offer services 

for, the early identification and treatment of substance use disorders. Moreover, few medical, nursing, 

dental, or pharmacy schools teach their students about substance use disorders;83-86 and, until recently, 

few insurers offered adequate reimbursement for treatment of substance use disorders.87,88 

Recent Changes in Health Care Policy and Law

The longstanding separation of substance use disorders from 

the rest of health care began to change with enactment of the 

Paul Wellstone and Pete Domenici Mental Health Parity and 

Addiction Equity Act of 2008 (MHPAEA) and the Affordable 

Care Act in 2010.89,90 MHPAEA requires that the financial 

requirements and treatment limitations imposed by health plans and insurers for substance use disorders 

be no more restrictive than the financial requirements and treatment limitations they impose for medical 

and surgical conditions. The Affordable Care Act requires the majority of United States health plans and 

insurers to offer prevention, screening, brief interventions, and other forms of treatment for substance use 

disorders.89

It is difficult to overstate the importance of these two Acts for creating a public health-oriented 

approach to reducing substance misuse and related disorders. These laws and related changes in health 

care financing are creating incentives for health care organizations to integrate substance use disorder 

treatment with general health care. Many questions remain, but those questions are no longer whether

but how this much-needed integration will occur. These changes combine to create a new, challenging 

but exceptionally promising era for the prevention and treatment of substance use disorders and set the 

context for this Report.

See Chapter 6 - Health Care Systems 

and Substance Use Disorders.
INTRODUCTION

PAGE | 1-21

Marijuana: A Changing Legal and Research 

Environment 

Although this Report does not examine the issue of marijuana legalization, its continually evolving 

legal status is worth mentioning because of implications for both research and policy. As mentioned 

elsewhere, marijuana is the most commonly used illicit drug in the United States, with 22.2 million 

people aged 12 or older using it in the past month.3 In recent years marijuana use has become more 

socially acceptable among both adults and youth, while perceptions of risk among adolescents of the 

drug’s harms have been declining over the past 13 years.91

As use of marijuana and its constituent components and derivatives becomes more widely accepted, it is 

critical to strengthen understanding of the effects and consequences for individual users and for public 

health and safety. Conducting such research can be complex as laws and policies vary significantly from 

state to state. For example, some states use a decriminalization model, which means production and sale of 

marijuana are still illegal and no legal marijuana farms, distributors, companies, stores, or advertising are 

permitted. Through ballot initiatives, other states have “legalized” marijuana use, which means they allow 

the production and sales of marijuana for personal use. Additionally, some states have legalized marijuana 

for medical purposes, and this group includes a wide variety of different models dictating how therapeutic 

marijuana is dispensed. The impacts of state laws regarding therapeutic and recreational marijuana are 

still being evaluated, although the differences make comparisons between states challenging.92

As of June 2016, 25 states and the District of Columbia have legalized medical marijuana use. Four states 

have legalized retail sales; the District of Columbia has legalized personal use and home cultivation 

(both medical and recreational), with more states expecting to do so. None of the permitted uses under 

state laws alters the status of marijuana and its constituent compounds as illicit drugs under Schedule 

I of the federal Controlled Substances Act.93 It should also be noted that use for recreational purposes 

has not been legalized by any jurisdiction for people under age 21, and few jurisdictions have legalized 

medical marijuana for young people. While laws are changing, so too is the drug itself with average 

potency more than doubling over the past decade (1998 to 2008).94 The ways marijuana is used are 

also changing – in addition to smoking, consuming edible forms like baked goods and candies, using 

vaporizing devices, and using high-potency extracts and oils (e.g., “dabbing”) are becoming increasingly 

common.95 Because these products and methods are unregulated even in states that have legalized 

marijuana use, users may not have accurate information about dosage or potency, which can lead and 

has led to serious consequences such as hospitalizations for psychosis and other overdose-related 

symptoms.95 Marijuana use can also impair driving skills and, while estimates vary, is linked to a roughly 

two-fold increase in accident risk.96-98 The risk is compounded when marijuana is used with alcohol.96,99

There is a growing body of research suggesting the potential therapeutic value of marijuana’s constituent 

cannabinoid chemicals in numerous health conditions including pain, nausea, epilepsy, obesity, wasting 

disease, addiction, autoimmune disorders, and other conditions. Given the possibilities around therapeutic 

use, it is necessary to continue to explore ways of easing existing barriers to research. Marijuana has 

more than 100 constituent cannabinoid compounds, with cannabidiol (CBD) and tetrahydrocannabinol 

(THC, the chemical responsible for most of marijuana’s intoxicating effects) being the most well-studied. 

Evidence collected so far in clinical investigations of the marijuana plant is still insufficient to meet 
PAGE | 1-22

FDA standards for a finding of safety and efficacy for any therapeutic indications. However, the FDA 

has approved three medications containing synthetically derived cannabinoids: Marinol capsules and 

Syndros oral solution (both containing dronabinol, which is identical in chemical structure to THC), 

and Cesamet capsules (containing nabilone, which is similar in structure to THC) for severe nausea and 

wasting in certain circumstances, for instance in AIDS patients. Recognizing the potential therapeutic 

importance of compounds found in marijuana, the FDA has granted Fast Track designation to four 

development programs of products that contain marijuana constituents or their synthetic equivalents. The 

therapeutic areas in which products are being developed granted Fast Track by FDA include the treatment 

of pain in patients with advanced cancer; treatment of Dravet syndrome (two programs), a rare and 

catastrophic treatment-resistant form of childhood epilepsy; and treatment of neonatal hypoxic ischemic 

encephalopathy, brain injury resulting from oxygen deprivation during birth. 

Additionally, there are clinical investigations for the treatment of refractory seizure syndromes, including 

Lennox Gastaut Syndrome, and for treatment of post-traumatic stress disorder (PTSD). However, further 

exploration of these issues always requires consideration of the serious health and safety risks associated with 

marijuana use. Research shows that risks can include respiratory illnesses, dependence, mental health-related 

problems, and other issues affecting public health such as impaired driving. Within this context of changing 

marijuana policies at the state level, research is needed on the impact of different models of legalization and 

how to minimize harm based on what has been learned from legal substances subject to misuse, such as 

alcohol and tobacco. Continued assessment of barriers to research and surveillance will help build the best 

scientific foundation to support good public policy while also protecting the public health.

Purpose, Focus, and Format of the Report

The Audience

This Report is intended for individuals, families, community members, educators, health care 

professionals, public health practitioners, advocates, public policymakers, and researchers who are 

looking for effective, sustainable solutions to the problems created by alcohol and other substances. To 

meet those needs, the Report reviews and synthesizes the most important and reliable scientific findings 

in key topic areas and distills those findings into recommendations for:

$ Improving public awareness of substance misuse and related problems;

$ Reducing negative attitudes related to substance use disorders; 

$ Closing the gap between what is known to reduce substance misuse at the population level and 

within specific subgroups, and the implementation of these effective programs, policies, and 

environmental strategies at the federal, state, and community levels;

$ Understanding the need for and effectiveness of programs for high-risk populations; 

$ Expanding the capacity of health care systems to deliver evidence-based substance use disorder 

treatment;

$ Integrating financing and health care system models to facilitate access and affordability of care 

for substance use disorders;
PAGE | 1-23

$ Continuing to build the science base of effective prevention, treatment, and recovery practices 

and policies; and

$ Engaging stakeholders in reducing substance use and misuse problems and protecting the health 

of all individuals across the lifespan.

Because of the broad audience, the Report is purposely written in accessible language without excessive 

scientific jargon. The Report also focuses on current issues and practical questions that trouble so many people: 

$ What are the health and social impacts of alcohol and drug use and misuse in the United States? 

What key factors influence these behaviors?

$ What are the major substance misuse problems facing the United States?

$ What causes substance use disorders and why do they change people so dramatically?

$ Can substance misuse problems and disorders be prevented? How? 

$ What constitutes effective treatment?

$ Can addicted individuals recover? What will it take to manage their disorders and sustain recovery?

Topics Covered in the Report

Individual chapters in the Report review the science associated with the major substance use, misuse, 

and disorder issues for specific topics. Tobacco, also an addictive substance, is mentioned only briefly, 

because problems associated with tobacco use and nicotine addiction have been covered extensively in 

other Surgeon General’s Reports.14-16,100-103

Because of the broad audience and the practical emphasis, the Report is intentionally selective rather 

than exhaustive, emphasizing findings that have the potential for the greatest public health impact 

and the greatest potential for action. For readers wanting greater scientific detail or more specific 

information, detailed research reports, as well as supplemental resource materials, are supplied in 

references, in the Appendices, and in special emphasis boxes throughout the Report.

Scientific Standards Used to Develop the Report

Findings cited in all of the chapters came from electronic database searches of research articles 

published in English. Within those searches, priority was given to systematic literature reviews and 

to findings that were replicated by multiple controlled trials. However, many important issues in 

prevention, treatment, recovery, and health care systems have not yet been examined in rigorous 

controlled trials, or are not appropriate for such research designs. In these cases, the best available 

evidence was cited and labeled according to the reporting conventions published by the CDC:104

$ Well-supported: Evidence derived from multiple controlled trials or large-scale population studies. 

$ Supported: Evidence derived from rigorous but fewer or smaller trials or restricted samples. 

$ Promising: Findings that do not derive from rigorously controlled studies but that nonetheless 

make practical or clinical sense and are widely practiced. 
PAGE | 1-24

In cases in which evidence was based on findings of neurobiological research, the CDC standards were 

adapted. 

A summary of the key findings appears at the beginning of each chapter. The key findings highlight 

what is currently known from available research about the chapter topic, as well as the strength of 

the evidence. As with the rest of the Report, the key findings are not intended to be exhaustive, but 

are instead considered the important “take-aways” from each chapter. Readers interested in a fuller 

discussion of the topics are encouraged to read the chapters in their entirety.

Addressing Substance Use in Specific Populations

As indicated, the chapters are designed to prioritize best available research findings that apply most 

broadly across different substances and across various subgroups, while also identifying program and 

policy interventions that have strong evidence for particular substances (e.g., alcohol), when available. 

The rationale for this decision is that the available research suggests that the genetic, neurobiological, 

and environmental processes underlying substance use, misuse, and disorders are largely similar across 

most known substances and unrelated to the age, sex, race and ethnicity, gender identity, or culture of 

the individual. The available research also clearly indicates that many of the interventions, including 

population-level policies, focused programs, behavioral therapies, medications, and social services 

shown to be effective in one subgroup are generally effective for other subgroups. Put differently, it is 

reasonable to assume that the findings presented in this Report are relevant for many substance use types 

and patterns; for most age, gender, racial and ethnic, and cultural subgroups; and for many special needs 

subgroups (e.g., those with co-occurring mental or physical illnesses; those involved with the criminal 

justice system).

However, this general statement has some important caveats. First, the statement depends heavily 

on the phrase “available research.” There is insufficient research examining subgroup differences in 

the neurobiology of substance use disorders and in interventions aimed at preventing, treating, and 

promoting recovery from substance use disorders. Additional research designed to examine these 

differences and to test interventions in specific populations is needed. 

A second caveat is that individual variability in response to standard prevention, treatment, and 

recovery support interventions is common throughout health care. Individuals with the same disease 

often react quite differently to the same medicine or behavioral intervention. Accordingly, general 

health care has moved toward “personalized medicine,” an individualized treatment regimen derived 

from specific information about the individual’s genetics and stage of illness, as well as lifestyle, 

language, culture, and personal preferences. Personalized care is not common in the substance use 

disorder field because many prevention, treatment, and recovery regimens were created as standardized 

“programs” rather than individualized protocols. 

The third caveat to the statement on general research findings is that even if research has shown that 

certain medications, therapies, or recovery support services are likely to be effective, this does not mean 

that they will be adequate, especially for groups with specific needs. For example, a medication that is 

effective in blocking the rewarding effects of opioid use will not fully address the multiple, complex 

problems of those with opioid use disorders, nor address any co-occurring health conditions such as 

depression or HIV/AIDS. 
PAGE | 1-25

Recognizing these limitations to the generalizability of research findings, each chapter has a dedicated 

section on Specific Populations that focuses particularly on age, racial and ethnic subgroups, and 

individuals with co-occurring mental and physical illnesses. Findings relevant to other important 

groups (e.g., military veterans; lesbian, gay, bisexual, and transgender [LGBT] populations; those with 

criminal justice involvement; those in rural areas) are referred to throughout the Report when available.

The Organization of the Report 

This Report is divided into Chapters, highlighting the key issues and most important research findings 

in those topics. The final chapter concludes with recommendations for key stakeholders, including 

implications for practice and policy.

This Chapter 1 - Introduction and Overview describes the overall rationale for the Report, defines key 

terms used throughout the Report, introduces the major issues covered in the topical chapters, and 

describes the organization, format, and the scientific standards that dictated content and emphasis 

within the Report. 

Chapter 2 - The Neurobiology of Substance Use, Misuse, and Addiction reviews brain research on the 

neurobiological processes that turn casual substance use into a compulsive disorder.

Chapter 3 - Prevention Program and Policies reviews the scientific evidence on preventing substance 

misuse, substance use-related problems, and substance use disorders.

Chapter 4 - Early Intervention, Treatment, and Management of Substance Use Disorders describes the 

goals, settings, and stages of treatment, and reviews the effectiveness of the major components of early 

intervention and treatment approaches, including behavioral therapies, medications, and social services.

Chapter 5 - Recovery: The Many Paths to Wellness discusses perspectives on remission and recovery from 

substance use disorders and reviews the types and effectiveness of RSS.

Chapter 6 - Health Care Systems and Substance Use Disorders reviews ongoing changes in organization, 

delivery, and financing of care for substance use disorders in both specialty treatment programs and in 

mainstream health care settings. 

Chapter 7 - Vision for the Future: A Public Health Approach presents a realistic vision for a 

comprehensive, effective, and humane public health approach to addressing substance misuse and 

substance use disorders in our country, including actionable recommendations for parents, families, 

communities, health care organizations, educators, researchers, and policymakers.

The Appendices provide additional detail about the topics covered in this Report. Appendix A - Review 

Process for Prevention Programs details the review process for the prevention programs included in 

Chapter 3 and the evidence on these programs; Appendix B - Evidence-Based Prevention Programs and 

Policies provides detail on scientific evidence grounding the programs and policies discussed in Chapter 

3; Appendix C - Resource Guide provides resources specific to those seeking information on preventing 

and treating substance misuse or substance use disorders; and Appendix D - Important Facts about 

Alcohol and Drugs contains facts about alcohol and specific drugs, including descriptions, uses and 

possible health effects, treatment options, and statistics as of 2015. 
PAGE | 1-26

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PAGE | 2-1

CHAPTER 2.

THE NEUROBIOLOGY OF SUBSTANCE USE, 

MISUSE, AND ADDICTION

Chapter 2 Preview

A substantial body of research has accumulated over several decades and transformed our 

understanding of substance use and its effects on the brain. This knowledge has opened the door to new 

ways of thinking about prevention and treatment of substance use disorders.

This chapter describes the neurobiological framework underlying substance use and why some people 

transition from using or misusing alcohol or drugs to a substance use disorder—including its most 

severe form, addiction. The chapter explains how these substances produce changes in brain structure 

and function that promote and sustain addiction and contribute to relapse. The chapter also addresses 

similarities and differences in how the various classes of addictive substances affect the brain and 

behavior and provides a brief overview of key factors that influence risk for substance use disorders.

An Evolving Understanding of Substance Use Disorders 

Scientific breakthroughs have revolutionized the understanding of substance use disorders. For 

example, severe substance use disorders, commonly called addictions, were once viewed largely as a moral 

failing or character flaw, but are now understood to be chronic illnesses characterized by clinically 

significant impairments in health, social function, and voluntary control over substance use.3 Although 

the mechanisms may be different, addiction has many features in common with disorders such as 

diabetes, asthma, and hypertension. All of these disorders are chronic, subject to relapse, and influenced 

by genetic, developmental, behavioral, social, and environmental factors. In all of these disorders, 

affected individuals may have difficulty in complying with the prescribed treatment.4

This evolving understanding of substance use disorders as medical conditions has had important 

implications for prevention and treatment. Research demonstrating that addiction is driven by changes 

in the brain has helped to reduce the negative attitudes associated with substance use disorders and 

provided support for integrating treatment for substance use disorders into mainstream health care. 

Moreover, research on the basic neurobiology of addiction has already resulted in several effective 
NEUROBIOLOGY

PAGE | 2-2

KEY FINDINGS*

• Well-supported scientific evidence shows that addiction to alcohol or drugs is a chronic brain disease 

that has potential for recurrence and recovery.

• Well-supported evidence suggests that the addiction process involves a three-stage cycle: binge/

intoxication, withdrawal/negative affect, and preoccupation/anticipation. This cycle becomes more 

severe as a person continues substance use and as it produces dramatic changes in brain function that 

reduce a person’s ability to control his or her substance use. 

• Well-supported scientific evidence shows that disruptions in three areas of the brain are particularly 

important in the onset, development, and maintenance of substance use disorders: the basal ganglia, 

the extended amygdala, and the prefrontal cortex. These disruptions: (1) enable substance-associated 

cues to trigger substance seeking (i.e., they increase incentive salience); (2) reduce sensitivity of brain 

systems involved in the experience of pleasure or reward, and heighten activation of brain stress 

systems; and (3) reduce functioning of brain executive control systems, which are involved in the ability 

to make decisions and regulate one’s actions, emotions, and impulses.

• Supported scientific evidence shows that these changes in the brain persist long after substance use 

stops. It is not yet known how much these changes may be reversed or how long that process may take. 

• Well-supported scientific evidence shows that adolescence is a critical “at-risk period” for substance 

use and addiction. All addictive drugs, including alcohol and marijuana, have especially harmful effects 

on the adolescent brain, which is still undergoing significant development.

* Well-supported: when evidence is derived from multiple rigorous human and nonhuman studies; Supported: 

when evidence is derived from rigorous but fewer human and nonhuman studies. 

medications for the treatment of alcohol, opioid, and nicotine use disorders, and clinical trials are 

ongoing to test other potential new treatments.5

All addictive substances have powerful effects on the brain. These effects account for the euphoric 

or intensely pleasurable feelings that people experience during their initial use of alcohol or other 

substances, and these feelings motivate people to use those substances again and again, despite the risks 

for significant harms. 

As individuals continue to misuse alcohol or other substances, 

progressive changes, called neuroadaptations, occur in the 

structure and function of the brain. These neuroadaptations 

compromise brain function and also drive the transition from 

controlled, occasional substance use to chronic misuse, which 

can be difficult to control. Moreover, these brain changes 

endure long after an individual stops using substances. They may produce continued, periodic craving 

for the substance that can lead to relapse: More than 60 percent of people treated for a substance use 

disorder experience relapse within the first year after they are discharged from treatment,4,6 and a 

person can remain at increased risk of relapse for many years.7,8 

However, addiction is not an inevitable consequence of substance use. Whether an individual ever uses 

alcohol or another substance, and whether that initial use progresses to a substance use disorder of any 

severity, depends on a number of factors. These include: a person’s genetic makeup and other individual 

See the section on ”Factors that 

Increase Risk for Substance Use, Misuse, 

and Addiction” later in this chapter.
NEUROBIOLOGY

PAGE | 2-3

biological factors; the age when use begins; psychological 

factors related to a person’s unique history and personality; 

and environmental factors, such as the availability of drugs, 

family and peer dynamics, financial resources, cultural norms, 

exposure to stress, and access to social support.9 Some of 

these factors increase risk for substance use, misuse, and use disorders, whereas other factors provide 

buffers against those risks. Nonetheless, specific combinations of factors can drive the emergence and 

continuation of substance misuse and the progression to a disorder or an addiction. 

See Chapter 3 - Prevention Programs 

and Policies.

Conducting Research on the Neurobiology of 

Substance Use, Misuse, and Addiction 

Until recently, much of our knowledge about the neurobiology of substance use, misuse, and addiction 

came from the study of laboratory animals. Although no 

animal model fully reflects the human experience, animal 

studies let researchers investigate addiction under highly 

controlled conditions that may not be possible or ethical 

to replicate in humans. These types of studies have greatly 

helped to answer questions about how particular genes, 

developmental processes, and environmental factors, such as stressors, affect substance-taking behavior. 

Neurobiology studies in animals have historically focused on what happens in the brain right after 

taking an addictive substance (this is called the acute impact), but research has shifted to the study of 

how ongoing, long-term (or chronic) substance use changes the brain. One of the main goals of this 

research is to understand at the most basic level the mechanisms through which substance use alters 

brain structure and function and drives the transition from occasional use to misuse, addiction, and 

relapse.10

A growing body of substance use research conducted with humans is complementing the work in 

animals. For example, human studies have benefited greatly from the use of brain-imaging technologies, 

such as magnetic resonance imaging (MRI) and positron emission tomography (PET) scans. These 

technologies allow researchers to “see” inside the living human brain so that they can investigate and 

characterize the biochemical, functional, and structural changes in the brain that result from alcohol 

and drug use. The technologies also allow them to understand how differences in brain structure and 

function may contribute to substance use, misuse, and addiction. 

Animal and human studies build on and inform each other, and in combination provide a more 

complete picture of the neurobiology of addiction. The rest of this chapter weaves together the most 

compelling data from both types of studies to describe a neurobiological framework for addiction.

Neurobiology. The study of the 

anatomy, function, and diseases of the 

brain and nervous system.
NEUROBIOLOGY

PAGE | 2-4

A Basic Primer on the Human Brain

To understand how addictive substances affect the brain, it is important to first understand the basic biology of 

healthy brain function. The brain is an amazingly complex organ that is constantly at work. Within the brain, a mix 

of chemical and electrical processes controls the body’s most basic functions, like breathing and digestion. These 

processes also control how people react to the multitudes of sounds, smells, and other sensory stimuli around 

them, and they organize and direct individuals’ highest thinking and emotive powers so that they can interact with 

other people, carry out daily activities, and make complex decisions.

The brain is made of an estimated 86 billion nerve cells—called neurons—as well as other cell types. Each neuron 

has a cell body, an axon, and dendrites (Figure 2.1). The cell body and its nucleus control the neuron’s activities. 

The axon extends out from the cell body and transmits messages to other neurons. Dendrites branch out from the 

cell body and receive messages from the axons of other neurons.

Neurons communicate with one another through chemical messengers called neurotransmitters. The 

neurotransmitters cross a tiny gap, or synapse, between neurons and attach to receptors on the receiving neuron. 

Some neurotransmitters are inhibitory—they make it less likely that the receiving neuron will carry out some action. 

Others are excitatory, meaning that they stimulate neuronal function, priming it to send signals to other neurons. 

Neurons are organized in clusters that perform specific functions (described as networks or circuits). For example, 

some networks are involved with thinking, learning, emotions, and memory. Other networks communicate with 

muscles, stimulating them into action. Still others receive and interpret stimuli from the sensory organs, such as the 

eyes and ears, or the skin. The addiction cycle disrupts the normal functions of some of these neuronal networks. 

Figure 2.1: A Neuron and its Parts 
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The Primary Brain Regions Involved in Substance 

Use Disorders

The brain has many regions that are interconnected with one another, forming dynamic networks that 

are responsible for specific functions, such as attention, self-regulation, perception, language, reward, 

emotion, and movement, along with many other functions. This chapter focuses on three regions that 

are the key components of networks that are intimately involved in the development and persistence 

of substance use disorders: the basal ganglia, the extended amygdala, and the prefrontal cortex (Figure 

2.2). The basal ganglia control the rewarding, or pleasurable, effects of substance use and are also 

responsible for the formation of habitual substance taking. The extended amygdala is involved in stress 

and the feelings of unease, anxiety, and irritability that typically accompany substance withdrawal. The 

prefrontal cortex is involved in executive function (i.e., the ability to organize thoughts and activities, 

prioritize tasks, manage time, and make decisions), including exerting control over substance taking.

These brain areas and their associated networks are not solely involved in substance use disorders. 

Indeed, these systems are broadly integrated and serve many critical roles in helping humans and 

other animals survive. For example, when people engage in certain activities, such as consuming food 

or having sex, chemicals within the basal ganglia produce feelings of pleasure. This reward motivates 

individuals to continue to engage in these activities, thereby ensuring the survival of the species. 

Likewise, in the face of danger, activation of the brain’s stress systems within the extended amygdala 

drives “fight or flight” responses. These responses, too, are critical for survival. As described in more 

detail below, these and other survival systems are “hijacked” by addictive substances.

Figure 2.2: Areas of the Human Brain that Are Especially Important in Addiction
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The Basal Ganglia

The basal ganglia are a group of structures located deep within the brain that play an important role in 

keeping body movements smooth and coordinated. They are also involved in learning routine behaviors 

and forming habits. Two sub-regions of the basal ganglia are particularly important in substance use 

disorders: 

$ The nucleus accumbens, which is involved in motivation and the experience of reward, and 

$ The dorsal striatum, which is involved in forming habits and other routine behaviors.11

The Extended Amygdala 

The extended amygdala and its sub-regions, located beneath the basal ganglia, regulate the brain’s 

reactions to stress-including behavioral responses like “fight or flight” and negative emotions like 

unease, anxiety, and irritability. This region also interacts with the hypothalamus, an area of the brain 

that controls activity of multiple hormone-producing glands, such as the pituitary gland at the base of 

the brain and the adrenal glands at the top of each kidney. These glands, in turn, control reactions to 

stress and regulate many other bodily processes.12

The Prefrontal Cortex 

The prefrontal cortex is located at the very front of the brain, over the eyes, and is responsible for 

complex cognitive processes described as “executive function.” Executive function is the ability to 

organize thoughts and activities, prioritize tasks, manage time, make decisions, and regulate one’s 

actions, emotions, and impulses.13

The Addiction Cycle

Addiction can be described as a repeating cycle with three stages. Each stage is particularly associated 

with one of the brain regions described above—basal ganglia, extended amygdala, and prefrontal cortex 

(Figure 2.3).10 This three-stage model draws on decades of human and animal research and provides a 

useful way to understand the symptoms of addiction, how it can be prevented and treated, and how 

people can recover from it.14 The three stages of addiction are:

$ Binge/Intoxication, the stage at which an individual consumes an intoxicating substance and 

experiences its rewarding or pleasurable effects; 

$ Withdrawal/Negative Affect, the stage at which an individual experiences a negative emotional 

state in the absence of the substance; and

$ Preoccupation/Anticipation, the stage at which one seeks substances again after a period of 

abstinence.
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Figure 2.3: The Three Stages of the Addiction Cycle and the Brain Regions Associated 

with Them 

 

The three stages are linked to and feed on each other, but they also involve different brain regions, 

circuits (or networks), and neurotransmitters and result in specific kinds of changes in the brain. A 

person may go through this three-stage cycle over the course of weeks or months or progress through 

it several times in a day. There may be variation in how people progress through the cycle and the 

intensity with which they experience each of the stages. Nonetheless, the addiction cycle tends to 

intensify over time, leading to greater physical and psychological harm.10

The following sections describe each of the stages in more detail. But first, it is necessary to explain 

four behaviors that are central to the addiction cycle: impulsivity, positive reinforcement, negative 

reinforcement, and compulsivity. 

For many people, initial substance use involves an element of impulsivity, or acting without foresight 

or regard for the consequences. For example, an adolescent may impulsively take a first drink, smoke a 

cigarette, begin experimenting with marijuana, or succumb to peer pressure to try a party drug. If the 

experience is pleasurable, this feeling positively reinforces the substance use, making the person more 

likely to take the substance again. 

Another person may take a substance to relieve negative feelings such as stress, anxiety, or depression. 

In this case, the temporary relief the substance brings from the negative feelings negatively reinforces
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substance use, increasing the likelihood that the person will 

use again. Importantly, positive and negative reinforcement 

need not be driven solely by the effects of the drugs. Many 

other environmental and social stimuli can reinforce a 

behavior. For example, the approval of peers positively 

reinforces substance use for some people. Likewise, if 

drinking or using drugs with others provides relief from 

social isolation, substance use behavior could be negatively 

reinforced. 

The positively reinforcing effects of substances tend to 

diminish with repeated use. This is called tolerance and may 

lead to use of the substance in greater amounts and/or more 

frequently in an attempt to experience the initial level of 

reinforcement. Eventually, in the absence of the substance, 

a person may experience negative emotions such as stress, 

anxiety, or depression, or feel physically ill. This is called 

withdrawal, which often leads the person to use the substance 

again to relieve the withdrawal symptoms. 

As use becomes an ingrained behavior, impulsivity shifts to 

compulsivity, and the primary drivers of repeated substance 

use shift from positive reinforcement (feeling pleasure) to 

negative reinforcement (feeling relief), as the person seeks to 

stop the negative feelings and physical illness that accompany 

withdrawal.15 Eventually, the person begins taking the 

substance not to get “high,” but rather to escape the “low” feelings to which, ironically, chronic drug 

use has contributed. Compulsive substance seeking is a key characteristic of addiction, as is the loss of 

control over use. Compulsivity helps to explain why many people with addiction experience relapses 

after attempting to abstain from or reduce use. 

The following sections provide more detail about each of the three stages—binge/intoxication, 

withdrawal/negative affect, and preoccupation/anticipation—and the neurobiological processes 

underlying them.

Impulsivity. An inability to resist urges, 

deficits in delaying gratification, and 

unreflective decision-making. It is 

a tendency to act without foresight 

or regard for consequences and to 

prioritize immediate rewards over longterm goals.1 

Positive reinforcement. The process 

by which presentation of a stimulus such 

as a drug increases the probability of a 

response like drug taking.

Negative reinforcement. The process 

by which removal of a stimulus such as 

negative feelings or emotions increases 

the probability of a response like drug 

taking.

Compulsivity. Repetitive behaviors 

in the face of adverse consequences, 

and repetitive behaviors that are 

inappropriate to a particular situation. 

People suffering from compulsions 

often recognize that the behaviors 

are harmful, but they nonetheless feel 

emotionally compelled to perform 

them. Doing so reduces tension, stress, 

or anxiety.1

Binge/Intoxication Stage: Basal Ganglia

The binge/intoxication stage of the addiction cycle is the stage at which an individual consumes the 

substance of choice. This stage heavily involves the basal ganglia (Figure 2.4) and its two key brain subregions, the nucleus accumbens and the dorsal striatum. In this stage, substances affect the brain in 

several ways.
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Figure 2.4: The Binge/Intoxication Stage and the Basal Ganglia

Addictive Substances “Hijack” Brain Reward Systems

All addictive substances produce feelings of pleasure. These “rewarding effects” positively reinforce 

their use and increase the likelihood of repeated use. The rewarding effects of substances involve 

activity in the nucleus accumbens, including activation of the brain’s dopamine and opioid signaling 

system. Many studies have shown that neurons that release dopamine are activated, either directly or 

indirectly, by all addictive substances, but particularly by stimulants such as cocaine, amphetamines, and 

nicotine (Figure 2.5).16 In addition, the brain’s opioid system, which includes naturally occurring opioid 

molecules (i.e., endorphins, enkephalins, and dynorphins) and three types of opioid receptors (i.e., mu, 

delta, and kappa), plays a key role in mediating the rewarding effects of other addictive substances, 

including opioids and alcohol. Activation of the opioid system 

by these substances stimulates the nucleus accumbens directly 

or indirectly through the dopamine system. Brain imaging 

studies in humans show activation of dopamine and opioid 

neurotransmitters during alcohol and other substance use 

(including nicotine).10,17 Other studies show that antagonists, 

or inhibitors, of dopamine and opioid receptors can block 

drug and alcohol seeking in both animals and humans.14,18,19

Antagonist. A chemical substance that 

binds to and blocks the activation of 

certain receptors on cells, preventing 

a biological response. Naloxone is 

an example of an opioid receptor 

antagonist.
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Cannabinoids such as delta-9-tetrahydrocannabinol (THC), the primary psychoactive component of 

marijuana, target the brain’s internal or endogenous cannabinoid system. This system also contributes 

to reward by affecting the function of dopamine neurons and the release of dopamine in the nucleus 

accumbens. 

Figure 2.5: Actions of Addictive Substances on the Brain

Notes: Figure 2.5 is a simplified schematic of converging acute rewarding actions of addictive substances on the nucleus 

accumbens (NAc). Dopamine neurons that originate in the ventral tegmental area (VTA) project to the NAc. Opioid peptides act 

both in the VTA and NAc. Despite diverse initial actions, addictive substances produce some common effects on the VTA and NAc. 

Stimulants directly increase dopamine (DA) transmission in the NAc. Opioids, alcohol, and inhalants (e.g., the solvent toluene) 

do the same indirectly. Alcohol also activates the release of opioid peptides. Heroin and prescribed opioid pain relievers directly 

activate opioid peptide receptors. Nicotine activates dopamine neurons in the VTA. Cannabinoids may act in the VTA to activate 

dopamine neurons but also act on NAc neurons themselves.

Source: Modified with permission from Nestler, (2005).16

Stimuli Associated with Addictive Substances Can Trigger 

Substance Use

Activation of the brain’s reward system by alcohol and drugs not only generates the pleasurable feelings 

associated with those substances, it also ultimately triggers changes in the way a person responds to 

stimuli associated with the use of those substances. A person learns to associate the stimuli present 

while using a substance—including people, places, drug paraphernalia, and even internal states, such 

as mood—with the substance’s rewarding effects. Over time, these stimuli can activate the dopamine 

system on their own and trigger powerful urges to take the substance. These “wanting” urges are called 

incentive salience and they can persist even after the rewarding effects of the substance have diminished. 

As a result, exposure to people, places, or things previously associated with substance use can serve as 

“triggers” or cues that promote substance seeking and taking, even in people who are in recovery. 
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Figure 2.6 shows the major neurotransmitter systems involved in the binge/intoxication stage of 

addiction. In this stage, the neurons in the basal ganglia contribute to the rewarding effects of addictive 

substances and to incentive salience through the release of dopamine and the brain’s natural opioids.

Figure 2.6: Major Neurotransmitter Systems Implicated in the Neuroadaptations Associated 

with the Binge/Intoxication Stage of Addiction

Withdrawal/

Negative

Affect

Preoccupation/

Anticipation

Prefrontal

Cortex

Extended

Amygdala

Notes: Blue represents the basal ganglia involved in the Binge/Intoxication stage. Red represents the extended amygdala involved 

in the Negative Affect/Withdrawal stage. Green represents the prefrontal cortex involved in the Preoccupation/Anticipation stage.

Abbreviations: PFC - prefrontal cortex, DS - dorsal striatum, NAc - nucleus accumbens, BNST - bed nucleus of the stria terminalis, 

CeA - central nucleus of the amygdala, VTA - ventral tegmental area. 

Source: Modified with permission from Koob & Volkow, (2010).14

Early studies in animals demonstrated how incentive salience works. For example, after researchers 

repeatedly gave an animal a stimulant drug (e.g., cocaine) along with a previously neutral stimulus, such 

as a light or a sound, they found that the neutral stimulus by itself caused the animal to engage in drugseeking behavior, and it also resulted in dopamine release that had previously occurred only in response 

to the drug.20 Even more compelling results were seen when scientists recorded the electrical activity 

of dopamine-transmitting neurons in animals that had been exposed multiple times to a neutral (non-
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drug) stimulus followed by a drug. At first, the neurons responded only when they were exposed to the 

drug. However, over time, the neurons stopped firing in response to the drug and instead fired when 

they were exposed to the neutral stimulus associated with it. This means that the animals associated the 

stimulus with the substance and, in anticipation of getting the substance, their brains began releasing 

dopamine, resulting in a strong motivation to seek the drug.21,22 Imaging studies in humans have shown 

similar results. For example, dopamine is released in the brains of people addicted to cocaine when they 

are exposed to cues they have come to associate with cocaine.23,24 This effect occurs even though cocaine 

itself causes less dopamine to be released in these individuals compared to those who are not addicted to 

cocaine (an effect also seen with other substances).25

Together, these studies indicate that stimuli associated with addictive drugs can, by themselves, produce druglike effects on the brain and trigger drug use. These findings help to explain why individuals with substance 

use disorders who are trying to maintain abstinence are at increased risk of relapse if they continue to have 

contact with the people they previously used drugs with or the places where they used drugs.

Substances Stimulate Areas of the Brain Involved in Habit 

Formation

A second sub-region of the basal ganglia, the dorsal striatum, is involved in another critical component 

of the binge/intoxication stage: habit formation. The release of dopamine (along with activation of brain 

opioid systems) and release of glutamate (an excitatory neurotransmitter) can eventually trigger changes 

in the dorsal striatum.2,26 These changes strengthen substance-seeking and substance-taking habits as 

addiction progresses, ultimately contributing to compulsive use. 

In Summary: The Binge/Intoxication Stage and the Basal Ganglia

The “reward circuitry” of the basal ganglia (i.e., the nucleus accumbens), along with dopamine and naturally 

occurring opioids, play a key role in the rewarding effects of alcohol and other substances and the ability of stimuli, 

or cues, associated with that substance use to trigger craving, substance seeking, and use. 

As alcohol or substance use progresses, repeated activation of the “habit circuitry” of the basal ganglia (i.e., the 

dorsal striatum) contributes to the compulsive substance seeking and taking that are associated with addiction. 

The involvement of these reward and habit neurocircuits helps explain the intense desire for the substance (craving) 

and the compulsive substance seeking that occurs when actively or previously addicted individuals are exposed to 

alcohol and/or drug cues in their surroundings. 

Withdrawal/Negative Affect Stage: Extended 

Amygdala

The withdrawal/negative affect stage of addiction follows the binge/intoxication stage, and, in turn, 

sets up future rounds of binge/intoxication. During this stage, a person who has been using alcohol or 

drugs experiences withdrawal symptoms, which include negative emotions and, sometimes, symptoms 

of physical illness, when they stop taking the substance. Symptoms of withdrawal may occur with all 
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addictive substances, including marijuana, though they vary in intensity and duration depending on 

both the type of substance and the severity of use. The negative feelings associated with withdrawal are 

thought to come from two sources: diminished activation in the reward circuitry of the basal ganglia14

and activation of the brain’s stress systems in the extended amygdala (Figure 2.7).

Figure 2.7: The Withdrawal/Negative Affect Stage and the Extended Amygdala

When used over the long-term, all substances of abuse cause dysfunction in the brain’s dopamine 

reward system.27 For example, brain imaging studies in humans with addiction have consistently shown 

long-lasting decreases in a particular type of dopamine receptor, the D2 receptor, compared with 

non-addicted individuals (Figure 2.8).25,28 Decreases in the activity of the dopamine system have been 

observed during withdrawal from stimulants, opioids, nicotine, and alcohol. Other studies also show 

that when an addicted person is given a stimulant, it causes a smaller release of dopamine than when the 

same dose is given to a person who is not addicted. 

These findings suggest that people addicted to substances experience an overall reduction in the sensitivity 

of the brain’s reward system (especially the brain circuits involving dopamine), both to addictive substances 

and also to natural reinforcers, such as food and sex. This is because natural reinforcers also depend upon 

the same reward system and circuits. This impairment explains why those who develop a substance use 

disorder often do not derive the same level of satisfaction or pleasure from once-pleasurable activities. 

This general loss of reward sensitivity may also account for the compulsive escalation of substance use as 

addicted individuals attempt to regain the pleasurable feelings the reward system once provided.15
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Figure 2.8: Time-Related Decrease in Dopamine Released in the Brain of a Cocaine User

 

Notes: These fMRI images compare the brain of an individual with a history of cocaine use disorder (middle and right) to the 

brain of an individual without a history of cocaine use (left). The person who has had a cocaine use disorder has lower levels of 

the D2 dopamine receptor (depicted in red) in the striatum one month (middle) and four months (right) after stopping cocaine 

use compared to the non-user. The level of dopamine receptors in the brain of the cocaine user are higher at the 4-month mark 

(right), but have not returned to the levels observed in the non-user (left). 

Source: Modified with permission from Volkow et al., (1993).29

At the same time, a second process occurs during the withdrawal stage: activation of stress 

neurotransmitters in the extended amygdala. These stress neurotransmitters include corticotropinreleasing factor (CRF), norepinephrine, and dynorphin (Figure 2.9).

30

Studies suggest that these neurotransmitters play a key role in the negative feelings associated with 

withdrawal and in stress-triggered substance use. In animal and human studies, when researchers use 

special chemicals called antagonists to block activation of the stress neurotransmitter systems, it has 

the effect of reducing substance intake in response to withdrawal and stress. For example, blocking the 

activation of stress receptors in the brain reduced alcohol consumption in both alcohol-dependent rats 

and humans with an alcohol use disorder.31 Thus, it may be that an additional motivation for drug and 

alcohol seeking among individuals with substance use disorders is to suppress overactive brain stress 

systems that produce negative emotions or feelings. Recent research also suggests that neuroadaptations 

in the endogenous cannabinoid system within the extended amygdala contribute to increased stress 

reactivity and negative emotional states in addiction.32

The desire to remove the negative feelings that accompany withdrawal can be a strong motivator 

of continued substance use. As noted previously, this motivation is strengthened through negative 

reinforcement, because taking the substance relieves the negative feelings associated with withdrawal, at 

least temporarily. Of course, this process is a vicious cycle: Taking drugs or alcohol to lessen the symptoms 

of withdrawal that occur during a period of abstinence actually causes those symptoms to be even worse 

the next time a person stops taking the substance, making it even harder to maintain abstinence.
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Figure 2.9: Major Neurotransmitter Systems Implicated in the Neuroadaptations Associated 

with the Withdrawal/Negative Affect Stage of Addiction

Notes: Not shown is the neurotransmitter norepinephrine which is also activated in the extended amygdala during withdrawal.

Abbreviations: PFC - prefrontal cortex, DS - dorsal striatum, NAc - nucleus accumbens, BNST - bed nucleus of the stria 

terminalis, CeA - central nucleus of the amygdala, VTA - ventral tegmental area.

Source: Modified with permission from Koob & Volkow, (2010).14

In Summary: The Withdrawal/Negative Affect Stage and the Extended 

Amygdala

This stage of addiction involves a decrease in the function of the brain reward systems and an activation of stress 

neurotransmitters, such as CRF and dynorphin, in the extended amygdala. Together, these phenomena provide a 

powerful neurochemical basis for the negative emotional state associated with withdrawal. The drive to alleviate 

these negative feelings negatively reinforces alcohol or drug use and drives compulsive substance taking. 

Preoccupation/Anticipation Stage: Prefrontal Cortex

The preoccupation/anticipation stage of the addiction cycle is the stage in which a person may begin to 

seek substances again after a period of abstinence. In people with severe substance use disorders, that 

period of abstinence may be quite short (hours). In this stage, an addicted person becomes preoccupied 

with using substances again. This is commonly called “craving.” Craving has been difficult to measure in 

human studies and often does not directly link with relapse. 
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This stage of addiction involves the brain’s prefrontal cortex (Figure 2.10) the region that controls executive 

function: the ability to organize thoughts and activities, prioritize tasks, manage time, make decisions, and 

regulate one’s own actions, emotions, and impulses. Executive function is essential for a person to make 

appropriate choices about whether or not to use a substance and to override often strong urges to use, 

especially when the person experiences triggers, such as stimuli associated with that substance (e.g., being 

at a party where alcohol is served or where people are smoking) or stressful experiences.

Figure 2.10: The Preoccupation/Anticipation Stage and the Prefrontal Cortex

To help explain how the prefrontal cortex is involved in addiction, some scientists divide the functions 

of this brain region into a “Go system” and an opposing “Stop system.”33 The Go system helps 

people make decisions, particularly those that require significant attention and those involved with 

planning. People also engage the Go system when they begin behaviors that help them achieve goals. 

Indeed, research shows that when substance-seeking behavior is triggered by substance-associated 

environmental cues (incentive salience), activity in the Go circuits of the prefrontal cortex increases 

dramatically. This increased activity stimulates the nucleus accumbens to release glutamate, the main 

excitatory neurotransmitter in the brain. This release, in turn, promotes incentive salience, which 

creates a powerful urge to use the substance in the presence of drug-associated cues.

The Go system also engages habit-response systems in the dorsal striatum, and it contributes to the 

impulsivity associated with substance seeking. Habitual responding can occur automatically and 

subconsciously, meaning a person may not even be aware that they are engaging in such behaviors. The 
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neurons in the Go circuits of the prefrontal cortex stimulate the habit systems of the dorsal striatum 

through connections that use glutamate (Figure 2.11). 

Figure 2.11: Major Neurotransmitter Systems Implicated in the Neuroadaptations Associated 

with the Preoccupation/Anticipation Stage of Addiction

Abbreviations: PFC - prefrontal cortex, DS - dorsal striatum, NAc - nucleus accumbens, BNST - bed nucleus of the stria 

terminalis, CeA - central nucleus of the amygdala, VTA - ventral tegmental area.

Source: Modified with permission from Koob & Volkow, (2010).14

The Stop system inhibits the activity of the Go system. Especially relevant to its role in addiction, this 

system controls the dorsal striatum and the nucleus accumbens, the areas of the basal ganglia that are 

involved in the binge/intoxication stage of addiction. Specifically, the Stop system controls habit responses 

driven by the dorsal striatum, and scientists think that it plays a role in reducing the ability of substanceassociated stimuli to trigger relapse—in other words, it inhibits incentive salience.34

The Stop system also controls the brain’s stress and emotional systems, and plays an important role in 

relapse triggered by stressful life events or circumstances. Stress-induced relapse is driven by activation of 

neurotransmitters such as CRF, dynorphin, and norepinephrine in the extended amygdala. As described 

above, these neurotransmitters are activated during prolonged abstinence during the withdrawal/negative 

affect stage of addiction. More recent work in animals also implicates disruptions in the brain’s cannabinoid 

system, which also regulates the stress systems in the extended amygdala, in relapse. Studies show that lower 

activity in the Stop component of the prefrontal cortex is associated with increased activity of stress circuitry 

involving the extended amygdala, and this increased activity drives substance-taking behavior and relapse.37
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Brain imaging studies in people with addiction show disruptions in the function of both the Go and 

Stop circuits.35-37 For example, people with alcohol, cocaine, or opioid use disorders show impairments 

in executive function, including disruption of decision-making and behavioral inhibition. These 

executive function deficits parallel changes in the prefrontal cortex and suggest decreased activity in the 

Stop system and greater reactivity of the Go system in response to substance-related stimuli.

Indeed, a smaller volume of the prefrontal cortex in abstinent, previously addicted individuals predicts a 

shorter time to relapse.38 Studies also show that diminished prefrontal cortex control over the extended 

amygdala is particularly prominent in humans with post-traumatic stress disorder (PTSD), a condition 

that is frequently accompanied by drug and alcohol use disorders.39 These findings bolster support for 

the role of the prefrontal cortex-extended amygdala circuit in stress-induced relapse, and suggest that 

strengthening prefrontal cortex circuits could aid substance use disorder treatment. 

In Summary: The Preoccupation/Anticipation Stage and the Prefrontal 

Cortex

This stage of the addiction cycle is characterized by a disruption of executive function caused by a compromised 

prefrontal cortex. The activity of the neurotransmitter glutamate is increased, which drives substance use habits 

associated with craving, and disrupts how dopamine influences the frontal cortex.2

 The over-activation of the Go 

system in the prefrontal cortex promotes habit-like substance seeking, and the under-activation of the Stop system 

of the prefrontal cortex promotes impulsive and compulsive substance seeking. 

To recap, addiction involves a three-stage cycle—binge/intoxication, withdrawal/negative affect, and 

preoccupation/anticipation—that worsens over time and involves dramatic changes in the brain reward, 

stress, and executive function systems. Progression through this cycle involves three major regions 

of the brain: the basal ganglia, the extended amygdala, and the prefrontal cortex, as well as multiple 

neurotransmitter systems (Figure 2.12). The power of addictive substances to produce positive feelings 

and relieve negative feelings fuels the development of compulsive use of substances. The combination of 

increased incentive salience (binge/intoxication stage), decreased reward sensitivity and increased stress 

sensitivity (withdrawal/negative affect stage), and compromised executive function (preoccupation/

anticipation stage) provides an often overwhelming drive for substance seeking that can be unrelenting.

Different Classes of Substances Affect the Brain and 

Behavior in Different Ways

Although the three stages of addiction generally apply to all addictive substances, different substances 

affect the brain and behavior in different ways during each stage of the addiction cycle. Differences in the 

pharmacokinetics of various substances determine the duration of their effects on the body and partly 

account for the differences in their patterns of use. For example, nicotine has a short half-life, which 

means smokers need to smoke often to maintain the effect. In contrast, THC, the primary psychoactive 

compound in marijuana, has a much longer half-life. As a result, marijuana smokers do not typically smoke 
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as frequently as tobacco smokers.40 Typical patterns of use are 

described below for the major classes of addictive substances. 

However, people often use these substances in combination.41

Additional research is needed to understand how using more 

than one substance affects the brain and the development and 

progression of addiction, as well as how use of one substance 

affects the use of others.

Pharmacokinetics. What the body does 

to a drug after it has been taken, including 

how rapidly the drug is absorbed, broken 

down, and processed by the body.

Figure 2.12: The Primary Brain Regions and Neurotransmitter Systems Involved in Each of the 

Three Stages of the Addiction Cycle 

Opioids

Opioids attach to opioid receptors in the brain, which leads to a release of dopamine in the nucleus 

accumbens, causing euphoria (the high), drowsiness, and slowed breathing, as well as reduced pain 

signaling (which is why they are frequently prescribed as pain relievers). Opioid addiction typically 

involves a pattern of: (1) intense intoxication, (2) the development of tolerance, (3) escalation in use, 

and (4) withdrawal signs that include profound negative emotions and physical symptoms, such as 
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bodily discomfort, pain, sweating, and intestinal distress and, in the most severe cases, seizures. As use 

progresses, the opioid must be taken to avoid the severe negative effects that occur during withdrawal. 

With repeated exposure to opioids, stimuli associated with the pleasant effects of the substances 

(e.g., places, persons, moods, and paraphernalia) and with the negative mental and physical effects of 

withdrawal can trigger intense craving or preoccupation with use. 

Alcohol

When alcohol is consumed it interacts with several 

neurotransmitter systems in the brain, including the inhibitory 

neurotransmitter GABA, glutamate, and others that produce 

euphoria as well as the sedating, motor impairing, and anxietyreducing effects of alcohol intoxication. Alcohol addiction 

often involves a similar pattern as opioid addiction, often 

characterized by periods of binge or heavy drinking followed 

by withdrawal. As with opioids, addiction to alcohol is characterized by intense craving that is often 

driven by negative emotional states, positive emotional states, and stimuli that have been associated with 

drinking, as well as a severe emotional and physical withdrawal syndrome. Many people with severe 

alcohol use disorder engage in patterns of binge drinking followed by withdrawal for extended periods 

of time. Extreme patterns of use may evolve into an opioid-like use pattern in which alcohol must be 

available at all times to avoid the negative consequences of withdrawal.

Binge drinking. For men, drinking 5 or 

more standard alcoholic drinks, and for 

women, 4 or more standard alcoholic 

drinks on the same occasion on at least 

1 day in the past 30 days.

Stimulants

Stimulants increase the amount of dopamine in the reward circuit (causing the euphoric high) either 

by directly stimulating the release of dopamine or by temporarily inhibiting the removal of dopamine 

from synapses, the gaps between neurons. These drugs also boost dopamine levels in brain regions 

responsible for attention and focus on tasks (which is why stimulants like methylphenidate [Ritalin®] 

or dextroamphetamine [Adderall®] are often prescribed for people with attention deficit hyperactivity 

disorder). Stimulants also cause the release of norepinephrine, a neurotransmitter that affects 

autonomic functions like heart rate, causing a user to feel energized. 

Addiction to stimulants, such as cocaine and amphetamines (including methamphetamine), typically 

follows a pattern that emphasizes the binge/intoxication stage. A person will take the stimulant 

repeatedly during a concentrated period of time lasting for hours or days (these episodes are called 

binges). The binge is often followed by a crash, characterized by negative emotions, fatigue, and 

inactivity. Intense craving then follows, which is driven by environmental cues associated with the 

availability of the substance, as well as by a person’s internal state, such as their emotions or mood.

Marijuana (Cannabis)

Like other drugs, marijuana (also called cannabis) leads to increased dopamine in the basal ganglia, 

producing the pleasurable high. It also interacts with a wide variety of other systems and circuits in 

the brain that contain receptors for the body’s natural cannabinoid neurotransmitters. Effects can be 

different from user to user, but often include distortions in motor coordination and time perception. 

Cannabis addiction follows a pattern similar to opioids. This pattern involves a significant binge/
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PAGE | 2-21

intoxication stage characterized by episodes of using the substance to the point of intoxication. Over 

time, individuals begin to use the substance throughout the day and show chronic intoxication during 

waking hours. Withdrawal is characterized by negative emotions, irritability, and sleep disturbances.40

Although the craving associated with cannabis42 has been less studied than for other substances, it is most 

likely linked to both environmental and internal states, similar to those of other addictive substances.43,44

Synthetic Drugs

Different classes of chemically synthesized (hence the term synthetic) drugs have been developed, each 

used in different ways and having different effects in the brain. Synthetic cathinones, more commonly 

known as “bath salts,” target the release of dopamine in a similar manner as the stimulant drugs described 

above. To a lesser extent, they also activate the serotonin neurotransmitter system, which can affect 

perception. Synthetic cannabinoids, sometimes referred to as “K2”, “Spice”, or “herbal incense,” somewhat 

mimic the effects of marijuana but are often much more powerful. Drugs such as MDMA (ecstasy) and 

lysergic acid diethylamide (LSD) also act on the serotonin neurotransmitter system to produce changes 

in perception. Fentanyl is a synthetic opioid medication that is used for severe pain management and is 

considerably more potent than heroin. Prescription fentanyl, as well as illicitly manufactured fentanyl 

and related synthetic opioids, are often mixed with heroin but are also increasingly used alone or sold on 

the street as counterfeit pills made to look like prescription opioids or sedatives.

Factors that Increase Risk for Substance Use, 

Misuse, and Addiction 

Not all people use substances, and even among those who use them, not all are equally likely to become 

addicted. Many factors influence the development of substance use disorders, including developmental, 

environmental, social, and genetic factors, as well as co-occurring mental disorders. Other factors protect 

people from developing a substance use disorder or addiction. The relative influence of these risk and protective 

factors varies across individuals and the lifespan. The following sections discuss some of these factors.

Early Life Experiences 

The experiences a person has early in childhood and in 

adolescence can set the stage for future substance use and, 

sometimes, escalation to a substance use disorder or addiction. 

Early life stressors can include physical, emotional, and sexual 

abuse; neglect; household instability (such as parental substance 

use and conflict, mental illness, or incarceration of household 

members);45 and poverty.46 Research suggests that the stress caused by these risk factors may act on the same 

stress circuits in the brain as addictive substances, which may explain why they increase addiction risk.47

Adolescence is a critical period in the vulnerability to substance use and use disorders, because a 

hallmark of this developmental period is risk taking and experimentation, which for some young 

people includes trying alcohol, marijuana, or other drugs. In addition, the brain undergoes significant 

changes during this life stage, making it particularly vulnerable to substance exposure.48 Importantly, 

See Chapter 1 - Introduction and 

Overview and Chapter 3 - Prevention 

Programs and Policies.
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PAGE | 2-22

the frontal cortex—a region in the front part of the brain that includes the prefrontal cortex—does not 

fully develop until the early to mid-20s, and research shows that heavy drinking and drug use during 

adolescence affects development of this critical area of the brain.49 

About three quarters (74 percent) of 18- to 30-year-olds admitted to treatment programs began using 

substances at the age of 17 or younger.50 Individuals who start using substances during adolescence 

often experience more chronic and intensive use, and they are at greater risk of developing a substance 

use disorder compared with those who begin use at an older age. In other words, the earlier the 

exposure, the greater the risk.51

Not all adolescents who experiment with alcohol, cigarettes, or other substances go on to develop a 

substance use disorder, but research suggests that those who do progress to more harmful use may have 

pre-existing differences in their brains. For example, a brain imaging study of adolescents revealed that 

the volume of the frontal cortex was smaller in youth who transitioned from no or minimal drinking 

to heavy drinking over the course of adolescence than it was in youth who did not drink during 

adolescence.49 Additional research can shed light on how these differences contribute to the progression 

from use to a disorder, as well as how changes caused by substance use affect brain function and 

behavior and whether they can be reversed. 

Genetic and Molecular Factors

Genetic factors are thought to account for 40 to 70 percent of individual differences in risk for 

addiction.52,53 Although multiple genes are likely involved in the development of addiction, only a few 

specific gene variants have been identified that either predispose to or protect against addiction. Some 

of these variants have been associated with the metabolism of alcohol and nicotine, while others involve 

receptors and other proteins associated with key neurotransmitters and molecules involved in all parts of 

the addiction cycle.54 Genes involved in strengthening the connections between neurons and in forming 

drug memories have also been associated with addiction risk.55,56 Like other chronic health conditions, 

substance use disorders are influenced by the complex interplay between a person’s genes and environment. 

Additional research on the mechanisms underlying gene by environment interactions is expected to 

provide insight into how substance use disorders develop and how they can be prevented and treated. 

Use of Multiple Substances and Co-occurring 

Mental Health Conditions

Many individuals with a substance use disorder also have a mental disorder,57,58 and some have multiple 

substance use disorders. For example, according to the 2015 National Survey on Drug Use and Health 

(NSDUH), of the 20.8 million people aged 12 or older who had a substance use disorder during the 

past year, about 2.7 million (13 percent) had both an alcohol use and an illicit drug use disorder, and 

41.2 percent also had a mental illness.59 Particularly striking is the 3- to 4-fold higher rate of tobacco 

smoking among patients with schizophrenia and the high prevalence of co-existing alcohol use disorder 

in those meeting criteria for PTSD. It is estimated that 30-60 percent of patients seeking treatment for 
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PAGE | 2-23

alcohol use disorder meet criteria for PTSD,60,61 and approximately one third of individuals who have 

experienced PTSD have also experienced alcohol dependence at some point in their lives.60

The reasons why substance use disorders and mental disorders often occur together are not clear, and 

establishing the relationships between these conditions is difficult. Still, three possible explanations 

deserve attention. One reason for the overlap may be that having a mental disorder increases 

vulnerability to substance use disorders because certain substances may, at least temporarily, be able to 

reduce mental disorder symptoms and thus are particularly negatively reinforcing in these individuals. 

Second, substance use disorders may increase vulnerability for mental disorders,62-64 meaning that the 

use of certain substances might trigger a mental disorder that otherwise would have not occurred. For 

example, research suggests that alcohol use increases risk for PTSD by altering the brain’s ability to 

recover from traumatic experiences.65,66 Similarly, the use of marijuana, particularly marijuana with a 

high THC content, might contribute to schizophrenia in those who have specific genetic vulnerabilities.67

Third, it is also possible that both substance use disorders and mental disorders are caused by shared, 

overlapping factors, such as particular genes, neurobiological deficits, and exposure to traumatic or 

stressful life experiences. As these possibilities are not mutually exclusive, the relationship between 

substance use disorders and mental disorders may result from a combination of these processes. 

Regardless of which one might influence the development of the other, mental and substance use 

disorders have overlapping symptoms, making diagnosis and treatment planning particularly 

difficult. For example, people who use methamphetamine for a long time may experience paranoia, 

hallucinations, and delusions that may be mistaken for symptoms of schizophrenia. And, the 

psychological symptoms that accompany withdrawal, such as depression and anxiety, may be mistaken 

as simply part of withdrawal instead of an underlying mood disorder that requires independent 

treatment in its own right. Given the prevalence of co-occurring substance use and mental disorders, 

it is critical to continue to advance research on the genetic, neurobiological, and environmental factors 

that contribute to co-occurring disorders and to develop interventions to prevent and treat them.

Biological Factors Contributing to Population-based 

Differences in Substance Misuse and Substance Use 

Disorders

Differences Based on Sex 

Some groups of people are also more vulnerable to substance misuse and substance use disorders. For 

example, men tend to drink more than women and they are at higher risk for alcohol use disorder, 

although the gender differences in alcohol use are declining.68 Men are also more likely to have other 

substance use disorders.69 However, clinical reports suggest that women who use cocaine, opioids, or 

alcohol progress from initial use to a disorder at a faster rate than do men (called “telescoping”).70-72 

Compared with men, women also exhibit greater symptoms of withdrawal from some drugs, such as 

nicotine. They also report worse negative affects during withdrawal and have higher levels of the stress 

hormone cortisol.73
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Sex differences in reaction to addictive substances are not particular to humans. Female rats, in general, 

learn to self-administer drugs and alcohol more rapidly, escalate their drug taking more quickly, show 

greater symptoms of withdrawal, and are more likely to resume drug seeking in response to drugs, 

drug-related cues, or stressors. The one exception is that female rats show less withdrawal symptoms 

related to alcohol use.74 Researchers are investigating the neurobiological bases for these differences. 

Differences Based on Race and Ethnicity

Research on the neurobiological factors contributing to differential rates of substance use and substance 

use disorders in particular racial and ethnic groups is much more limited. A study using functional 

magnetic resonance imaging (fMRI) found that African American smokers showed greater activation of 

the prefrontal cortex upon exposure to smoking-related cues than did White smokers, an effect that may 

partly contribute to the lower smoking-cessation success rates observed among African Americans.75

Alcohol research with racial and ethnic groups has shown that approximately 36 percent of East Asians 

carry a gene variant that alters the rate at which members of that racial group metabolize alcohol, causing a 

buildup of acetaldehyde, a toxic byproduct of alcohol metabolism that produces symptoms such as flushing, 

nausea, and rapid heartbeat. Although these effects may protect some individuals of East Asian descent 

from alcohol use disorder, those who drink despite the effects are at increased risk for esophageal76 and 

head and neck cancers.77 Another study found that even low levels of alcohol consumption by Japanese 

Americans may result in adverse effects on the brain, a finding that may be related to the differences in 

alcohol metabolism described above.78 Additional research will help to clarify the interactions between race, 

ethnicity, and the neuroadaptations that underlie substance misuse and addiction. This work may inform 

the development of more precise preventive and treatment interventions.

Recommendations for Research 

Decades of research demonstrate that chronic substance misuse leads to profound disruptions of brain 

circuits involved in the experience of pleasure or reward, habit formation, stress, and decision-making. 

This work has paved the way for the development of a variety of therapies that effectively help people 

reduce or abstain from alcohol and drug misuse and regain control over their lives. In spite of this 

progress, our understanding of how substance use affects the brain and behavior is far from complete. 

Four research areas are specifically emphasized in the text below.

Effects of Substance Use on Brain Circuits and Functions 

Continued research is necessary to more thoroughly explain how substance use affects the brain 

at the molecular, cellular, and circuit levels. Such research has the potential to identify common 

neurobiological mechanisms underlying substance use disorders, as well as other related mental 

disorders. This research is expected to reveal new neurobiological targets, leading to new medications 

and non-pharmacological treatments—such as transcranial magnetic stimulation or vaccines—for 

the treatment of substance use disorders. A better understanding of the neurobiological mechanisms 

underlying substance use disorders could also help to inform behavioral interventions. Therefore, 

basic research that further elucidates the neurobiological framework of substance use disorders and 
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PAGE | 2-25

co-occurring mental disorders, as well as research leading to the development of new medications 

and other therapeutics to treat the underlying neurobiological mechanisms of substance use disorders 

should be accelerated. 

As with other diseases, individuals vary in the development and progression of substance use disorders. 

Not only are some people more likely to use and misuse substances than are others and to progress from 

initial use to addiction differently, individuals also differ in their vulnerability to relapse and in how 

they respond to treatments. For example, some people with substance use disorders are particularly 

vulnerable to stress-induced relapse, but others may be more likely to resume substance use after being 

exposed to drug-related cues. Developing a thorough understanding of how neurobiological differences 

account for variation among individuals and groups will guide the development of more effective, 

personalized prevention and treatment interventions. Additionally, determining how neurobiological 

factors contribute to differences in substance misuse and addiction between women and men and 

among racial and ethnic groups is critical. 

Continued advances in neuroscience research will further enhance our understanding of substance 

use disorders and accelerate the development of new interventions. Data gathered through the 

National Institutes of Health’s Adolescent Brain Cognitive Development study, the largest long-term 

study of cognitive and brain development in children across the United States, is expected to yield 

unprecedented information about how substance use affects adolescent brain development. The 

Human Connectome Project and the Brain Research through Advancing Innovative Neurotechnologies 

(BRAIN) initiative are poised to spur an explosion of knowledge about the structure and function 

of brain circuits and how the brain affects behavior. Technologies that can alter the activity of 

dysfunctional circuits are being explored as possible treatments. Moreover, continued advances in 

genomics, along with President Obama’s Precision Medicine Initiative, a national effort to better 

understand how individual variability in genes, environment, and lifestyle contribute to disease, 

are expected to bring us closer to developing individually-tailored preventive and treatment 

interventions for substance-related conditions. 

Neurobiological Effects of Recovery

Little is known about the factors that facilitate or inhibit long-term recovery from substance use 

disorders or how the brain changes over the course of recovery. Developing a better understanding 

of the recovery process, and the neurobiological mechanisms that enable people to maintain changes 

in their substance use behavior and promote resilience to relapse, will inform the development of 

additional effective treatment and recovery support interventions. Therefore, an investigation of the 

neurobiological processes that underlie recovery and contribute to improvements in social, educational, 

and professional functioning is necessary.
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PAGE | 2-26

Adolescence, Brain Change, and Vulnerability to Substance Use 

Disorders

Although young people are particularly vulnerable to 

the adverse effects of substance use, not all adolescents 

who experiment with alcohol or drugs go on to develop a 

substance use disorder. Prospective, longitudinal studies are 

needed to investigate whether pre-existing neurobiological 

factors contribute to adolescent substance use and the 

development of substance use disorders, how adolescent 

substance use affects brain structure and function, and whether the changes in brain structure and 

function that accompany chronic substance use can recover over time. Studies that follow groups of 

adolescents over time to learn about the developing human brain should be conducted. These studies 

should investigate how pre-existing neurobiological factors contribute to substance use, misuse, and 

addiction, and how adolescent substance use affects brain function and behavior.

Longitudinal study. A type of study 

in which data on a particular group of 

people are gathered repeatedly over a 

period of years or even decades. 

Neurobiological Effects of Polysubstance Use and Emerging 

Drug Products

Patterns of alcohol and drug use change over time. New drugs or drug combinations, delivery systems, 

and routes of administration emerge, and with them new questions for public health. For example, 

concern is growing that increasing use of marijuana extracts with extremely high amounts of THC 

could lead to higher rates of addiction among marijuana users. Concerns also are emerging about how 

new products about which little is known, such as synthetic cannabinoids and synthetic cathinones, 

affect the brain. Additional research is needed to better understand how such products - as well as 

emerging addictive substances - affect brain function and behavior, and contribute to addiction.
NEUROBIOLOGY

PAGE | 2-27

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Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593-602.

62. Jacobsen, L. K., Southwick, S. M., & Kosten, T. R. (2001). Substance use disorders in patients 

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63. Leeies, M., Pagura, J., Sareen, J., & Bolton, J. M. (2010). The use of alcohol and drugs to self‐

medicate symptoms of posttraumatic stress disorder. Depression and Anxiety, 27(8), 731-736.

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65. Anthenelli, R. M. (2010). Focus on: Comorbid mental health disorders. Alcohol Research & Health, 

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67. Kelley, M. E., Wan, C. R., Broussard, B., Crisafio, A., Cristofaro, S., Johnson, S., . . . Walker, E. F. 

(2016). Marijuana use in the immediate 5-year premorbid period is associated with increased risk 

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subjects. Journal of the Neurological Sciences, 278(1), 30-34.
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CHAPTER 3.

PREVENTION PROGRAMS 

AND POLICIES

Chapter 3 Preview 

As discussed in earlier chapters, the misuse of alcohol and drugs and substance use disorders has a huge 

impact on public health in the United States. In 2014, over 43,000 people died from a drug overdose, more 

than in any previous year on record2 and alcohol misuse accounts for about 88,000 deaths in the United 

States each year (including 1 in 10 total deaths among working-age adults).4 The yearly economic impact 

of alcohol misuse and alcohol use disorders is estimated at $249 billion ($2.05 per drink) in 20106 and the 

impact of illicit drug use and drug use disorders is estimated at $193 billion–figures that include both direct 

and indirect costs related to crime, health, and lost productivity.7 Over half of these alcohol-related deaths 

and three-quarters of the alcohol-related economic costs were due to binge drinking. In addition, alcohol is 

involved in about 20 percent of the overdose deaths related to prescription opioid pain relievers.6

Substance misuse is also associated with a wide range of health and social problems, including heart 

disease, stroke, high blood pressure, various cancers (e.g., breast cancer), mental disorders, neonatal 

abstinence syndrome (NAS), driving under the influence (DUI) and other transportation-related 

injuries,8,9 sexual assault and rape,10,11 unintended pregnancy, sexually transmitted infections,12

intentional and unintentional injuries,13 and property crimes.14

See Chapter 4 - Early Intervention, 

Treatment, and Management of 

Substance Use Disorders.

Given the impact of substance misuse on public health and the 

increased risk for long-term medical consequences, including 

substance use disorders, it is critical to prevent substance 

misuse from starting and to identify those who have already 

begun to misuse substances and intervene early. Evidencebased prevention interventions, carried out before the need for 

treatment, are critical because they can delay early use and stop the progression from use to problematic 

use or to a substance use disorder (including its severest form, addiction), all of which are associated 

with costly individual, social, and public health consequences.6,15-17 This chapter will demonstrate that 

prevention can markedly reduce the burden of disease and related costs. The good news is that there is 

strong scientific evidence supporting the effectiveness of prevention programs and policies. 
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This chapter uses the term evidence-based interventions (EBIs) to refer to programs and policies 

supported by research. The chapter discusses the predictors of substance use initiation early in life and 

substance misuse throughout the lifespan, called risk factors, as well as factors that can mitigate those 

risks, called protective factors. The chapter also includes a system of categorizing prevention strategies 

defined by the Institute of Medicine (IOM).18 This discussion is followed by a review of rigorous 

research on substance use initiation and misuse prevention programs that have demonstrated evidence 

of effectiveness. The chapter continues with a review of the rigorous research on the effectiveness 

and population impact of prevention policies, most of which are associated with alcohol misuse, 

as there is limited scientific literature on policy interventions for other drugs. Detailed reviews of 

these programs and policies are in Appendix B - Evidence-Based Prevention Programs and Policies. The 

chapter then describes how communities can build the capacity to implement effective programs and 

policies community wide to prevent substance use and related harms, and concludes with research 

recommendations. 

KEY FINDINGS*

• Well-supported scientific evidence exists for robust predictors (risk and protective factors) of substance 

use and misuse from birth through adulthood. These predictors show much consistency across gender, 

race and ethnicity, and income. 

• Well-supported scientific evidence demonstrates that a variety of prevention programs and alcohol 

policies that address these predictors prevent substance initiation, harmful use, and substance userelated problems, and many have been found to be cost-effective. These programs and policies are 

effective at different stages of the lifespan, from infancy to adulthood, suggesting that it is never too 

early and never too late to prevent substance misuse and related problems.

• Communities and populations have different levels of risk, protection, and substance use. Wellsupported scientific evidence shows that communities are an important organizing force for bringing 

effective EBIs to scale. To build effective, sustainable prevention across age groups and populations, 

communities should build cross-sector community coalitions which assess and prioritize local levels of 

risk and protective factors and substance misuse problems and select and implement evidence-based 

interventions matched to local priorities.

• Well-supported scientific evidence shows that federal, state, and community-level policies designed 

to reduce alcohol availability and increase the costs of alcohol have immediate, positive benefits in 

reducing drinking and binge drinking, as well as the resulting harms from alcohol misuse, such as motor 

vehicle crashes and fatalities.

• There is well-supported scientific evidence that laws targeting alcohol-impaired driving, such as 

administrative license revocation and lower per se legal blood alcohol limits for adults and persons under the 

legal drinking age, have helped cut alcohol-related traffic deaths per 100,000 in half since the early 1980s.

• As yet, insufficient evidence exists of the effects of state policies to reduce inappropriate prescribing of 

opioid pain medications. 

*The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence as: “Well-supported”: 

when evidence is derived from multiple controlled trials or large-scale population studies; “Supported”: when 

evidence is derived from rigorous but fewer or smaller trials; and “Promising”: when evidence is derived from a 

practical or clinical sense and is widely practiced.5
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Why We Should Care About Prevention

Beginning in the twentieth century, the major illnesses leading to death shifted from infectious diseases, 

such as tuberculosis and infections in newborns, to noncommunicable diseases, such as heart disease, 

diabetes, and cancer. This shift was a result of effective public health interventions, such as improved 

sanitation and immunizations that reduced the rate of infectious diseases, as well as increased rates of 

unhealthy behaviors and lifestyles, including smoking, poor nutrition, physical inactivity, and substance 

misuse. In fact, behavioral health problems such as substance use, violence, risky driving, mental health 

problems, and risky sexual activity are now the leading causes of death for those aged 15 to 24.19

To effectively prevent substance misuse, it is important to understand the nature of the problem, including 

age of onset. Although people generally start using and misusing substances during adolescence, misuse 

can begin at any age and can continue to be a problem across the lifespan. As seen in Figure 3.1, likelihood 

of substance use escalates dramatically across adolescence, peaks in a person’s twenties, and declines 

thereafter. For example, the highest prevalence of past month binge drinking and marijuana use occurs at 

ages 21 and 20, respectively. Other drugs follow similar trajectories, although their use typically begins at 

a later age.20 Early substance misuse, including alcohol misuse, is associated with a greater likelihood of 

developing a substance use disorder later in life.21,22 Of those who begin using a substance, the percentage 

of those who develop a substance use disorder, and the rate at which they develop it, varies by substance.

Figure 3.1: Past-Month Alcohol Use, Binge Alcohol Use, and Marijuana Use, by Age: 

Percentages, 2015 National Survey on Drug and Health (NSDUH)

Note: Binge alcohol use is defined as drinking five or more drinks (for males) or four or more drinks (for females) on the same 

occasion (i.e., at the same time or within a couple of hours of each other) on at least 1 day in the past 30 days.

Source: Center for Behavioral Health Statistics and Quality, (2016).20
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It is important to note that the vast majority of people in the United States who misuse substances do 

not have substance use disorders.20,23 Nonetheless, substance misuse can put individual users and others 

around them at risk of harm, whether or not they have a disorder. Also, early initiation, substance 

misuse, and substance use disorders are associated with a variety of negative consequences, including 

deteriorating relationships, poor school performance, loss of employment, diminished mental health, 

and increases in sickness and death (e.g., motor vehicle crashes, poisoning, violence, or accidents).15-17

It is therefore critical to prevent the full spectrum of substance misuse problems in addition to treating 

those with substance use disorders. 

Preventing or reducing early substance use initiation, substance misuse, and the harms related to misuse 

requires the implementation of effective programs and policies that address substance misuse across 

the lifespan. The prevention science reviewed in this chapter demonstrates that effective prevention 

programs and policies exist, and if implemented well, they can markedly reduce substance misuse 

and related threats to the health of the population. However, evidence-based programs and policies 

are underutilized. For example, studies have found that many schools and communities are using 

prevention programs and strategies that have little or no evidence of effectiveness.24,25 In fact, underuse 

of effective prevention programs and policies was the impetus for the creation of Communities That Care

(CTC), a prevention service delivery system that promotes healthy youth development, improves youth 

outcomes, and reduces substance use and other problem behavior.26

At the policy level, research shows that higher alcohol prices reduce alcohol misuse and related harms 

(e.g., alcohol-related motor vehicle crashes),27-31 and taxes are one component of price. As of January 1, 

2015, 42 states had a beer excise tax of less than $0.50 per gallon, while only four states had an excise tax 

more than $1.00 per gallon (Table 3.4).

32,33

Risk and Protective Factors 

Longitudinal research has identified predictors of substance 

use and other behavioral health problems that are targets 

for preventive interventions.34-36 Risk and protective factors 

influence the likelihood that a person will use a substance and 

whether they will develop a substance use disorder. 

Risk factors. Factors that increase the 

likelihood of beginning substance use, 

of regular and harmful use, and of other 

behavioral health problems associated 

with use.

Protective factors. Factors that 

directly decrease the likelihood of 

substance use and behavioral health 

problems or reduce the impact of risk 

factors on behavioral health problems.

Risk and protective factors become influential at different 

times during development, and they often relate to 

physiological changes that occur over the course of 

development or to factors in a person’s environment—for 

example, biological transitions such as puberty or social 

transitions such as attending a new school, parental divorce 

or military deployment, or graduation.37 These factors can be 

influenced by programs and policies at multiple levels, including the federal, state, community, family, 

school, and individual levels.38-41 Targeted programs implemented at the family, school, and individual 

levels can complement the broader population-level policy interventions, and assist in reducing specific 

risk factors (Table 3.1) and promoting protective factors (Table 3.2). Although there are exceptions, most 
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risk and protective factors associated with substance use also predict other problems affecting youth, 

including delinquency, psychiatric conditions, violence, and school dropout. Therefore, programs 

and policies addressing those common or overlapping predictors of problems have the potential to 

simultaneously prevent substance misuse as well as other undesired outcomes.42-44

Some risk and protective factors appear to have consistent effects across cultural and gender groups, 

although low-income and disadvantaged populations are generally exposed to more risk factors, 

including risk factors within the environment, and to fewer protective factors than are other groups in 

the population. However, research has shown that binge drinking is more common among individuals 

in higher income households as compared to lower income households.45 This has implications for 

the types of prevention programs and policies that might be most successful with disadvantaged 

populations. Despite the similarities in many identified risk factors across groups, it is important to 

examine whether there are subpopulation differences in the exposure of groups to risk factors.

Table 3.1: Risk Factors for Adolescent and Young Adult Substance Use

Risk Factors Definition

Adolescent 

Substance 

Use

Young Adult 

Substance 

Use

Individual/Peer

Early initiation of substance use46,47 Engaging in alcohol or drug use at a 

young age.  

Early and persistent problem 

behavior48,49

Emotional distress, aggressiveness, and 

“difficult” temperaments in adolescents. 

Rebelliousness48,50 High tolerance for deviance and 

rebellious activities.  

Favorable attitudes toward 

substance use51,52

Positive feelings towards alcohol or drug 

use, low perception of risk.  

Peer substance use53-55 Friends and peers who engage in alcohol 

or drug use.  

Genetic predictors56 Genetic susceptibility to alcohol or drug 

use.  

Family

Family management problems 

(monitoring, rewards, etc.)57-60

Poor management practices, including 

parents’ failure to set clear expectations 

for children’s behavior, failure to supervise 

and monitor children, and excessively 

severe, harsh, or inconsistent punishment.

 

Family conflict61-63

Conflict between parents or between 

parents and children, including abuse or 

neglect.

 

Favorable parental attitudes64,65

Parental attitudes that are favorable 

to drug use and parental approval of 

drinking and drug use.

 

Family history of substance 

misuse66,67

Persistent, progressive, and generalized 

substance use, misuse, and use disorders 

by family members.

 
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Risk Factors Definition

Adolescent 

Substance 

Use

Young Adult 

Substance 

Use

School

Academic failure beginning in late 

elementary school68,69 Poor grades in school.  

Lack of commitment to school70,71

When a young person no longer considers 

the role of the student as meaningful 

and rewarding, or lacks investment or 

commitment to school.

 

Community

Low cost of alcohol30,72 Low alcohol sales tax, happy hour 

specials, and other price discounting.  

High availability of substances73,74

High number of alcohol outlets in a 

defined geographical area or per a sector 

of the population.

 

Community laws and norms 

favorable to substance use75,76

Community reinforcement of norms 

suggesting alcohol and drug use is 

acceptable for youth, including low tax 

rates on alcohol or tobacco or community 

beer tasting events.

 

Media portrayal of alcohol use77-79 Exposure to actors using alcohol in 

movies or television. 

Low neighborhood attachment80,81 Low level of bonding to the 

neighborhood. 

Community disorganization82,83

Living in neighborhoods with high 

population density, lack of natural 

surveillance of public places, physical 

deterioration, and high rates of adult 

crime.



Low socioeconomic status84,85

A parent’s low socioeconomic status, 

as measured through a combination of 

education, income, and occupation.



Transitions and mobility80,86 Communities with high rates of mobility 

within or between communities. 

Table 3.2: Protective Factors for Adolescent and Young Adult Substance Use

Protective Factors Definition

Adolescent 

Substance 

Use

Young Adult 

Substance 

Use

Individual

Social, emotional, behavioral, 

cognitive, and moral competence87,88

Interpersonal skills that help youth 

integrate feelings, thinking, and actions to 

achieve specific social and interpersonal 

goals.

 

Self-efficacy89,90 An individual’s belief that they can modify, 

control, or abstain from substance use.  

Spirituality91,92 Belief in a higher being, or involvement in 

spiritual practices or religious activities.  
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Protective Factors Definition

Adolescent 

Substance 

Use

Young Adult 

Substance 

Use

Resiliency88

An individual’s capacity for adapting to 

change and stressful events in healthy and 

flexible ways.

 

Family, School, and Community

Opportunities for positive social 

involvement93,94

Developmentally appropriate 

opportunities to be meaningfully involved 

with the family, school, or community.

 

Recognition for positive behavior51

Parents, teachers, peers and community 

members providing recognition for 

effort and accomplishments to motivate 

individuals to engage in positive behaviors 

in the future.

 

Bonding95-97

Attachment and commitment to, and 

positive communication with, family, 

schools, and communities.

 

Marriage or committed relationship98

Married or living with a partner in a 

committed relationship who does not 

misuse alcohol or drugs.



Healthy beliefs and standards for 

behavior51,99

Family, school, and community norms 

that communicate clear and consistent 

expectations about not misusing alcohol 

and drugs. 

 

Note: These tables present some of the key risk and protective factors related to adolescent and young adult substance initiation 

and misuse. 

Types of Prevention Interventions 

The IOM has described three categories of prevention interventions: universal, selective, and indicated.

18

Universal interventions are aimed at all members of a given population (for instance, all children of a 

certain age); selective interventions are aimed at a subgroup determined to be at high-risk for substance use 

(for instance, justice-involved youth); indicated interventions are targeted to individuals who are already 

using substances but have not developed a substance use disorder. Communities must choose from these 

three types of preventive interventions, but research has not yet been able to suggest an optimal mix. 

Communities may think it is best to direct services only to those with the highest risk and lowest protection 

or to those already misusing substances.100 However, a relatively high percentage of substance misuserelated problems come from people at lower risk, because they are a much larger group within the total 

population than are people at high-risk. This follows what is known as the Prevention Paradox: “a large 

number of people at a small risk may give rise to more cases of disease than the small number who are at 

a high risk.”1 By this logic, providing prevention interventions to everyone (i.e., universal interventions) 

rather than only to those at highest risk is likely to have greater benefits.3

One advantage of a properly implemented universal prevention intervention is that it is likely to reach 

most or all of the population (for example, school-based interventions are likely to reach all students). 

Targeted (selective and indicated) approaches are likely to miss a large percentage of their targets, but 
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they provide more intensive services to those who are reached. Because the best mix of interventions 

has not yet been determined, it is prudent for communities to provide a mix of universal, selective, and 

indicated preventive interventions.

Universal Prevention Interventions 

Universal interventions attempt to reduce specific health problems across all people in a particular 

population by reducing a variety of risk factors and promoting a broad range of protective factors. 

Examples of universal interventions include policies—such as the setting of a minimum legal drinking 

age (MLDA) or reducing the availability of substances in a community—and school-based programs that 

promote social and emotional competencies to reduce stress, express emotion appropriately, and resist 

negative social influences. Because they focus on the entire population, universal interventions tend to 

have the greatest overall impact on substance misuse and related harms relative to interventions focused 

on individuals alone.18

Selective Interventions

Selective interventions are delivered to particular communities, families, or children who, due to their 

exposure to risk factors, are at increased risk of substance misuse problems. Target audiences for 

selective interventions may include families living in poverty, the children of depressed or substanceusing parents, or children who have difficulties with social skills. Selective interventions typically 

deliver specialized prevention services to individuals with the goal of reducing identified risk factors, 

increasing protective factors, or both. Selective programs focus effort and resources on interventions 

that are intentionally designed for a specific high-risk group.101 Selective programs have an advantage 

in that they focus effort and resources on those who are at higher risk for developing behavioral health 

problems. In so doing, they allow planners to create interventions that are more specifically designed for 

that audience. However, they are typically not population-based and therefore, compared to populationlevel interventions, they have more limited reach.

Indicated Interventions

Indicated prevention interventions are directed to those who are already involved in a risky behavior, 

such as substance misuse, or are beginning to have problems, but who have not yet developed a 

substance use disorder. Such programs are often intensive and expensive but may still be cost-effective, 

given the high likelihood of an ensuing expensive disorder or other costly negative consequences in the 

future.102

Evidence-based Prevention Programs

This section identifies universal, selective, and indicated prevention programs that have been shown to 

successfully reduce the number of people who start using alcohol or drugs or who progress to harmful 

use. Inclusion of the programs here was based on an extensive review of published research studies. Of 

the 600 programs considered, 42 met criteria to be included in this Report. Studies on programs that 
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included people who already had a substance use or related disorder were excluded. The review used 

standard literature search procedures which are summarized in detail in Appendix A - Review Process 

for Prevention Programs. 

The vast majority of prevention studies have been conducted on children, adolescents, and young 

adults, but prevention trials of older populations meeting the criteria were also included. Programs 

that met the criteria are categorized as follows: Programs for children younger than age 10 (or their 

families); programs for adolescents aged 10 to 18; programs for individuals ages 18 years and older; 

and programs coordinated by community coalitions. Due to the number of programs that have 

proven effective, the following sections highlight just a few of the effective programs from the more 

comprehensive tables in Appendix B - Evidence-Based Prevention Programs and Policies, which describe 

the outcomes of all the effective prevention programs. Representative programs highlighted here were 

chosen for each age group, domain, and level of intervention, and with attention to coverage of specific 

populations and culturally based population subgroups. It is important to note that screening and brief 

intervention (SBI) and electronic SBI for reducing alcohol misuse have been recognized as effective 

strategies for identifying and reducing substance misuse among adults, but these are discussed in detail 

in Chapter 4 -Early Intervention, Treatment, and Management of Substance Use Disorders as effective early 

intervention strategies.103-106

Interventions for Youth Aged 0 to 10

Few substance use prevention programs for children under the age of 10 have been evaluated for their 

effect on substance misuse and related problems. Such studies are rare because they require expensive 

long-term follow-up tracking and assessment to demonstrate an impact on substance initiation or 

misuse years or decades into the future. Consistent with general strategies to increase protective factors 

and decrease risk factors, universal prevention interventions for infants, preschoolers, and elementary 

school students have primarily focused on building healthy parent-child relationships, decreasing 

aggressive behavior, and building children’s social, emotional, and cognitive competence for the 

transition to school. Both universal and selective programs have shown reductions in child aggression 

and improvements in social competence and relations with peers and adults (generally predictive of 

favorable longer-term outcomes), but only a few have studied longer-term effects on substance use.107,108

Select programs showing positive effects are described below. 

Nurse-Family Partnership

Only one program that focused on children younger than age 5—the Nurse-Family Partnership—has 

shown significant reductions in the use of alcohol in the teen years compared with those who did 

not receive the intervention.

109,110 This selective prevention program uses trained nurses to provide 

an intensive home visitation intervention for at-risk, first-time mothers during pregnancy. This 

intervention provides ongoing education and support to improve pregnancy outcomes and infant health 

and development while strengthening parenting skills.
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The Good Behavior Game and Classroom-Centered Intervention

One universal elementary school-based prevention program has shown long-term preventive effects on 

substance use among a high-risk subgroup, males with high levels of aggression. The Good Behavior Game 

is a classroom behavior management program that rewards children for acting appropriately during 

instructional times through a team-based award system. Implemented by Grade 1 and 2 teachers, this 

program significantly lowered rates of alcohol, other substance use, and substance use disorders when 

the children reached the ages of 19 to 21.111 The Classroom-Centered Intervention, which combined the Good 

Behavior Game with additional models of teacher instruction, also reduced rates of cocaine and heroin 

use in middle and high school, but it had no preventive effects on alcohol or marijuana initiation.112,113 

Raising Healthy Children

A number of multicomponent, universal, elementary school programs involving both schools and 

parents are effective in preventing substance misuse.114,115 One example is the Raising Healthy Children

program (also known as Seattle Social Development Project) which targets Grades 1 through 6 and combines 

social and emotional learning, classroom instruction and management training for teachers, and 

training for parents conducted by school-home coordinators, who work with the children in school 

and the parents at home, focusing on in-home problem solving and similar workshops. Studies of this 

program showed reductions in heavy drinking at age 18 (6 years after the intervention)114,115 and in rates 

of alcohol and marijuana use.115 

The Fast Track Program

Two multicomponent selective and universal prevention programs were effective. An example is the Fast 

Track Program, an intensive 10-year intervention that was implemented in four United States locations 

for children with high rates of aggression in Grade 1. The program includes universal and selective 

components to improve social competence at school, early reading tutoring, and home visits as well as 

parenting support groups through Grade 10. Follow-up at age 25 showed that individuals who received 

the intervention as adolescents decreased alcohol and other substance misuse, with the exception of 

marijuana use.116 

Interventions for Adolescents Aged 10 to 18 

A variety of universal interventions focused on youth aged 10 to 18 have been shown to affect either 

the initiation or escalation of substance use.117-124 In general, school-based programs share a focus 

on building social, emotional, cognitive, and substance refusal skills and provide children accurate 

information on rates and amounts of peer substance use.119,120,124

School-based Programs

One well-researched and widely used program is LifeSkills Training, a school-based program delivered 

over 3 years.117 Research has shown that this training delayed early use of alcohol, tobacco, and other 

substances and reduced rates of use of all substances up to 5 years after the intervention ended. A 

multicultural model, keepin’it REAL, uses student-developed videos and narratives and has shown 
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positive effects on substance use among Mexican American youth in the Southwestern United States.121

Another example is Project Toward No Drug Abuse, which focuses on youth who are at high risk for drug 

use and violence. It is designed for youth who are attending alternative high schools but can be delivered 

in traditional high schools as well. The twelve 40-minute interactive sessions have shown positive 

effects on alcohol and drug misuse.125

Family-based Programs

A number of family-focused, universal prevention interventions show substantial preventive effects 

on substance use.126-130 For example, Strengthening Families Program: For Parents and Youth 10–14 (SFP) 

is a widely used seven-session universal, family-focused program that enhances parenting skills—

specifically nurturing, setting limits, and communicating—as well as adolescent substance refusal 

skills. Across multiple studies conducted in rural United States communities, SFP showed reductions 

in tobacco, alcohol, and drug use up to 9 years after the intervention (i.e., to age 21) compared with 

youth who were not assigned to the SFP.126,130 SFP also shows reductions in prescription drug misuse 

up to 13 years after the intervention (i.e., to age 25), both on its own and when paired with effective 

skills-focused school-based prevention.131,132 Strong African American Families, a cultural adaptation of 

SFP, shows reductions in early initiation and rate of alcohol use for Black or African American rural 

youth.127-129

Three selective programs focus on interventions with families.133-135 An example is Familias Unidas, a 

family-based intervention for Hispanic or Latino youth. It includes both multi-parent groups (eight 

weekly 2-hour sessions) and four to ten 1-hour individual family visits and has been shown to lower 

substance use or delay the start of substance use among adolescents.133

A number of selective and indicated interventions successfully prevent substance misuse when delivered 

to youth aged 10 to 18.125,136-142 Most of these interventions target students who show early aggressive 

behavior, delinquency, or early substance use, as these are risk factors for later substance misuse, and 

some offer both a youth component in the classroom setting and a parent component. An example 

is Coping Power, a 16-month program for children in Grades 5 and 6 who were identified with early 

aggression. The program, which is designed to build problem-solving and self-regulation skills, has both 

a parent and a child component and reduces early substance use.136

Internet-based Programs

A number of computer- and Internet-based interventions also show positive effects on preventing 

substance use.143-146 An example is I Hear What You’re Saying, which involves nine 45-minute sessions to 

improve communication, establish family rules, and manage conflict. Specifically focused on mothers and 

daughters, follow-up results showed lower rates of substance use in an ethnically diverse sample.143-145

Additionally, Project Chill, a brief intervention (30 to 45 minutes) delivered in primary care settings through 

either a computer or a therapist, reduced the number of youth who started using marijuana.146 
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Programs for Young Adults 

Young adulthood is a key developmental period, when individuals are exposed to new social contexts 

with greater freedom and less social control than they experienced during their high school years. Social 

roles are changing at the same time that social safety net supports are weakening.147 In addition, many 

young adults are undergoing transitions, such as leaving home, leaving the compulsory educational 

system, beginning college, entering the workforce, and forming families. As a result of all these forces, 

young adulthood is typically associated with increases in substance use, misuse, and misuse-related 

consequences. 

Numerous studies have examined the effectiveness of brief alcohol interventions for adolescents 

and young adults. One review examined 185 such experimental studies among adolescents aged 11 

to 18 and adults aged 19 to 30. Overall, brief alcohol interventions were associated with significant 

reductions in alcohol consumption and alcohol-related problems in both adults and adolescents, and in 

some studies, effects persisted up to one year.148 The United States Preventive Services Task Force has 

recommended screening and brief intervention for reducing alcohol misuse among adults, as discussed 

in Chapter 4 - Early Intervention, Treatment, and Management Of Substance Use Disorders, and the 

American Academy of Pediatrics recommends that screening and brief interventions for alcohol misuse 

or use disorders be implemented for adolescent patients as well.149

Programs for College Students

Many interventions have been developed to reduce alcohol and marijuana misuse among college students. 

Several literature reviews of alcohol screening and brief interventions in this population have reported 

that these interventions reduce college student drinking,150-154 and several other interventions for college 

students have shown longer term reductions in substance misuse.155-165 One analysis reviewed 41 studies 

with 62 individual or group interventions and found that recipients of interventions experienced reduced 

alcohol use and fewer alcohol related problems up to four years post intervention.166 Effective intervention 

components were personalized feedback, protective strategies to moderate drinking, setting alcoholrelated goals, and challenging alcohol expectancies. Interventions with four or more components were 

most effective. Two example interventions for college students are described below. 

Brief Alcohol Screening and Intervention for College Students (BASICS) is an example of a brief motivational 

intervention for which results have been positive. BASICS is designed to help students reduce alcohol 

misuse and the negative consequences of their drinking. It consists of two 1-hour interviews, with a 

brief online assessment after the first session. The first interview gathers information about alcohol 

consumption patterns and personal beliefs about alcohol, while providing instructions for selfmonitoring drinking between sessions. The second interview uses data from the online assessment 

to develop personalized, normative feedback that reviews negative consequences and risk factors, 

clarifies perceived risks and benefits of drinking, and provides options for reducing alcohol use and 

its consequences. Follow-up studies of students who used BASICS have shown reductions in drinking 

quantity in the general college population, among fraternity members, with heavy drinkers who 

volunteered to use BASICS, and among those who were mandated to engage in the program from 

college disciplinary bodies.106,162,164
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A second intervention, the Parent Handbook, focuses on teaching parents how and when to intervene 

during the critical time between high school graduation and college entry to disrupt the escalation of 

heavy drinking during the first year of college. The Parent Handbook is distributed during the summer 

before college, and parents receive a booster call to encourage them to read the materials. Research has 

found that the timing for the Parent Handbook is critical. If parents received it during the summer before 

college, it reduced the odds of students becoming heavy drinkers, but this intervention was not effective 

if used after the transition to college.167 One study showed the combination of BASICS, and the Parent 

Handbook significantly reduced alcohol consumption among incoming college students who showed 

heavy rates of high school drinking.168

Many other interventions have been developed for this population that have not shown effects beyond 

3 or 6 months after the intervention, and most positive effects are not maintained by 12-month followup.155-159 For example, even though brief motivational interviewing (BMI) interventions have appeared 

promising, a recent analysis of 17 randomized trials demonstrated little effectiveness among collegeaged individuals.160

A Resource: The National Institute on Alcohol Abuse and Alcoholism’s 

(NIAAA’s) CollegeAIM: Alcohol Intervention Matrix 

In an effort to inform colleges and universities of the rapidly growing evidence base of programs and policies 

that can reduce harmful and underage drinking and related harms by college students, NIAAA has published 

CollegeAIM-the College Alcohol Intervention Matrix. 

CollegeAIM reviews nearly 60 interventions, including both individual-level strategies and environmental-level 

policy strategies. The strategies are ranked by effectiveness (higher, moderate, lower, not effective, and too few 

studies to evaluate). Implementation costs (lower, mid-range, and higher) and implementation barriers (higher, 

moderate, and lower) are also ranked, as is public health reach (broad or focused).169

Programs in Adult Workplaces 

Two programs met this Report’s criteria for workplace or clinic-based prevention programs;170-172 others 

have not shown significant preventive effects longer than 6 months.173 The successful programs, Team 

Awareness and Team Resilience, were delivered in three 2-hour sessions to restaurant workers and led to 

decreases in heavy drinking and work-related problems. These programs reached approximately 30,000 

workers in diverse settings, including military, tribal, and government settings, and with ex-offenders, 

young restaurant workers, and more.170,172

Programs for Older Adults

Only two studies showed preventive effects on alcohol use in older adults.174,175 One is Project Share, 

which showed reductions in heavy drinking among those aged 60 and older. Project Share provided 

personalized feedback to at-risk older drinkers, which included a personalized patient report, 

discussion with a physician, and three phone calls from a health educator.174 A second study, the 

Computerized Alcohol-Related Problems Survey (CARPS) assessed personalized reports of drinking risks and 
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benefits accompanied with education for physicians and patients aged 65 and older. 

The study found a significant decrease in alcohol misuse, including reductions in the quantity and 

frequency that older individuals reported drinking.175

Economics of Prevention 

The Washington State Institute for Public Policy developed a standardized model using scientifically rigorous 

standards to estimate the costs and benefits associated with various prevention programs. Benefit-per-dollar 

cost ratios for EBIs ranged from small returns per dollar invested to more than $64 for every dollar invested. 

These estimates are illustrated below in Table 3.3. 

Table 3.3: Cost-Benefit of EBIs Reviewed by the Washington State Institute for Public 

Policy, 2016

Program Benefit per Dollar Cost

Nurse-Family Partnership $1.61

Raising Healthy Children/SSDP $4.27

Good Behavior Game $64.18

LifeSkills Training $17.25

keepin’ it REAL $11.79

Strengthening Families Program 10-14 $5.00

Guiding Good Choices $2.69

Positive Family Support/ Family Check Up $0.62

Project Towards No Drug Abuse $6.54

BASICS $17.61

*Cost estimates are per participant, based on 2015 United States dollars. 

Note: This is a general indication of the potential health and social value of EBIs. It is not possible to estimate specific costbenefit for every EBI due to challenges in calculating accurate intervention effect sizes, the failure to document costs, the 

variation of methods used, and few mandates or incentives to complete this research. Reaching a consensus on standards 

for cost-benefit analyses and making them a routine part of prevention program evaluation could help policymakers choose 

EBIs that both prevent substance misuse and ensure that investments return benefits over the life course.

Source: Washington State Institute for Public Policy, (2016).176

Evidence-based Community Coalition-based 

Prevention Models

Community-based prevention programs can be effective in helping to address major challenges raised 

by substance misuse and its consequences. Such programs are often coordinated by local community 

coalitions composed of representatives from multiple community sectors or organizations (e.g., 

government, law enforcement, health, education) within a community, as well as private citizens. 
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These coalitions work to change community-level risk and protective factors and achieve communitywide reductions in substance use by planning and implementing one or more prevention strategies 

in multiple sectors simultaneously, with the goal of reaching as many members of the community as 

possible with accurate, consistent messages. For example, interventions may be implemented in family, 

educational, workplace, health care, law enforcement, and other settings, and they may involve policy 

interventions and publicly funded social and traditional media campaigns.28,74,177-179

 A common feature of successful community programs is their reliance on local coalitions to select 

effective interventions and implement them with fidelity. An important requirement is that coalitions 

receive proactive training and technical assistance on prevention science and the use of EBIs and that 

they have clear goals and guidelines. Technical assistance can be provided by independent organizations 

such as Community Anti-Drug Coalitions of America (CADCA), academic institutions, the program 

developers, or others with expertise in the substance misuse prevention field. Three examples of 

effective community-based coalition models are provided below.

Communities That Care

Communities That Care (CTC) creates a broad-based community coalition to assess and prioritize risk 

and protective factors and substance use rates, using a school survey of all students in Grades 6, 8, 10, 

and 12. The coalition then chooses and implements EBIs that address their chosen priorities. CTC was 

tested in a 24-community trial, where 12 communities were randomly assigned to receive the CTC 

intervention. 

Among a panel of students in Grade 5 who were enrolled in the study before the intervention, those in 

the CTC communities who were compared to the prevention as usual communities had lower rates of 

alcohol and tobacco initiation at Grades 10 and 12.26,180-182

PROmoting School-community-university Partnerships to Enhance Resilience 

The PROmoting School-community-university Partnerships 

to Enhance Resilience (PROSPER) delivery system focuses 

on community-based collaboration and capacity building 

that links the land-grant university Cooperative Extension 

System with the public school system. Local teams select and 

implement family-focused EBIs in Grade 6 and a school-based 

EBI in Grade 7. PROSPER has shown reductions through Grade 12 in marijuana, methamphetamine, 

and inhalant use, and lifetime prescription opioid misuse and prescription drug misuse. Analysis showed 

greater intervention benefits for youth at higher versus lower risk for most substances.183,184

Prescription drug misuse. Use of a 

drug in any way a doctor did not direct 

an individual to use it.
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Communities That Care - 24 Community 

Randomized Trials in Colorado, Illinois, 

Kansas, Maine, Oregon, Utah, and 

Washington 

I think one of the biggest advantages 

of Communities That Care is that it 

has really brought together the entire 

community. When I preach and prepare, 

and if I’m speaking specifically to 

something that bears upon the teen culture 

and teen population, the fact is [with CTC 

assessment data from the community], 

I’m able to speak with greater clarity 

with greater directness and with greater 

understanding of what they are facing.

– Adam Kohlstrom, Pastor, Camden, ME

Agency or Organization:

University of Washington Center for Communities That Care

Purpose:

This evidence-based system provides communities with 

strategic consultation, training and research-based tools 

for prevention planning. The CTC system engages entire 

communities (e.g. youth, parents, elected officials, law 

enforcement, schools, businesses, etc.) and is tailored to the 

risks and needs of each defined community population. 

Goals:

1. Promote positive development and healthy behaviors for all children and youth.

2. Prevent problem behaviors, including substance use, delinquency, teen pregnancy, school drop-out, and 

violence. 

Outcomes:

• Following a panel of over 4,000 young people in 24 CTC communities from Grades 5 to 8, researchers 

found that compared to control communities not using the CTC model, youth in the CTC communities 

were: 

 33 percent less likely to begin smoking;

 32 percent less likely to begin using alcohol;

 33 percent less likely to begin using smokeless tobacco; and

 25 percent less likely to initiate delinquent behavior (itself a risk factor for future substance use).

Communities Mobilizing for Change on Alcohol

Community coalition-driven environmental models attempt to reduce substance use by changing the 

macro-level physical, social, and economic risk and protective factors that influence these behaviors. Most 

research on environmental interventions has focused on alcohol misuse and related problems, including 

DUI, injuries, and alcohol use by minors.185-187 For example, Communities Mobilizing for Change on Alcohol (CMCA) 

implemented coalition-led policy changes aimed at reducing youth access to alcohol, including training for 

alcohol retailers to reduce sales to minors, increased enforcement of underage drinking laws, measures to 

reduce availability of alcohol at community events, and media campaigns emphasizing that underage drinking 

is not acceptable.188,189 In a randomized trial comparing seven communities in Minnesota and Wisconsin using 

CMCA with eight communities in states not implementing CMCA, significant reductions in alcohol-related 

problem behaviors were shown among young adults aged 18 to 20 from the beginning of the initiative to 2.5 
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years after coalition activities began. The proportion of young adults aged 19 to 20 who reported providing 

alcohol to other minors declined by 17 percent,188 and arrests for DUI decreased more for this age group in 

the intervention compared to the control sites.189

Evidence-based Prevention Policies

This section primarily discusses the evidence of effectiveness for policies to reduce alcohol misuse, 

as well as the more limited body of scientific literature on the effectiveness of policies to prevent the 

misuse of prescription medications, including pain relievers, tranquilizers, stimulants, and sedatives. 

Policies to Reduce Alcohol Misuse and Related Problems 

Research has shown that policies focused on reducing alcohol misuse for the general population can 

effectively reduce alcohol consumption among adults as well as youth, and they can reduce alcoholrelated problems including alcohol-impaired driving.190,191 In addition to discussing a number of 

effective population-level alcohol policies, this section will also describe policies designed specifically to 

reduce drinking and driving and underage drinking. 

Price and Tax Policies

Evidence indicates that higher prices on alcoholic beverages are associated with reductions in alcohol 

consumption and alcohol-related problems, including alcohol-impaired driving. Several systematic 

reviews have linked higher alcohol taxes and prices with reduction in alcohol misuse, including both 

underage and binge drinking.28,31,72,192-197 One 2009 review examined 1,003 separate estimates from 112 

studies.72 The authors concluded, “We know of no other prevention intervention to reduce drinking that 

has the numbers of studies and consistency of effects seen in the literature on alcohol taxes and prices.” 

Similarly, a 2010 review of 73 taxation studies found “consistent evidence that higher alcohol prices and 

alcohol taxes are associated with reductions in both alcohol misuse and related, subsequent harms.”31

For example, a study found that the price elasticity of binge drinking among individuals aged 18 to 21 

was -0.95 for men and -3.54 for women, meaning that a 10.0 percent increase in the price of alcohol is 

expected to decrease binge drinking by 9.5 percent among men and 35.4 percent among women in that 

age group.198 

The effectiveness of increasing alcohol taxes as a strategy for reducing alcohol misuse and related 

problems has also been acknowledged outside the United States.28 For example, a 2009 World Health 

Organization (WHO) review stated that “when other factors are held constant, such as income and 

the price of other goods, a rise in alcohol prices leads to less alcohol consumption” and “[p]olicies that 

increase alcohol prices delay the time when young people start to drink, slow their progression towards 

drinking larger amounts, and reduce their heavy drinking and the volume of alcohol drunk on each 

occasion.”192 Additionally, studies have found that increasing alcohol taxes is not only cost effective but 

can result in a net cost savings (i.e., the savings outweigh the costs of the intervention). 
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Policies that Affect Access to and Availability of Alcohol 

Policies Affecting Alcohol Outlet Density

Research suggests that an increase in the number of retail alcohol outlets in an area—called higher 

alcohol outlet density—is associated with an increase in alcohol-related problems in that area, such as 

violence, crime, and injuries.177,199,200 Four longitudinal studies of communities that reduced the number 

of alcohol outlets showed consistent and significant reductions in alcohol-related crimes, relative to 

comparison communities that had not reduced alcohol outlet density.199,201-203 Although no studies have 

explicitly analyzed the cost-benefit ratio of this intervention, research suggests that the costs of limiting 

the number of alcohol outlets is expected to be much smaller than the societal costs of alcohol misuse.177

Commercial Host (Dram Shop) Liability Policies 

Commercial host (dram shop) liability allows alcohol retailers—such as the owner or server(s) at a bar, 

restaurant, or other retail alcohol outlet—to be held legally liable for harms resulting from illegal beverage 

service to intoxicated or underage customers.204 In a systematic review, 11 studies assessed the association 

between dram shop laws and alcohol-related health outcomes.205 The review found a median reduction 

of 6.4 percent (range was 3.7 percent to 11.3 percent) in alcohol-related motor vehicle fatalities associated 

with these policies. Two studies on the effects of these laws did not find reductions in binge drinking. 

Policies to Reduce Days and Hours of Alcohol Sales 

A review of 11 studies of changing days of sale (both at on-premise alcohol outlets such as restaurants 

and bars, and off-premise outlets such as grocery, liquor, and convenience stores) indicated that 

increasing the number of days alcohol could be sold was associated with increases in alcohol misuse 

and alcohol-related harms, while reducing days alcohol is sold was associated with decreases in 

alcohol-related harms.206 Similarly, a review of 10 studies (none conducted in the United States) found 

that increasing hours of sale by two or more hours increased alcohol-related harms, while policies 

decreasing hours of sale by at least two hours reduced alcohol-related harms.207 One study found that 

lifting a ban on Sunday sales of alcohol led to an estimated 41.6 percent increase in alcohol-related 

fatalities on Sundays during the period from 1995 to 2000, equating to an additional cost of more than 

$6 million in medical care and lost productivity per year in one state.208 Banning sales of alcohol on 

Sundays has been recognized as a cost-effective strategy.

State Policies to Privatize Alcohol Sales 

The privatization of alcohol sales involves changing from direct governmental control over the retail 

sales of one or more types of alcohol, and allowing private, commercial entities to obtain alcohol 

licenses, typically to sell liquor in convenience, grocery, or other off-premise locations. A systematic 

review of studies evaluating the impact of privatizing retail alcohol sales found that such policies 

increased per capita alcohol sales in privatized states by a median of 44.4 percent. Studies show that per 

capita alcohol sales is known to be a proxy for alcohol misuse.209,210

Policies to Reduce Drinking and Driving 

Since the early 1980s, alcohol-related traffic deaths in the United States have been cut by more than half 

(Figure 3.2). It has been estimated that reductions in driving after drinking prevented more than 300,000 
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deaths during this time period.211 In fact, declines in traffic deaths due to reductions in drinking and 

driving have exceeded declines from the combined effects of increased use of seat belts, airbags, and 

motorcycle and bicycle helmets.212 From 1982 to 2013, alcohol-related traffic deaths decreased by 67 

percent, whereas non-alcohol-related traffic deaths decreased by only 14 percent.213

Several policies and law enforcement approaches have been found to reduce rates of drinking and 

driving and related traffic crashes, injuries, and deaths within the general population, among both youth 

and adults. These DUI policies and enforcement approaches create deterrence by increasing the public’s 

awareness of the consequences of drinking and driving, including the possibility of arrest. Some of these 

strategies include: 

$ 0.08 percent criminal per se legal blood alcohol content (BAC) limits, meaning that no further 

evidence of intoxication beyond a BAC of 0.08 percent is needed for a DUI case;214-221 and

$ Sobriety checkpoints.222-224

Figure 3.2: Alcohol- Versus Non-alcohol-related Traffic Deaths, Rate per 100,000, All Ages, 

United States, 1982-2013

Source: Adapted from Hingson and White, (2014).213 
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Other proven DUI prevention strategies fall under the rubric of indicated interventions as they target 

drivers who have been convicted of DUI to reduce recidivism:223

$ Lower legal blood alcohol limits for people convicted of DUI;217,223

$ Mandatory ignition interlock laws for all convicted offenders, including first offenders;223,225,226

$ Mandatory assessment and treatment of persons convicted of DUI;223

$ DUI courts;223

$ Continuous 24/7 alcohol monitoring of persons with one or multiple DUI charges;223 and

$ Vehicle impoundment or immobilization.223

The Implications of Drinking-Oriented and Driving-Oriented Policies 

to Reduce Harms 

An examination of state-level data on 29 alcohol control policies in all 50 states from 2001-2009227 divided those 

policies into two mutually exclusive groups: (1) drinking-oriented policies, intended to regulate alcohol production, 

sales, and consumption, raise alcohol taxes, and prevent sales to minors; and (2) driving-oriented policies, which 

are intended to prevent an already intoxicated person from driving. State data on impaired driving from more than 

12 million adults during the even years of 2002 through 2010 were evaluated, and four results were reported, two 

of which are presented here: 

• First, the review found that drinking-oriented policies were slightly more effective in reducing impaired 

driving than driving-oriented policies, though both types of policy changes were independently 

associated with lower levels of impaired driving. 

• Second, drinking-oriented policies appeared to exert their effects by reducing binge drinking, which in 

turn was associated with a lower likelihood of impaired driving. The authors concluded that most states 

may have a greater opportunity for adopting and aggressively implementing drinking-oriented policies 

to reduce overall harms, although there is a need to strengthen driving-oriented policies as well.

Overall, these findings support the importance of implementing a comprehensive range of alcohol policies to 

effectively reduce alcohol misuse and related harms, including strengthening both drinking-oriented policies and 

driving-oriented policies. 

Policies to Reduce Underage Drinking

Raising the Minimum Legal Drinking Age 

Before 1984, only 22 states had a MLDA of 21. To reduce DUIs, Congress passed the National 

Minimum Drinking Age Act, which threatened to withhold a portion of states’ federal highway 

construction funds if states made the purchase or public possession of alcoholic beverages legal for 

those under the age of 21. By 1988, all states had adopted age 21 as the MLDA. In the 1982 Monitoring 

the Future annual national survey of middle and high school students, 71.2 percent of high school 

seniors reported that they drank in the past 30 days and 42 percent reported binge drinking in the past 

2 weeks.228 In 2014, these same statistics were 37.4 percent and 19 percent respectively (Figure 3.3).213

These declines may be partially attributable to the MLDA214 along with other policy and behaviorchange interventions occurring at the same time.
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Many studies have shown the benefits of raising the MLDA. A Community Guide review found that 

raising the MLDA reduced crashes among drivers aged 18 to 20 by a median of 16 percent:215 A finding 

replicated in a prospective analysis of the National Highway Traffic Safety Administration’s (NHTSA’s) 

Fatality Analysis Reporting System (FARS) examining the ratio of drinking to non-drinking drivers 

aged 20 and younger. The analysis statistically adjusted for zero tolerance laws, graduated licensing 

restrictions (e.g., provisional licenses for new drivers that include restrictions on driving at night or 

with any measurable alcohol in their systems), use/lose laws, administrative license revocation, 0.08% 

BAC per se laws, per capita beer consumption, unemployment rate, vehicle miles traveled, frequency of 

sobriety check points, number of licensed drivers, and the ratio of drinking to non-drinking drivers in 

fatal crashes ages 26 and older.214 An additional analysis examined national alcohol-related fatal traffic 

crash data before and after states raised the MLDA to 21. Before those laws were instituted, 61 percent 

of drivers aged 16 to 20 had a positive BAC compared with 33 percent following institution of those 

laws.229 These analyses showed general declines in alcohol-related fatal crashes across age groups, but 

the declines were highest for drivers aged 16 to 20. Comparing the declines across ages is useful because 

these older drivers were not the main focus of the MLDA changes. 

Figure 3.3: Trends in 2-Week Prevalence of 5 or More Drinks in a Row among 12th Graders, 

1980-2015

Note: The first vertical bar indicates institution of the MLDA 21 policy change in 7 states in 1984. The second vertical bar 

indicates federal passage of the MLDA 21 policy in all states in 1988.

Source: Adapted from Hingson and White, (2014).213
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An extensive review concluded that raising the MLDA to 21 has been directly associated with less 

frequent drinking, less heavy drinking, and fewer alcohol-related traffic fatalities in the age groups 

targeted by the law.178 More specifically, NHTSA estimates that raising the MLDA to 21 may have 

prevented 30,323 traffic deaths since 1975.230

MLDA Compliance Checks

As a complement to the MLDA laws, research has shown the importance of repeated compliance check 

surveys on alcohol sales to people younger than age 21. These compliance check surveys monitor the 

percentage of attempts to buy alcohol that result in a sale to a person appearing to be younger than age 

21. Alcohol outlet owners are informed in writing whether or not they were observed selling alcohol to 

underage-appearing individuals, told about the penalties for selling to minors, which can include fines 

or license suspension, and informed that the surveys will be repeated. A review identified several studies 

that found these compliance check surveys reduce the percentage of underage alcohol buying attempts 

and sales of alcohol to youthful-looking decoys by more than 40 percent.187 This strategy is an effective 

way to reduce alcohol consumption by minors and can be implemented in conjunction with population 

level alcohol policies. 

Zero Tolerance Laws 

All 50 states have passed laws making it illegal for persons younger than age 21 to drive with any 

measurable BAC. These laws, called zero tolerance laws, were instituted because of the higher fatal crash 

risk among drivers younger than age 21215,231 and because of studies showing that lowering the drinking 

age below age 21 was related to increases in fatal crashes.232 Another study examined the first eight 

states to implement zero tolerance laws, comparing each with a nearby state that did not enact such a 

law.233 Examining an equal number of years before and after these laws changed, researchers found 20 

percent fewer alcohol-related traffic crash deaths in the targeted age groups within the zero tolerance 

states compared to nearby states without these laws. Similarly, a more recent examination of Monitoring 

the Future survey data for high school seniors in 30 states before and after adoption of zero tolerance 

laws found that after the laws were enacted, a 19 percent decline in driving after drinking occurred as 

well as a 23 percent decline in driving after five or more drinks.234

Use/Lose Laws 

Use/lose laws allow states to suspend a person’s driver’s license for underage alcohol violations. An 

examination of the Youth Risk Behavior Surveillance System survey data by state (statistically adjusted 

to account for state differences in age, gender, race, ethnicity, and other factors) from 1999 to 2009 

found past-month drinking declined after use/lose laws were instituted.235 The study also found that 

after these laws were instituted, survey respondents were half as likely to report driving after drinking 

compared with before the laws were instituted.

Criminal Social Host Liability Laws 

Criminal state social host liability laws require law enforcement to prove intent to provide alcohol 

to underage guests. Specifically, “social host” refers to adults who knowingly or unknowingly host 

underage drinking parties on property that they own, lease, or otherwise control. With social host 

ordinances, law enforcement can hold adults accountable for underage drinking through fines and 

potentially criminal charges. More than 30 states have some form of social host liability laws. To see 
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the effect of these laws, researchers examined rates of alcohol consumption, binge drinking, and DUI 

between 1984 and 2004 from the annual Behavioral Risk Factor Surveillance System. They also looked at 

data from the FARS from 1975 to 2005 on alcohol-related versus non-alcohol-related fatal traffic deaths 

among those aged 18 to 20. After controlling for the state’s legal drinking age, several drinking laws, and 

socioeconomic factors, social host liability laws were independently associated with declines in binge 

drinking (3 percent), driving after drinking (1.7 percent), and alcohol-related traffic deaths (9 percent).236

Civil Social Host Liability Laws

In contrast to state-level criminal social host ordinances, city- or county-level civil liability ordinances 

allow for a lower burden of proof but still deter underage drinking parties. Through civil social host 

liability laws, adults can be held responsible for underage drinking parties held on their property, 

regardless of whether they directly provided alcohol to minors. To date, more than 150 cities or 

counties have social host liability ordinances in place. The research on this strategy is still emerging, but 

findings currently show that social host liability reduces alcohol-related motor vehicle crashes as well as 

other alcohol-related problems.28,237

Proposals for Reductions in Alcohol Advertising

Although evidence of a causal relationship is lacking, research has found an association between 

increased exposure to marketing and increased alcohol consumption among youth.77 For example, 

one study found that for every additional advertisement seen by youth per month, they drank one 

percent more, while for every additional dollar per capita spent on alcohol advertising in a youth’s 

media market, they drank three percent more.238 Typically, these studies have not controlled for other 

factors known to influence underage drinking, such as parental attitudes and drinking by peers. 

Further, studies have yet to determine whether reducing alcohol marketing leads to reductions in youth 

drinking. One study estimated that a 28 percent decrease in alcohol marketing in the United States 

could lead to a decrease in the monthly prevalence of adolescent drinking from 25 percent to between 

21 and 24 percent.239 A separate study of alcohol advertising bans concluded that “there is a lack of 

robust evidence for or against recommending the implementation of alcohol advertising restrictions.”240 

Many Policy Interventions Are Not Consistently Implemented

Despite the evidence discussed in this section, many policies are not consistently implemented in states 

or communities. For example, commercial host (dram shop) liability laws, which permit alcohol retail 

establishments to be held responsible for injuries or harms caused by service to intoxicated or underage 

patrons have not been implemented consistently, have been changed over time, or both. Consequently, 

as of January 1, 2015, only 20 states had dram shop liability laws with no major limitations; 25 states had 

these laws but with major limitations (e.g., restrictions on who this liability applied to and the evidence 

required to determine liability); and six states have no dram shop liability laws at all.241 These numbers 

have not changed since 2013 (Table 3.4).242

Policies related to the regulation of alcohol outlet density have changed over time. For example, as of 

2013, only 18 states had exclusive local or joint state/local alcohol retail licensing authority, and eight 

states allowed no local control over alcohol retail licensing. 
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Additionally, one study analyzed FARS from 1982-2012. The authors compared the ratio of drinking 

drivers in fatal crashes to non-drinking drivers in fatal crashes among drivers aged 20 and younger and 

those 26 and older. Using advanced statistical analyses that adjusted for state DUI laws, safety belt laws, 

economic strength, driving exposure, and beer consumption, the authors identified nine laws designed 

to reduce underage drinking and driving whose implementation was prospectively, independently, and 

significantly associated with decreases in the ratio of drinking to non-drinking drivers under age 21 in 

fatal crashes, including laws prohibiting underage possession and purchase of alcohol; use alcohol lose 

your license (use/lose) laws; zero tolerance laws; laws requiring bartenders to be aged 21 or older; state 

responsible beverage/server programs; fake identification state support services for retailers; dram shop 

liability; and social host civil liability. Those nine laws were estimated to save approximately 1,135 lives 

annually, yet only five states have enacted all nine laws. The authors estimated that if all states adopted 

these laws an additional 210 lives could be saved every year.243

Table 3.4: Status of Selected Evidence-Based Strategies in States for Preventing Alcohol 

Misuse and Related Harms

Alcohol Policy

(Ratings categories)

Number of states by rating and year of CDC 

Prevention Status Report

Green Yellow Red

2013 2015 2013 2015 2013 2015

State excise taxes on beer*

(Green: ≥$1.00 per gallon; Yellow: $0.50-$0.99 per 

gallon; Red: <$0.50 per gallon)

3 4 4 4 43 42

State excise taxes on distilled spirits*

(Green: ≥$8.00 per gallon; Yellow: $4.00-$7.99 per 

gallon; Red: <$4.00 per gallon)

3 3 10 11 21 20

State excise taxes on wine*

(Green: ≥$2.00 per gallon; Yellow: $1.00-1.99 per gallon; 

Red: <$1.00 per gallon)

2 2 7 8 30 29

Commercial host (dram shop) liability laws

(Green: Commercial host liability with no major 

limitations; Yellow: Commercial host liability with major 

limitations; Red: No commercial host liability)

21 20 24 25 6 6

Local authority to regulate alcohol outlet density

(Green: Exclusive local or joint state/local alcohol retail 

licensing; Yellow: Exclusive state alcohol retail licensing 

but with local zoning authority or other mixed policies; 

Red: Exclusive state alcohol retail licensing)

18 N/A 24 N/A 8 N/A

Note: *The ratings reflect where each state’s tax fell within this range. N/A: Not Applicable.

Sources: Centers for Disease Control and Prevention, (2014)242 and (2016).241

These data suggest that effective alcohol control policies are not being widely implemented in the 

United States despite the well-documented, scientific evidence on the effectiveness of such policies 

for reducing alcohol misuse and related harms. To have maximum public health impact, it is critical 

to implement effective policy interventions that address alcohol misuse and related harms, and that 

recognize the widespread nature of the problem and the strong relationship between alcohol misuse, 

particularly binge drinking, and related harms among adults and youth in states.190,191,244 
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Policies to Reduce Other Substance Misuse and Related 

Problems

Preventing Prescription Drug Misuse

Policies to prevent prescription drug misuse and related harms have only begun to receive research 

attention. However, some studies have begun to examine the impact of prescription drug monitoring 

programs (PDMPs) on misuse of prescription medications.245 These state-initiated policies are designed 

to curb the rate of inappropriate prescribing of opioid pain relievers through various methods. Data 

from the U.S. Drug Enforcement Administration’s (DEA’s) Automation of Reports and Consolidated Orders 

System (ARCOS)246 showed little impact of these monitoring systems, perhaps because of the variability 

of the policies controlling different state systems. The ARCOS is an automated, comprehensive 

drug reporting system which monitors the movement of controlled substances from where they are 

manufactured through distribution at the retail level, such as hospitals, pharmacies, and practitioners. 

Some studies associate state PDMPs with lower rates of prescription drug misuse and altered 

prescribing practices, although evidence is mixed and inconclusive.247 One reason for inconsistent 

findings may be low and variable prescriber utilization of PDMPs. Because mandates are relatively 

new, their efficacy in increasing PDMP utilization has not been formally studied. However, preliminary 

data suggest that in some states mandates have contributed to a rapid increase in provider enrollment 

and utilization of PDMPs and subsequent decreases in prescribing of controlled substances and the 

number of patients who visit multiple providers seeking the same or similar drugs.248 Data from 

Kentucky, Tennessee, New York and Ohio—early adopters of comprehensive PDMP use mandates—

indicate substantial increases in queries, reductions in opioid prescribing, and declines in multiple 

provider episodes (doctor shopping) following implementation.249 In one of the most rigorous studies 

to date, Florida’s simultaneous institution of a prescription drug monitoring system and “pill mill” 

control policies was compared to Georgia, a state without either policy. This study demonstrated 

“modest reductions in total opioid volume, mean morphine milligram equivalent per transaction, 

and total number of opioid prescriptions dispensed, but no effect on duration of treatment. These 

reductions were generally limited to patients and prescribers with the highest baseline opioid use and 

prescribing.”250

A 2016 study found that the implementation of a PDMP was associated with 1.12 fewer opioid-related 

overdose deaths per 100,000 people in the year immediately after the program was implemented, and 

if every state in the United States had a robust PDMP, there would be an estimated 600 fewer overdose 

deaths per year.251 However, another study analyzed eight types of laws that restricted the prescribing 

and dispensing of opioids (including PDMP laws but not including prescriber mandate laws) and found 

no relationship between the laws and opioid-related outcomes among disabled Medicare beneficiaries, 

who accounted for nearly 25 percent of opioid overdose deaths in 2008.252
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Collectively, these early results suggest the potential influence of PDMPs to reduce unsafe controlled 

substance prescribing and rates of misuse and diversion, but there is a need to conduct additional 

research on the effectiveness of specific strategies for implementation and use of PDMPs. Multiple 

efforts to address prescription drug misuse within states occurring in concert with mandatory PDMP 

legislation may limit the ability to draw causal conclusions about the effectiveness of mandatory use of 

PDMPs. 

The CDC has developed the CDC Guideline for Prescribing Opioids for Chronic Pain, which provides 

research-based recommendations for the prescribing of opioids for pain in patients aged 18 and older in 

primary care settings. The guideline includes a discussion of when to start opioids for chronic pain, how 

to select the right opioid and dosage, and how to assess risks and address harms from opioid use.253 This 

guideline can help providers reduce opioid misuse and related harms among those with chronic pain.

Adolescent Use of Marijuana 

Marijuana use, in adolescents in particular, can cause negative neurological effects. Long-term, regular use 

starting in the young adult years may impair brain development and functioning. The main chemical in 

marijuana is delta-9-tetrahydrocannabinol (THC), which, when smoked, quickly passes from the lungs into the 

bloodstream, which then carries it to organs throughout the body, including the brain.254 THC disrupts the brain’s 

normal functioning and can lead to problems studying, learning new things, and recalling recent events.255 One 

study followed people from age 13 to 38 and found that those who began marijuana use in their teens and 

developed a persistent cannabis use disorder had up to an eight point drop in IQ, even if they stopped using 

in adulthood.256 Frequent marijuana use has also been linked to increased risk of psychosis in individuals with 

specific pre-existing genetic vulnerabilities.257,258 And marijuana use—particularly long-term, chronic use or use 

starting at a young age—can also lead to dependence and addiction.

These effects highlight the importance of prevention. To prevent marijuana use before it starts, or to intervene 

when use has already begun, parents and other caregivers as well as those with relationships with young 

people—such as teachers, coaches, and others—should be informed about marijuana’s effects in order to 

provide relevant and accurate information on the dangers and misconceptions of marijuana use. Comprehensive 

prevention programs focusing on risk and protective factors have shown success preventing marijuana use.259,260

Evidence-based strategies or best practices in community level prevention efforts can be used to assess, build 

capacity, plan, implement, and evaluate initiatives.261

Prevention Interventions for Specific Populations 

An important consideration in any assessment of the overall effectiveness of EBIs is whether and to 

what extent they work with specific populations, such as Blacks or African Americans, Hispanics or 

Latino/as, Asians, American Indians or Alaska Natives, Native Hawaiians or Other Pacific Islanders, 

veterans, or lesbian, gay, bisexual, and transgender (LGBT) populations. The EBIs described in this 

chapter have been purposely selected because many have been implemented, tested, and found to be 

effective in diverse populations. It should be noted that while prevention policies have shown impacts 

for the entire population, and a number of prevention programs at each developmental period have 

shown positive outcomes with a mix of populations, most studies have not specifically examined their 

differential effects on racial and ethnic subpopulations. Studies finding significant prevention effects 
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across multiple population subgroups include LifeSkills 

Training, keepin’ it Real, Nurse Family Partnership, Raising Healthy 

Children, Good Behavior Game, Classroom-Centered Intervention, Fast 

Track, SODAs City, I Hear What You’re Saying, Project Chill, Positive 

Family Support, Coping Power, Project Towards No Drug Abuse, 

Communities That Care, Project Northland, and Project STAR. 

See Appendix A - Review Process for 

Prevention Programs and Appendix B 

- Evidence-Based Prevention Programs 

and Policies.

The following programs were found to be equally effective in White and specific racial and ethnic 

minority populations: Fast Track, which is equally effective for White and Black or African American 

adolescents, LifeSkills Training, which is equally effective with White and Black or African American 

and Hispanic or Latino adolescents, and keepin’ it REAL, which is equally effective with White and 

Hispanic or Latino adolescents. In addition, some interventions developed for specific populations have 

been shown to be effective in those populations, i.e., Strong African American Families, Familas Unidas for 

Hispanics or Latinos, Bicultural Competence for American Indian or Alaska Natives, and PROSPER for rural 

communities. 

Adaptation of EBIs in Diverse Communities 

A goal of prevention and public health professionals is to broadly disseminate all tested-and-effective 

EBIs, thus making them readily available to communities and consumers.262 Achieving population-level 

exposure of an EBI to all population groups—or “going to 

scale”—raises critical issues of “fit” of the EBI’s contents and 

the needs and preferences of local community residents.263

Often, some form of local adaptation is necessary when a 

certain feature of the selected EBI fails to engage a specific 

group within a local community. However, not all EBIs may 

work with all community subgroups.264,265 The sometimes 

delicate balance that needs to be struck between fidelity to the program as originally designed and 

tested and the need for adapting it to the needs of specific subgroups is an important issue and requires 

sophisticated methodology to address. Currently, several cultural adaptations of an original EBI have 

been developed and tested.266

Fidelity. The extent to which an 

intervention is delivered as it was 

designed and intended to be delivered. 

Issues regarding the cultural adaptation of EBIs have been reviewed extensively within the past two 

decades.266-268 Early studies examined the utility of developing a culturally-focused version of the EBI 

LifeSkills Training to fit the needs of racially and ethnically diverse adolescents living in the New York 

City area.269 In general, the challenge involves the viability of implementing an EBI with total fidelity 

to its protocol, versus adapting it by making adjustments so the EBI is more relevant and responsive 

to the needs of local community residents.270 Producing an adapted version of an established EBI may 

not generalize well enough to create the same effects when implemented with a culturally different 

group from that used to validate the original intervention. Such limited generalizability might occur if 

the intervention is insufficiently sensitive, culturally or otherwise, to the unique stressors, resources, 

cultural traditions, family practices, and other prevailing sociocultural factors that govern the lives of 

residents from that community.265
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It is worth noting that the major racial and ethnic populations in the United States—Hispanics 

or Latinos, Blacks or African Americans, Asians, and American Indians or Alaska Natives—also 

exhibit significant within-population variations in important sociocultural characteristics.271 Beyond 

differential EBI efficacy that may appear by racial or ethnic status—Black or African American versus 

White, for example—differential efficacy may also be observed by one of several demographic or 

clinical variables that define any one racial or ethnic group. These variables include gender (male vs. 

female), age group (younger vs. older), grade level (Grade 8 vs. Grade 10), sexual and gender identity, 

neighborhood status (problem vs. non-problem), problem severity (moderate vs. high), level of 

education (middle school vs. high school or greater), level of acculturation (low acculturation, bicultural, 

high acculturation). It can also include sociocultural needs and preferences that can be incorporated into 

the culturally adapted prevention intervention. 

Given the multiple sources of within-group variation, one dissenting view is that it is impractical to 

develop many different versions of an original EBI in efforts to respond to the needs of various groups. 

A contrasting view is that a few selective and directed adaptations may be sufficient to respond to the 

sociocultural needs of many of these groups “to ensure fit with diverse consumer populations.”265 Clusters 

of these groups may share common life experiences, such as their identity and identification as a person of 

color, experiences with discrimination and disempowerment, or the need for cultural validation.264

All of these issues create a “Fidelity-Adaptation Dilemma:” How to make necessary local or cultural 

adaptations that are responsive to the needs of a growing diversity of cultural groups in the United 

States, while also not compromising the fundamental science-based components or “active ingredients” 

that drive the effectiveness of the original EBI. As originally formulated, the Fidelity-Adaptation 

Dilemma framed fidelity and adaptation as diametrically opposed approaches in the implementation 

of an EBI.267,268 After more than a decade of analysis and research, this conceptualization appears 

no longer productive, given that both fidelity and adaptation are now recognized as important for 

the effective implementation of an EBI, especially when delivered within diverse racial and ethnic 

communities. The dual aim for resolving the Fidelity-Adaptation Dilemma is to adhere with fidelity to 

the intervention’s theory, principles, goals, and mechanisms of effect for attaining the EBI’s intended 

outcomes, while also making well-reasoned “cultural adaptations” that remedy emerging problems 

with the EBI’s contents and/or activities.272,273 A partnership between intervention developers, persons 

delivering the intervention, and potential program participants who can represent the group’s concerns, 

is recommended for developing well-reasoned solutions to remedy specific features of the original EBI 

that are not working as intended.121,274 The ultimate aim is to craft needed adaptive adjustments that 

aptly remedy these emerging problems and that also enhance the efficacy of the intervention in attaining 

the intended outcomes with local community residents. 

Several adaptations use a social participatory approach274-276 with a community advisory committee that 

is composed of local leaders who know the local community well.274 These individuals offer “insider” 

observations and recommendations that inform substantive deep-structure modifications that can make 

the original EBI more culturally responsive.267,277

Although sufficient evidence has not yet accrued to inform a single best approach for addressing 

this Fidelity-Adaptation Dilemma, a review of the EBI adaptation literature shows a convergence of 

specifically prescribed steps for adapting an original EBI.266 Several models describe these steps in the 
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cultural adaptation and testing of an original EBI.266 Other approaches have introduced the concept of 

“adaptive interventions” that aim to tailor the intervention individually based on empirically-developed 

decision rules.278,279

A future goal for effective cultural adaptation would be to identify robust principles and guidelines 

that can inform and guide the development of cultural adaptations. One emerging principle involves 

avoiding adaptations that produce detrimental changes, termed “misadaptations,” that erode the original 

EBI’s established efficacy for changing intended outcomes.263 A second emerging principle is to conduct 

adaptations that enhance consumer engagement based on curriculum activities that are culturally 

responsive to the needs and preferences of the local community of consumers. Additional research 

is needed to establish the robustness of these or other emerging principles and to generate clear and 

functional guidelines that can inform intervention design and implementation to promote both fidelity 

and adaptive fit. The aim of this adaptation is to maximize intervention effect when delivered to diverse 

groups of consumers. 

EBI adaptation that is based on evidence-based outcomes data constitutes an empirically-based 

methodology to correct, refine, and enhance an original EBI. From this perspective, these adaptations 

or modifications transcend fidelity-adaptation issues, advance toward EBI refinement that is conducted 

systematically, increase efficacy as well as generalizability, and reach and benefit a greater number of 

those who are most in need of EBIs.

Maximizing Prevention Program and Policy 

Effectiveness 

Although a variety of prevention policies and programs have been shown to reduce substance misuse 

and consequences of use, many are underutilized. Additionally, many programs are not currently being 

implemented with sufficient quality to effectively improve public health. For example, although it is 

difficult to collect data on this issue, research suggests that few family-serving agencies are using EBIs 

to address child behavioral and emotional problems,280,281 and surveys of school administrators indicate 

that only 8 to 10 percent report using EBIs to prevent substance misuse.282,283 Additionally, research has 

shown that untested or ineffective prevention programs are used more often than EBIs,282,283 and, when 

they are used, EBIs are often poorly implemented, do not serve large numbers of participants, and are 

not sustained.284,285 For example, family-based EBIs are often delivered with less intensity and/or to 

different types of participants than specified by program developers.286 School officials have reported 

low rates of implementation fidelity, including failure to deliver all required lessons, content, and 

activities; to use the required materials; to employ the recommended instructional strategies; to target 

the appropriate students with lessons; and/or to ensure that all teachers receive training.24,283,284,287,288

EBIs that are poorly implemented tend to have weak or no effects on participants.272,289-296 For example, 

in one study, the LifeSkills Training program delivered in middle and junior high schools has shown 

significant, long-term effects on Grade 12 students’ alcohol and marijuana use only among students 

whose teachers delivered at least 60 percent of the required material.292 
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Research demonstrates that building prevention infrastructure; activating federal, state, local, and 

tribal stakeholders; ensuring collaboration; and helping communities select, implement, and sustain 

EBIs297 is possible and can be done effectively. For example, one large-scale study provided schools 

and various human service agencies with training and technical assistance to replicate nine EBIs rated 

as “Model” by the Blueprints for Healthy Youth Development.

268 That study indicated that when provided 

with ongoing support, 74 percent of sites successfully implemented these systems.298 Evaluations of 

PROSPER and CTC, which provide community coalitions with prevention infrastructure to choose 

EBIs that addressed their needs and to implement the chosen EBIs with fidelity, have shown that 

communities using these delivery systems implement EBIs with high fidelity and sustain them over 

time.299-304 In addition, evaluations showed that CTC communities reached more participants with more 

EBIs compared with communities that did not use this prevention infrastructure support system.302,303

These and other studies indicate that prevention infrastructure can be generated by taking the actions 

discussed in the section on Improving the Dissemination and Implementation of Evidence-based 

Programs later in this chapter.

Additionally, strengthening state and local public health capacity will help to increase the surveillance and 

monitoring of risk and protective factors and substance misuse by adolescents and adults in the general 

population, including persons who drink to excess but are not dependent on alcohol. It is important to 

educate and raise awareness about the public health burden of substance misuse and effective program and 

policy interventions for preventing and reducing substance use across the population. 

The History of Substance Use and Misuse Policy Formation and 

Implementation 

The dissemination and implementation of evidence-based prevention programs have been studied extensively; less 

research has been conducted on evidence-based policy formation and implementation. This section describes three 

organizations or activities focusing on federal, state, and local policy to reduce substance misuse: Mothers Against 

Drunk Driving (MADD), CADCA, and the Congressional Sober Truth on Preventing Underage Drinking (STOP) Act. 

In the early 1980s, President Ronald Reagan established a bipartisan presidential commission to reduce drunk 

driving. The commission’s first recommended action was to raise the MLDA to 21. In 1984 and with strong 

support from the newly founded MADD, Congress passed legislation to withhold federal highway construction 

funds from states that did not raise the MLDA to 21. MADD was also instrumental in supporting the passage of 

legislation in 1996 to withhold federal highway construction funds from states that did not have zero tolerance 

laws. They were a key player in 2000 legislation to withhold construction funds from states that did not lower 

the legal blood alcohol limit to 0.08 percent for adult drivers. Since the early 1980s, more than 2,000 other 

state laws have been passed to reduce driving after drinking, and MADD has been a major citizen activist force 

encouraging the passage of many of those laws. 

MADD also has prepared and published periodic state and national “report cards” rating each state and the 

nation’s efforts to reduce alcohol-impaired driving.319 States have been rated on how many of the more than 30 

laws scientifically demonstrated to reduce impaired driving had been passed and how many were passed since the 

previous report card. In one study, these state report cards were found to clearly predict the percent of respondents 

in each state who reported driving after drinking in the past month.320 Although the impact of the report cards 

in accelerating passage of the laws has never been empirically tested, media monitoring of news stories derived 

from the report cards indicated that at least one third of the United States population has been exposed to media 

coverage about the report cards. 
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One study compared characteristics of MADD chapters that had early success in raising the MLDA to 21 to 

chapters in states that did not raise the age. The analysis found that having chapters headed by people who 

lost immediate family members through drinking and driving crashes and those with higher percentages of such 

victim members were the most successful in early passage of MLDA laws. Of note, the size of chapters’ financial 

budget did not predict the passage of these laws.321

Although MADD has helped to foster passage of more than 2,000 state-level laws, implementation of those 

laws is accomplished at the community level. This often requires the existence of trained coalitions focusing 

on substance use. One such collaboration, CADCA, has played a critical role in training local coalitions in 

implementing laws, particularly the MLDA law in all 50 states. CADCA’s membership includes more than 5,000 

community coalitions nationwide that seek to reduce underage drinking and drug use. CADCA has partnered 

with MADD and federal organizations to develop a manual on how to reduce drinking and driving and underage 

drinking in communities.322 CADCA holds its annual leadership meeting in Washington, D.C. so that its members 

can also meet with congressional representatives to explore better ways to reduce alcohol and drug misuse and 

underage drinking. 

In 2004, the IOM released Reducing Underage Drinking: A Collective Responsibility, a report on underage 

drinking in the United States.323 Partly in response to this report, Congress passed the STOP Act, which:

• Provided supplemental funding to community programs that were already addressing substance use so 

that they could also address underage drinking;

• Called on all states to test the BAC in anyone younger than age 21 who died from an injury or 

overdose;

• Encouraged every state to develop an interagency task force of officials from multiple state 

governmental departments and private citizens and organizations to develop strategic plans to reduce 

underage drinking (38 states have established task forces and strategic plans);

• Required the federal government to establish the Interagency Coordinating Committee for the 

Prevention of Underage Drinking (ICCPUD), comprising the following departments and agencies: 

Departments of Education, Health and Human Services, Transportation, and Defense; and the Federal 

Trade Commission. The Committee meets monthly to coordinate federal efforts to reduce underage 

drinking; and

• Required the federal government through ICCPUD and SAMHSA to provide annual reports to 

Congress on the magnitude of underage drinking and related problems and what the federal and state 

governments are doing to prevent and reduce underage drinking.
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Improving the Dissemination and Implementation of 

Evidence-based Programs 

Dissemination. The active distribution 

of EBIs to specific audiences, with the 

goal of increasing their adoption.

Implementation. A specified set of 

activities designed to put policies and 

programs into practice.

The emerging field of dissemination and implementation 

research seeks to identify ways to increase the use and highquality implementation of evidence-based programs and 

address challenges to implementation. This research indicates 

that the key to achieving significant gains in public health, 

including reductions in substance use initiation and substance 

misuse, is to build prevention infrastructure at the local 

level.305-307 This means increasing awareness of EBIs among 

community leaders, service providers, and local citizens. It 

also means providing tools to help communities select and use EBIs that will be feasible to implement 

and relevant for their populations.308-310 When agencies and staff are unaware of, do not support, or lack 

the ability to select and implement appropriate EBIs with quality, then dissemination, implementation, 

and sustainability will be hindered.285,311-313 In contrast, when local systems and agencies learn more 

about the effectiveness of prevention interventions, have a culture and climate that supports innovation 

and the use of EBIs, and have the budget and skills needed to plan for and monitor the implementation 

of EBIs, then effective dissemination and implementation will be fostered.294,311,312,314-318

Coalition-based systems have been developed to assist communities in building these capacities, and 

when tested in randomized trials, these systems have been shown to improve community capacity for 

effective prevention; increase dissemination, implementation, and sustainability of EBIs; and produce 

community-wide reductions in youth substance use.324 An important feature of these systems is the 

provision of community coalitions with multiple training workshops and ongoing technical assistance. 

Just as organizations require technical assistance to ensure high-quality implementation of specific 

EBIs, coalitions need technical assistance to support and develop their prevention capacities.325-328

Each community model has different steps that outline their process; the following four steps are one 

example of how to build broader implementation of evidence-based prevention.

Step 1. Form Diverse, Representative, Cross-Sector Community 

Coalitions

Coalitions, or groups of stakeholders working together to achieve a common goal, are a useful 

mechanism for building and maintaining local prevention infrastructure and capacity.25,34,324,325,329-331 The 

first step in building a coalition is to decide on the “community” to be involved in prevention activities, 

including the geographic area in which services will be delivered, and to identify the organizations, 

agencies, groups, and individuals whose participation is necessary for success. The more the coalitions 

represent the community in terms of demographic diversity, organizations expected to deliver services, 

and groups or individuals expected to receive services, the more likely they are to ensure that EBIs 

will be supported.329,332,333 Similarly, such coalitions will be better equipped to implement multiple 

EBIs across diverse contexts and to a larger percentage of the population, all of which should make 

population-level improvements more likely.329 In addition, by sharing information and resources, 
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community coalitions can help minimize duplication of efforts and potentially offer more cost-effective 

services that are better implemented and more likely to be sustained.25,334-337

Step 2. Conduct a Needs Assessment and a Fit Assessment

Needs and fit assessments help coalitions select the right EBIs for their community. The right EBIs are 

those that address the highest-priority local risk and protective factors the coalition identifies (e.g., the 

risk factors that are most elevated and the protective factors that are most depressed in the community) 

and the groups or individuals most in need of services.330,338 Coalitions conduct needs assessments by 

gathering data on risk and protective factors, substance misuse, and related problems. For example, 

in the CTC system, needs assessments rely primarily on data reported by adolescents on schoolbased, anonymous surveys. These data are reviewed by coalition members and risk factors that are 

consistently elevated and protective factors that are consistently depressed are identified as targets that 

need to be addressed by EBIs.334 The priorities may vary by neighborhood in larger cities or by specific 

subpopulations (e.g., gender or racial and ethnic groups).334

To select the best-fitting EBIs, coalitions need to be familiar with the list of possible interventions 

that can address their needs, and must consider whether or not they can meet all the implementation 

requirements of the EBIs.294,312,339 Consulting a registry of EBIs, such as the National Registry of Evidencebased Programs and Practices (NREPP)340 and the Blueprints for Healthy Youth Development341 or NIAAA’s 

Alcohol Policy Information System342 for alcohol policies, can assist in creating the list of EBIs that meet 

community needs. These databases compile information about programs that have met rigorous 

evaluation criteria in a user-friendly format, which makes it easy for communities to learn about 

and compare intervention costs and requirements.343,344 The databases also describe the intervention 

methods and population(s) with which the interventions were tested to help coalitions determine 

whether the EBI is culturally relevant and compatible with the norms, values, and needs of the local 

community. 

Step 3. Enhance Implementation Fidelity and Implementers’ 

Capacity

Some research suggests that EBIs can never be perfectly replicated in communities and that changes 

or adaptations to the EBI’s content, activities, materials, or methods of delivery will be necessary given 

the differences between well-controlled research trials and real-world settings.263,270,345-347 However, 

research has shown that when EBIs are implemented with fidelity, programs achieve expected results. 

While culturally relevant adaptations can be expected to increase the relevance of the material, better 

engage participants, and improve effectiveness, it is clear that poor or inappropriate adaptation can 

reduce effectiveness.268,295 For example, an evaluation showed that the effectiveness of the NurseFamily Partnership program was significantly reduced when paraprofessionals rather than registered 

nurses delivered services in communities that lack registered nurses.348 These types of inappropriate 

adaptations emphasize the need for communities to learn as much as they can about EBIs during the fit 

assessment and select only those interventions that are considered feasible given resources. 
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Steps to Build Prevention Infrastructure for Effective 

Community-based Prevention 

Conduct a local needs assessment: 

• Collect data on levels of substance use;

• Collect data on risk and protective factors related to substance use; and

• Identify and prioritize elevated risk factors and depressed protective factors.

Conduct a resource assessment: 

• Assess current prevention programming, including the risk and protective factors addressed by current 

services, numbers and types of populations served, effectiveness, and implementation quality; and

• Identify potential new services using EBI and policy registries. 

Assess the fit of new EBIs with the local community: 

• Determine whether or not each potential EBI addresses the identified substance misuse problems and 

priority risk and protective factors; and

• Assess the degree to which the new EBI is culturally relevant for the local population.

Assess local readiness and capacity to implement EBIs: 

• Identify the organization(s) that will deliver each new EBI; 

• Assess levels of support for each new EBI among all key personnel; and 

• Identify the financial and human resources and all other requirements necessary to implement each EBI.

Select the intervention(s) that is the best fit for the community: The ones that are most likely to be fully 

supported meet prioritized needs, are culturally relevant, can be well implemented, and can be sustained over 

the long-term.

Ensure high quality implementation of each new EBI:

• Create a detailed implementation plan; 

• Specify participant eligibility criteria, participation goals, and recruitment procedures; 

• Create teams to oversee implementation; 

• Hire all necessary staff and administrators;

• Ensure that all staff are trained and regularly supervised; and

• Seek regular technical assistance from intervention developers.

Evaluate the impact of the selected interventions: It is critical to systematically collect and analyze information 

about program activities, participant characteristics, and outcomes.

• Collect data on all aspects of implementation; and 

• Regularly review implementation and outcomes data and improve procedures as needed.
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In addition to appropriate cultural adaptations, staff competency is critical to successful delivery of 

EBIs, and coalition members can support local agencies to ensure that they hire staff who have the 

credentials and experience recommended by developers, and that they receive training in each EBI’s 

theory, content, and methods of delivery.142,294,312,339,349 Training is an important ingredient in ensuring 

greater levels of implementation fidelity, especially because the content, activities, and methods of 

delivery may be new to practitioners.24,294,295 In general, relatively few professionals responsible for 

implementing EBIs (including mental health counselors, teachers, psychologists, and social workers) 

receive training in substance misuse prevention, including knowledge of risk and protective factors 

that impact alcohol and drug use, the knowledge of EBIs that target these factors, or the importance of 

implementation fidelity when delivering interventions.18,350 These topics should be incorporated into 

undergraduate, graduate, and in-service professional training programs.351 In the meantime, staff should 

be supervised and receive coaching and corrective feedback to ensure they are implementing EBIs with 

quality.294,295,349,352

Technical assistance from EBI developers can assist local agencies in staff supervision, and most EBIs 

offer support in how to monitor implementation activities, overcome challenges when they arise, and 

integrate EBIs into agency operations.294,295,353 Although experimental studies are lacking, observational 

studies have reported that technical assistance, implementation monitoring, and staff feedback help 

ensure the high-quality delivery and sustainability of EBIs.268,285,294,312,314,354,355

Step 4. Plan for Long-Term Sustainability

A lack of funding is a significant barrier to the long-term sustainability of EBIs,294,308,311,356-359 and it is 

critical that, even before implementation, agencies and communities consider how each EBI will be 

integrated into existing systems and funded over time.304,360 Considering how a new EBI will address 

local needs can be useful in gaining support.361

Recommendations for Research

Although much has been learned in prevention research over the past four decades, much remains to be 

understood. Future research should develop and evaluate new prevention interventions, both programs 

and policies, and continue to assess the effectiveness of existing interventions about which little is 

known. This research will help guide the field toward strategies with the greatest potential for reducing 

substance misuse and related problems. 

Research also is needed to examine the effectiveness of screening and brief interventions for alcohol 

use in adolescents and for drug use in adolescents and adults; the combinations of evidence-based 

alcohol policies that most effectively reduce alcohol misuse and related harms; the public health impact 

of policies to reduce drug misuse; and the effectiveness of strategies to reduce marijuana misuse, 

driving after drug use, and simultaneous use of alcohol and drugs. In addition, the public health impact 

of marijuana decriminalization, legalization of medical marijuana, and legalization of recreational 

marijuana on marijuana, alcohol, and other drug use, as well as policies to reduce prescription drug 

misuse, should be monitored closely.
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PAGE | 3-36

Research is needed to develop and test new prevention interventions, both policies and programs, to fill 

gaps in existing EBIs and to meet emerging public health needs across the lifecourse. 

Given that racial and ethnic minority communities are often disproportionately affected by the adverse 

consequences of substance misuse, culturally-informed research should be conducted to examine 

ways to increase the cultural relevance, engagement, and effectiveness of prevention interventions for 

diverse communities. Additionally, studies of these interventions should be replicated and examined to 

determine the impact of prevention interventions for different cultural groups and contexts.

Consistent standards for evaluating interventions, conducting replication trials, and reporting the 

results should be developed. Examples of such standards have been developed by the Society for 

Prevention Research and the United Nations Office on Drugs and Crime.26,357,362-368 Studies evaluating 

the effectiveness of interventions for reducing substance misuse should collect data over extended 

periods of time to track the long-term effects of these interventions on persons of all ages. The impact 

of environmental interventions on substance misuse should also be followed for at least a year beyond 

the end of the period of intervention support. The field needs to develop a consensus on standardization 

of methods of cost-benefit analysis, and increase research on cost-effectiveness evaluations of 

prevention EBIs.

Evidence is also needed to develop improved strategies for intervention in primary health care settings 

to prevent the initiation and escalation of adolescent substance use. More research is also needed 

on linking screening with personalized interventions, improved strategies for effective referral to 

specialty treatment, and interventions for adolescents that use social media and capitalize on current 

technologies. Research should also consider the optimal conditions for bringing effective prevention 

interventions to scale, develop consensus on standardization of methods for cost-benefit analysis, and 

increase research on cost-effectiveness evaluations of prevention EBIs.

Surveillance of risky drinking, drug use, and related problems needs to be improved. All drivers in fatal 

crashes should have their blood alcohol content tested and be tested for drug use. All unintentional and 

intentional injury deaths, including overdoses, should be tested for both alcohol and drugs. Surveillance 

surveys need to add questions about simultaneous alcohol and drug use and questions about the 

maximum quantities consumed in a day and frequency of consumption at those levels. Efforts are 

needed to increase surveillance of the second-hand effects of alcohol and drug use, such as assaults, 

sexual assaults, motor vehicle crashes, homicides and suicides, and effects of substance use on academic 

and work performance. Efforts are needed to expand surveillance beyond national and state levels to the 

level of local communities.
P R E V E N T I O N 

PAGE | 3-37

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PAGE | 4-1

CHAPTER 4.

EARLY INTERVENTION, TREATMENT, 

AND MANAGEMENT OF SUBSTANCE USE 

DISORDERS

Chapter 4 Preview 

A substance use disorder is a medical illness characterized by clinically significant impairments in 

health, social function, and voluntary control over substance use.2 Substance use disorders range in 

severity, duration, and complexity from mild to severe. In 2015, 20.8 million people aged 12 or older 

met criteria for a substance use disorder. While historically the great majority of treatment has occurred 

in specialty substance use disorder treatment programs with little involvement by primary or general 

health care, a shift is occurring toward the delivery of treatment services in general health care practice. 

For those with mild to moderate substance use disorders, treatment through the general health care 

system may be sufficient, while those with severe substance use disorders (addiction) may require 

specialty treatment. 

The good news is that a spectrum of effective strategies and 

services are available to identify, treat, and manage substance 

use problems and substance use disorders. Research shows 

that the most effective way to help someone with a substance 

use problem who may be at risk for developing a substance 

use disorder is to intervene early, before the condition can progress. With this recognition, screening 

for substance misuse is increasingly being provided in general health care settings, so that emerging 

problems can be detected and early intervention provided if necessary. The addition of services to 

address substance use problems and disorders in mainstream health care has extended the continuum of 

care, and includes a range of effective, evidence-based medications, behavioral therapies, and supportive 

services. However, a number of barriers have limited the widespread adoption of these services, 

including lack of resources, insufficient training, and workforce shortages.5 This is particularly true for 

the treatment of those with co-occurring substance use and physical or mental disorders.6,7

See Chapter 6 - Health Care Systems 

and Substance Use Disorders.
TREATMENT

PAGE | 4-2

This chapter provides an overview of the scientific evidence supporting the effectiveness of treatment 

interventions, therapies, services, and medications available to identify, treat, and manage substance use 

problems and disorders. 

KEY FINDINGS*

• Well-supported scientific evidence shows that substance use disorders can be effectively treated, 

with recurrence rates no higher than those for other chronic illnesses such as diabetes, asthma, and 

hypertension. With comprehensive continuing care, recovery is now an achievable outcome. 

• Only about 1 in 10 people with a substance use disorder receive any type of specialty treatment. The 

great majority of treatment has occurred in specialty substance use disorder treatment programs with 

little involvement by primary or general health care. However, a shift is occurring to mainstream the 

delivery of early intervention and treatment services into general health care practice. 

• Well-supported scientific evidence shows that medications can be effective in treating serious 

substance use disorders, but they are under-used. The U.S. Food and Drug Administration (FDA)

has approved three medications to treat alcohol use disorders and three others to treat opioid use 

disorders. However, an insufficient number of existing treatment programs or practicing physicians offer 

these medications. To date, no FDA-approved medications are available to treat marijuana, cocaine, 

methamphetamine, or other substance use disorders, with the exception of the medications previously 

noted for alcohol and opioid use disorders.

• Supported scientific evidence indicates that substance misuse and substance use disorders can be 

reliably and easily identified through screening and that less severe forms of these conditions often 

respond to brief physician advice and other types of brief interventions. Well-supported scientific 

evidence shows that these brief interventions work with mild severity alcohol use disorders, but only 

promising evidence suggests that they are effective with drug use disorders. 

• Well-supported scientific evidence shows that treatment for substance use disorders—including 

inpatient, residential, and outpatient—are cost-effective compared with no treatment. 

• The primary goals and general management methods of treatment for substance use disorders are the 

same as those for the treatment of other chronic illnesses. The goals of treatment are to reduce key 

symptoms to non-problematic levels and improve health and functional status; this is equally true for 

those with co-occurring substance use disorders and other psychiatric disorders. Key components of 

care are medications, behavioral therapies, and recovery support services (RSS).

• Well-supported scientific evidence shows that behavioral therapies can be effective in treating 

substance use disorders, but most evidence-based behavioral therapies are often implemented with 

limited fidelity and are under-used. Treatments using these evidence-based practices have shown better 

results than non-evidence-based treatments and services. 

• Promising scientific evidence suggests that several electronic technologies, like the adoption of 

electronic health records (EHRs) and the use of telehealth, could improve access, engagement, 

monitoring, and continuing supportive care of those with substance use disorders. 

*The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence as: “Well-supported”: 

when evidence is derived from multiple controlled trials or large-scale population studies; “Supported”: when 

evidence is derived from rigorous but fewer or smaller trials; and “Promising”: when evidence is derived from a 

practical or clinical sense and is widely practiced.8
TREATMENT

PAGE | 4-3

Continuum of Treatment Services

Substance use disorders typically emerge during adolescence 

and often (but not always) progress in severity and complexity 

with continued substance misuse.9,10 Currently, substance 

use disorders are classified diagnostically into three severity 

categories: mild, moderate, and severe.2 

Substance use disorder treatment is designed to help 

individuals stop or reduce harmful substance misuse, improve 

their health and social function, and manage their risk for 

relapse. In this regard, substance use disorder treatment is 

effective and has a positive economic impact. Research shows 

that treatment also improves individuals’ productivity,11

health,11,12 and overall quality of life.13-15 In addition, studies 

show that every dollar spent on substance use disorder 

treatment saves $4 in health care costs and $7 in criminal 

justice costs.11

Mild substance use disorders can be identified quickly 

and reliably in many medical and social settings. These 

common but less severe disorders often respond to brief motivational interventions and/or supportive 

monitoring, referred to as guided self-change.16 In contrast, severe, complex, and chronic substance 

use disorders often require specialty substance use disorder treatment and continued post-treatment 

support to achieve full remission and recovery. To address the spectrum of substance use problems 

and disorders, a continuum of care provides individuals an array of service options based on need, 

including prevention, early intervention, treatment, and recovery support (Figure 4.1). Traditionally, 

the vast majority of treatment for substance use disorders has been provided in specialty substance use 

disorder treatment programs, and these programs vary substantially in their clinical objectives and in 

the frequency, intensity, and setting of care delivery.

Substance Use Disorder Treatment. 

A service or set of services that may 

include medication, counseling, and 

other supportive services designed 

to enable an individual to reduce or 

eliminate alcohol and/or other drug use, 

address associated physical or mental 

health problems, and restore the patient 

to maximum functional ability.3

Continuum of Care. An integrated 

system of care that guides and 

tracks a person over time through 

a comprehensive array of health 

services appropriate to the individual’s 

need. A continuum of care may 

include prevention, early intervention, 

treatment, continuing care, and recovery 

support.4
TREATMENT

PAGE | 4-4

Figure 4.1: Substance Use Status and Substance Use Care Continuum

Positive Physical, Social, and 

Mental Health

Substance Misuse Substance Use Disorder

A state of physical, mental, and 

social well-being, free from 

substance misuse, in which an 

individual is able to realize his 

or her abilities, cope with the 

normal stresses of life, work 

productively and fruitfully, and 

make a contribution to his or her 

community.

The use of any substance in a 

manner, situation, amount, or 

frequency that can cause harm to 

the user and/or to those around 

them.

Clinically and functionally significant 

impairment caused by substance 

use, including health problems, 

disability, and failure to meet major 

responsibilities at work, school, or 

home; substance use disorders are 

measured on a continuum from 

mild, moderate, to severe based on 

a person’s number of symptoms.

Substance Use Status Continuum

Substance Use Care Continuum

Enhancing Health Primary 

Prevention

Early 

Intervention

Treatment Recovery 

Support

Promoting 

optimum physical 

and mental 

health and wellbeing, free from 

substance misuse, 

through health 

mmunications and 

access to health 

care services, 

income and 

economic security, 

and workplace 

certainty.

Addressing 

individual and 

environmental 

risk factors 

for substance 

use through 

evidencebased 

programs, 

policies, and 

strategies.

Screening 

and detecting 

substance use 

problems at 

an early stage 

and providing 

brief 

intervention, 

as needed.

Intervening through medication, 

counseling, and other supportive 

services to eliminate symptoms 

and achieve and maintain sobriety, 

physical, spiritual, and mental health 

and maximum functional ability. 

Levels of care include:

• Outpatient services;

• Intensive Outpatient/ Partial 

Hospitalization Services;

• Residential/ Inpatient Services; and

• Medically Managed Intensive 

Inpatient Services.

Removing barriers 

and providing 

supports to 

aid the longterm recovery 

process. Includes 

a range of social, 

educational, 

legal, and other 

services that 

facilitate recovery, 

wellness, and 

improved quality 

of life.

This chapter describes the early intervention and treatment components of the continuum of care, the 

major behavioral, pharmacological, and service components of care, services available, and emerging 

treatment technologies:

$ Early Intervention, for addressing substance misuse problems or mild disorders and helping to 

prevent more severe substance use disorders. 

$ Treatment engagement and harm reduction interventions, for individuals who have a substance use 

disorder but who may not be ready to enter treatment, help engage individuals in treatment and 

reduce the risks and harms associated with substance misuse. 

$ Substance use disorder treatment, an individualized set of evidence-based clinical services designed 

to improve health and function, including medications and behavioral therapies.

$ Emerging treatment technologies are increasingly being used to support the assessment, treatment, 

and maintenance of continuing contact with individuals with substance use disorders. 
TREATMENT

PAGE | 4-5

Early Intervention: Identifying and Engaging 

Individuals At Risk for Substance Misuse and 

Substance Use Disorders

Early intervention services can be provided in a variety of settings (e.g., school clinics, primary care 

offices, mental health clinics) to people who have problematic use or mild substance use disorders.17 

These services are usually provided when an individual presents for another medical condition or social 

service need and is not seeking treatment for a substance use disorder. The goals of early intervention 

are to reduce the harms associated with substance misuse, to reduce risk behaviors before they lead to 

injury,18 to improve health and social function, and to prevent progression to a disorder and subsequent 

need for specialty substances use disorder services.17,18 Early intervention consists of providing 

information about substance use risks, normal or safe levels of use, and strategies to quit or cut down on 

use and use-related risk behaviors, and facilitating patient initiation and engagement in treatment when 

needed. Early intervention services may be considered the bridge between prevention and treatment 

services. For individuals with more serious substance misuse, intervention in these settings can serve as 

a mechanism to engage them into treatment.17

Populations Who Should Receive Early Intervention 

Early intervention should be provided to both adolescents and adults who are at risk of or show signs of 

substance misuse or a mild substance use disorder.17 One group typically in need of early intervention 

is people who binge drink: people who have consumed at least 5 (for men) or 4 (for women) drinks on 

a single occasion at least once in the past 30 days.19 Recent national survey data suggest that over 66 

million individuals aged 12 or older can be classified as binge drinkers.19 Of particular concern are the 

1.4 million binge drinkers aged 12 to 17, who may be at higher risk for future substance use disorders 

because of their young age.19

Other groups who are likely to benefit from early intervention are people who use substances while 

driving and women who use substances while pregnant. In 2015, an estimated 214,000 women 

consumed alcohol while pregnant, and an estimated 109,000 pregnant women used illicit drugs.19

Available research shows that brief, early interventions, given by a respected care provider, such as a 

nurse, nurse educator, or physician, in the context of usual medical care (for example, a routine medical 

exam or care for an injury or illness) can educate and motivate many individuals who are misusing 

substances to understand and acknowledge their risky behavior and to reduce their substance use.20,21

Regardless of the substance, the first step to early intervention is screening to identify behaviors that 

put the individual at risk for harm or for developing a substance use disorder. Positive screening results 

should then be followed by brief advice or counseling tailored to the specific problems and interests of 

the individual and delivered in a non-judgmental manner, emphasizing both the importance of reducing 

substance use and the individual’s ability to accomplish this goal.17 Later follow-up monitoring should 

assess whether the screening and brief intervention were effective in reducing the substance use below 

risky levels or whether the person needs formal treatment.
TREATMENT

PAGE | 4-6

Components of Early Intervention

One structured approach to delivering early intervention to people showing signs of substance misuse 

and/or early signs of a substance use disorder is through screening and brief intervention (SBI).22

Research has shown that several methods of SBI are effective in decreasing “at-risk” substance use and 

that they work for a variety of populations and in a variety of health care settings.22,23 As mentioned 

earlier, this research has demonstrated positive effects for reducing alcohol use;24,25 the research with 

SBI among those with other substance use disorders has shown mixed results.26-29

In addition, research shows that SBI can be cost-effective. 

For example, a randomized study compared SBI to screening 

alone for alcohol and drug use disorders among patients 

covered by Medicaid in eight emergency medicine clinics in 

the State of Washington. A year later, investigators compared 

total Medicaid expenditures between the two groups and found that the costs per member, per month 

for the SBI group were $185 to $192 lower than the costs for the screening-only group. This added up 

to a savings of more than $2,200 per patient in one year.30 

See Chapter 6 - Health Care Systems 

and Substance Use Disorders.

SBI: Screening 

Ideally, substance misuse screening should occur for all individuals who present in health care settings, 

including primary, urgent, psychiatric, and emergency care. Professional organizations, including the 

American College of Obstetricians and Gynecologists, the American Medical Association, the American 

Academy of Family Physicians, and the American Academy of Pediatrics recommend universal and 

ongoing screening for substance use and mental health issues for adults and adolescents.31-36 Such 

screening practices can help identify the severity of the individual’s substance use and whether 

substance use disorder treatment may be necessary. 

Within these contexts, substance misuse can be reliably identified through dialogue, observation, 

medical tests, and screening instruments.37 Several validated screening instruments have been developed 

to help non-specialty providers identify individuals who may have, or be at risk for, a substance use 

disorder.

Table 4.1 provides examples of available substance use screening tools, how they are used, and for which 

age groups. In addition to these tools, single-item screens for presence of drug use (“How many times in 

the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”) 

and for alcohol use (“How many times in the past year have you had X or more drinks in a day?”, where 

X is 5 for men and 4 for women) have been validated and shown in primary care to accurately identify 

individuals at risk for or experiencing a substance use disorder.38-42
TREATMENT

PAGE | 4-7

Table 4.1: Evidence-Based Screening Tools for Substance Use

Screening Tool Substance Type Age Group

Alcohol Drugs Adolescents Adults

Alcohol Screening and Brief 

Intervention for Adolescents and 

Youth: A Practitioner’s Guide

 

Alcohol Use Disorders Identification 

Test (AUDIT)  

Alcohol Use Disorders Identification 

Test-C (AUDIT-C)  

Brief Screener for Tobacco, 

Alcohol, and Other Drugs (BSTAD)   

CRAFFT   

CRAFFT (Part A)   

Drug Abuse Screen Test (DAST-10 )  

DAST-20: Adolescent version  

Helping Patients Who Drink Too 

Much: A Clinicians’ Guide   

NIDA Drug Use Screening Tool   

NIDA Drug Use Screening Tool: 

Quick Screen   See APA Adapted NM ASSIST tools 

Opioid Risk Tool  

S2BI   

Source: National Institute on Drug Abuse, (2015).43

SBI: Brief Interventions 

Brief interventions (or brief advice) range from informal counseling to structured therapies. They often 

include feedback to the individual about their level of use relative to safe limits, as well as advice to aid 

the individual in decision-making.17

Motivational interviewing (MI) is a client-centered 

counseling style that addresses a person’s ambivalence to 

change. A counselor uses a conversational approach to help 

their client discover their interest in changing their substance 

using behavior. The counselor asks the client to express their 

desire for change and any ambivalence they might have and 

then begins to work with the client on a plan to change their 

behavior and to make a commitment to the change process. The main purpose of MI is to examine and 

resolve ambivalence, and the counselor is intentionally directive in pursuing this goal.44 It is effective 

in reducing the substance misuse of patients who come to medical settings for other health-related 

conditions.45 In these settings, individuals who receive MI are more likely to adhere to a treatment plan 

and, subsequently, to have better outcomes.24,46 

SAMHSA SBIRT Education

SAMHSA offers free SBIRT Continuing 

Medical Education and Continuing 

Education courses for providers.
TREATMENT

PAGE | 4-8

Adding Referral to Treatment When Necessary

When an individual’s substance use problem meets criteria for a substance use disorder, and/or when 

brief interventions do not produce change, it may be necessary to motivate the patient to engage in 

specialized treatment. This is called Screening, Brief Intervention, and Referral to Treatment (SBIRT). 

In such cases, the care provider makes a referral for a clinical assessment followed by a clinical 

treatment plan developed with the individual that is tailored to meet the person’s needs.47 Effective 

referral processes should incorporate strategies to motivate patients to accept the referral. Although the 

screening and brief intervention components of SBIRT are the same as SBI, referral to treatment helps 

the individual access, select, and navigate barriers to substance use disorder treatment. 

The literature on the effectiveness of drug-focused brief intervention in primary care and emergency 

departments is less clear, with some studies finding no improvements among those receiving brief 

interventions.48,49 However, at least one study found significant reductions in subsequent drug use.50

Even if brief interventions are not found to be sufficient to address patients’ drug use disorders, general 

health care settings still have an important role to play in addressing drug use disorders, by providing 

medication-assisted treatment (MAT), providing more robust monitoring and care coordination, and 

actively promoting engagement in specialty substance use disorder treatment.

Trials evaluating different types of screening and brief interventions for drug use in a range of settings 

and on a range of patient characteristics are lacking. Recently, efforts have been made to adapt SBIRT 

for adolescents and for all groups with substance use disorders.51,52 The results of preliminary studies 

are promising,20,53 but gaps in knowledge about SBIRT for adolescents still need to be filled.54

Treatment Engagement: Reaching and Reducing 

Harm Among Those Who Need Treatment

Populations Who Need Treatment but Are Not Receiving It

Despite the fact that substance use disorders are widespread, 

only a small percentage of people receive treatment. Results 

from the 2015 National Survey of Drug Use and Health (NSDUH) 

reveal that only about 2.2 million people with a substance 

use disorder, or about 1 in 10 affected individuals, received 

any type of treatment in the year before the survey was administered.19 This “treatment gap” is a large 

and costly concern for individuals, families, and communities. Of those who needed treatment but 

did not receive treatment, over 7 million were women and more than 1 million were adolescents aged 

12 to 17.19 Some racial and ethnic groups experience disparities in entering and receiving substance 

use disorder treatment services.55 For example, approximately 13 million of those who did not receive 

treatment were non-Hispanic or non-Latino Whites, about 3 million were Hispanics or Latinos, and 

about 3 million were non-Hispanic Blacks or African Americans.19 Among all individuals who met 

criteria for a substance use disorder, alcohol was by far the most prevalent substance reported, followed 

by marijuana, misuse of prescription pain relievers, cocaine, and methamphetamines, and about 1 in 

See Chapter 1 - Introduction and 

Overview.
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PAGE | 4-9

10 reported use of multiple substances.19 Additionally, over 8 million individuals, or about 40 percent 

of those with a substance use disorder, also had a mental disorder diagnosed in the year before the 

survey.19 Nonetheless, only 6.8 percent of these individuals received treatment for both conditions, and 

52.0 percent received no treatment at all.19 Many individuals with substance use disorders also have 

related physical health problems. Substance use can contribute to medical issues, such as an increased 

risk of liver, lung, or cardiovascular disease, as well as infectious diseases such as Hepatitis B or C, and 

HIV/AIDS, and can worsen these health outcomes.56

Reasons for Not Seeking Treatment 

There are many reasons people do not seek treatment. The most common reason is that they are 

unaware that they need treatment; they have never been told they have a substance use disorder or 

they do not consider themselves to have a problem. This is one reason why screening for substance use 

disorders in general health care settings is so important. In addition, among those who do perceive that 

they need substance use disorder treatment, many still do not seek it. For these individuals, the most 

common reasons given are:19

$ Not ready to stop using (40.7 percent). A common 

clinical feature associated with substance use 

disorders is an individual’s tendency to underestimate 

the severity of their problem and to over-estimate 

their ability to control it. This is likely due to 

substance-induced changes in the brain circuits that control impulses, motivation, and decision 

making.

See Chapter 2 - The Neurobiology of 

Substance Use, Misuse, and Addiction.

$ Do not have health care coverage/could not afford (30.6 percent). 

$ Might have a negative effect on job (16.4 percent) or cause neighbors/community to have a 

negative opinion (8.3 percent).

$ Do not know where to go for treatment (12.6 percent) or no program has the type of treatment 

desired (11.0 percent). 

$ Do not have transportation, programs are too far away, or hours are inconvenient (11.8 

percent). 

The costs of care and lack of insurance coverage are particularly important issues for people with 

substance use disorders. The 2015 NSDUH found that among individuals who needed and made an 

effort to get treatment but did not receive specialty substance use treatment, 30.0 percent reported that 

they did not have insurance coverage and could not afford to pay for treatment.19 Thus, a way to reduce 

health disparities is to increase the number of people who have health insurance. However, even if an 

individual is insured, the payor may not cover some types or components of substance use disorder 

treatments, particularly medications.57,58 These challenges are magnified further for those who live in 

rural areas, where substance use disorder treatment services can be distant and thus difficult to reach, as 

well as expensive because of travel time and cost.58
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Strategies to Reduce Harm

Strategies to reduce the harms associated with substance use have been developed as a way to engage 

people in treatment and to address the needs of those who are not yet ready to participate in treatment. 

Harm reduction programs provide public health-oriented, evidence-based, and cost-effective services to 

prevent and reduce substance use-related risks among those actively using substances,59 and substantial 

evidence supports their effectiveness.60,61 These programs work with populations who may not be 

ready to stop substance use – offering individuals strategies to reduce risks while still using substances. 

Strategies include outreach and education programs, needle/syringe exchange programs, overdose 

prevention education, and access to naloxone to reverse potentially lethal opioid overdose.59,62 These 

strategies are designed to reduce substance misuse and its negative consequences for the users and 

those around them, such as transmission of HIV and other infectious diseases.63 They also seek to help 

individuals engage in treatment to reduce, manage, and stop their substance use when appropriate. 

Outreach and Education

Outreach activities seek to identify those with active substance use disorders who are not in treatment 

and help them realize that treatment is available, accessible, and necessary. Outreach and engagement 

methods may include telephone contacts, face-to-face street outreach, community engagement,64 or 

assertive outreach after a referral is made by a clinician or caseworker. These efforts often occur within 

or in collaboration with programs for intimate partner violence, homelessness, or HIV/AIDS.65-68 One 

study showed that 41 percent of referrals to treatment among substance-using individuals enrolled in 

a homelessness outreach project successfully resulted in treatment enrollment.69 This is notable and 

promising, but additional research is needed to validate that outreach efforts geared at identifying 

individuals who need treatment are successful at increasing substance use treatment enrollment and 

subsequent outcomes.

Educational campaigns are also a common strategy for reducing harms associated with substance 

use. Such campaigns have historically been targeted toward substance-using individuals, giving them 

information and guidance on risks associated with sharing medications or needles, how to access low or 

no-cost treatment services, and how to prevent a drug overdose death.59,61 Other education campaigns 

target the overall public to improve general understanding about addiction, community health and safety 

risks, and how to access available treatment services.70-72 Two examples are SAMHSA’s National Recovery 

Month, which seeks to increase awareness and understanding of mental and substance use issues, and the 

Anyone.Anytime. campaign in New Hampshire, which was implemented statewide to educate the public and 

professionals about addiction, emergency overdose medication, and accessibility to support services for 

those with opioid use disorders. The National Highway Traffic Safety Administration’s (NHTSA’s) annual 

Drive Sober or Get Pulled Over campaign is another example, aimed at reducing drunk driving and preventing 

alcohol-impaired fatalities.

Needle/Syringe Exchange Programs

Drugs such as heroin and other opioids, cocaine, and methamphetamine are commonly used by 

injection, and this route of administration has been a major source of infectious disease transmission 

including HIV, Hepatitis B, Hepatitis C, and other blood-borne diseases. Data from the CDC reveal 
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that even though HIV among people who inject drugs is declining, it is still a significant problem: 7 

percent (3,096) of the 47,352 newly diagnosed cases of HIV infection in the United States in 2013 were 

attributable to injection drug use, and another 3 percent (1,270) involved male-to-male sexual contact 

combined with injection drug use.73,74 Nearly 20,000 people died from Hepatitis C in 2014, and 3.5 

million are living with Hepatitis C. New cases of Hepatitis C infection increased 250 percent between 

2010 and 2014, and occur primarily among young White people who inject drugs.75 

Because of these data, providing sterile needles and syringes to people who inject drugs has become an 

important strategy for reducing disease transmission. The goal of needle/syringe exchange programs is 

to minimize infection transmission risks by giving individuals who inject drugs sterile equipment and 

other support services at little or no cost.76 Additional services from these programs often include HIV/

AIDS counseling and testing; strategies and education for preventing sexually transmitted infections, 

including condom use and use of medications before or after exposure to HIV to reduce the risk of 

becoming infected (pre-exposure prophylaxis [PrEP] or post-exposure prophylaxis [PEP]); and other 

health care services. Needle/syringe exchange programs also attempt to encourage individuals to engage 

in substance use disorder treatment.77 

Evaluation studies have clearly shown that needle/syringe exchange programs are effective in reducing 

HIV transmission and do not increase rates of community drug use.78 However, most of the research has 

not examined the impact of these programs on Hepatitis C transmission, therefore currently available 

data are insufficient to address this question.79

Naloxone

Opioid overdose incidents and deaths, either from prescription pain relievers or heroin, are a serious 

threat to public health in the United States. Overdose deaths from opioid pain relievers and heroin

have risen dramatically in the past 14 years,80 from 5,990 in 1999 to 29,467 in 2014, and most were 

preventable. Rates of opioid overdose deaths are particularly high among individuals with an opioid use 

disorder who have recently stopped their use as a result of detoxification or incarceration. As a result, 

their tolerance for the drug is reduced, making them more vulnerable to an overdose. Those who mix 

opioids with alcohol, benzodiazepines, or other drugs also have a high risk of overdose.59

Opioid overdose does not occur immediately after a person has taken the drug. Rather, the effects 

develop gradually as the drug depresses a person’s breathing and heart rate. This eventually leads to 

coma and death if the overdose is not treated. This gradual progress means that there is typically a 1- to 

3-hour window of opportunity after a user has taken the drug in which bystanders can take action to 

prevent the user’s death.59 

Naloxone is an opioid antagonist medication approved by the FDA to reverse opioid overdose in 

injectable and nasal spray forms. It works by displacing opioids from receptors in the brain, thereby 

blocking their effects on breathing and heart rate. 

The rising number of deaths from opioid overdose has led to increasing public health efforts to make 

naloxone available to at-risk individuals and their families, as well as to emergency medical technicians, 

police officers, and other first responders, or through community-based opioid overdose prevention 

programs. Although regulations vary by state, some states have passed laws expanding access to 
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PAGE | 4-12

naloxone without a patient-specific prescription in some localities.81,82 Additionally, some schools across 

the country are stocking naloxone for use by trained nurses. 

Interventions that distribute take-home doses of naloxone along with education and training for those 

actively using opioids and their peers and family members, have the potential to help decrease overdoserelated deaths.83,84 Current evidence from nonrandomized studies also suggests that family, friends, and 

other community members who are properly trained can and will administer naloxone appropriately 

during an overdose incident.85 And, despite concern that access to naloxone might increase the 

prevalence or frequency of opioid use, research demonstrates that neither of these problems has 

occurred.86

FDA Approval of Naloxone Nasal Spray

Naloxone, a safe medication that can quickly restore normal breathing to a person in danger of dying from an 

opioid overdose, is already carried by emergency medical personnel and other first responders. But by the time 

an overdosing person is reached and treated, it is often too late to save them. To solve this problem, several 

experimental Overdose Education and Naloxone Distribution (OEND) programs have given naloxone directly 

to opioid users, their friends or loved ones, and other potential bystanders, along with brief training on how to 

use this medication. These programs have been shown to be an effective, as well as cost-effective, way of saving 

lives.

Until recently, only injectable forms of naloxone were approved by the FDA. However, in November 2015, the 

FDA approved a user-friendly intranasal formulation of naloxone that matches the injectable version in terms 

of how much of the medication gets into the body and how rapidly. According to the CDC, more than 74 

Americans die each day from an overdose involving prescription pain relievers or heroin. To reverse these trends, 

it is important to do everything possible to ensure that emergency personnel, as well as at-risk opioid users and 

their loved ones, have access to lifesaving medications like naloxone.

Acute Stabilization and Withdrawal Management 

Withdrawal management, often called “detoxification,” includes interventions aimed at managing 

the physical and emotional symptoms that occur after a person stops using a substance. Withdrawal 

symptoms vary in intensity and duration based on the substance(s) used, the duration and amount of 

use, and the overall health of the individual. Some substances, such as alcohol, opioids, sedatives, and 

tranquilizers, produce significant physical withdrawal effects, while other substances, such as marijuana, 

stimulants, and caffeine, produce primarily emotional and cognitive withdrawal symptoms. Most 

periods of withdrawal are relatively short (3 to 5 days) and are managed with medications combined 

with vitamins, exercise, and sleep. One important exception is withdrawal from alcohol and sedatives/

tranquilizers, especially if the latter are combined with heavy alcohol use. Rapid or unmanaged 

withdrawal from these substances can be protracted and can produce seizures and other health 

complications.56

Withdrawal management is highly effective in preventing immediate and serious medical consequences 

associated with discontinuing substance use,56 but by itself it is not an effective treatment for any 

substance use disorder. It is best considered stabilization: The patient is assisted through a period of 

acute detoxification and withdrawal to being medically stable and substance-free. Stabilization includes 
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PAGE | 4-13

preparing the individual for treatment and involving the individual’s family and other significant people 

in the person’s life, as appropriate, to support the person’s treatment process. Stabilization is considered 

a first step toward recovery, much like acute management of a diabetic coma or a hypertensive stroke 

is simply the first step toward managing the underlying illness of diabetes or high blood pressure. 

Similarly, acute stabilization and withdrawal management are most effective when following evidencebased standards of care.87

Unfortunately, many individuals who receive withdrawal management do not become engaged in 

treatment. Studies have found that half to three quarters of individuals with substance use disorders 

who receive withdrawal management services do not enter treatment.88 One common result of not 

engaging in continuing care is rapid readmission to a detoxification center, an emergency department, 

or a hospital. For example, 27 percent of people who received detoxification services not followed by 

continuing care were readmitted within 1 year to public detoxification services in Delaware, Oklahoma, 

and Washington.89 Beginning substance use disorder treatment within 14 days of discharge from 

withdrawal management, however, has been shown to reduce readmission rates.90

One of the most serious consequences when individuals do not begin continuing care after withdrawal 

management is overdose. Because withdrawal management reduces much of an individual’s acquired 

tolerance, those who attempt to re-use their former substance in the same amount or frequency can 

experience physical problems. Individuals with opioid use disorders may be left particularly vulnerable 

to overdose and even death. It is critically important for health care providers to be prepared to properly 

assess the nature and severity of their patients’ clinical problems following withdrawal so that they can 

facilitate engagement into the appropriate intensity of treatment.56

Principles of Effective Treatment and Treatment 

Planning 

Principles and Goals of Treatment

Treatment can occur in a variety of settings but most treatment for substance use disorders has 

traditionally been provided in specialty substance use disorder treatment programs. For this reason, 

the majority of research has been performed within these specialty settings.91 The following sections 

describe what is known from this research about the processes, stages of, and outcomes from traditional 

substance use disorder treatment programs.

The National Institute on Drug Abuse (NIDA) has detailed the evidence-based principles of effective 

treatment for adults and adolescents with substance use disorders that apply regardless of the particular 

setting of care or type of substance use disorder treatment program (Table 4.2).85,92
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Table 4.2: Principles of Effective Treatment for Substance Use Disorders

Principles of Effective Treatment for Adults Principles of Effective Treatment for Adolescents

1. Addiction is a complex but treatable disease that 

affects brain function and behavior.

2. No single treatment is appropriate for everyone.

3. Treatment needs to be readily available.

4. Effective treatment attends to multiple needs of 

the individual, not just his or her drug abuse.

5. Remaining in treatment for an adequate period of 

time is critical.

6. Behavioral therapies—including individual, family, 

or group counseling-- are the most commonly 

used forms of drug abuse treatment.

7. Medications are an important element of 

treatment for many patients, especially when 

combined with counseling and other behavioral 

therapies.

8. An individual’s treatment and services plan 

must be assessed continually and modified as 

necessary to ensure that it meets his or her 

changing needs.

9. Many drug-addicted individuals also have other 

mental disorders.

10. Medically assisted detoxification is only the first 

stage of addiction treatment and by itself does 

little to change long-term drug abuse.

11. Treatment does not need to be voluntary to be 

effective.

12. Drug use during treatment must be monitored 

continuously, as lapses during treatment do occur.

13. Treatment programs should test patients for 

the presence of HIV/AIDS, Hepatitis B and C, 

tuberculosis, and other infectious diseases, 

provide risk-reduction counseling, and link 

patients to treatment if necessary.

1. Adolescent substance use needs to be identified 

and addressed as soon as possible.

2. Adolescents can benefit from a drug abuse 

intervention even if they are not addicted to a 

drug.

3. Routine annual medical visits are an opportunity to 

ask adolescents about drug use.

4. Legal interventions and sanctions or family pressure 

may play an important role in getting adolescents 

to enter, stay in, and complete treatment.

5. Substance use disorder treatment should be 

tailored to the unique needs of the adolescent.

6. Treatment should address the needs of the whole 

person, rather than just focusing on his or her drug 

use.

7. Behavioral therapies are effective in addressing 

adolescent drug use.

8. Families and the community are important aspects 

of treatment.

9. Effectively treating substance use disorders in 

adolescents requires also identifying and treating 

any other mental health conditions they may have.

10. Sensitive issues such as violence and child abuse or 

risk of suicide should be identified and addressed.

11. It is important to monitor drug use during 

treatment.

12. Staying in treatment for an adequate period 

of time and continuity of care afterward are 

important.

13. Testing adolescents for sexually transmitted 

diseases like HIV, as well as Hepatitis B and C, is an 

important part of drug treatment.

Source: National Institute on Drug Abuse, (2012)85 and (2014).92

The goals of substance use disorder treatment are similar to those of treatments for other serious, 

often chronic, illnesses: reduce the major symptoms of the illness, improve health and social function, 

and teach and motivate patients to monitor their condition and manage threats of relapse. Substance 

use disorder treatment can be provided in inpatient or outpatient settings, depending on the needs of 

the patient, and typically incorporates a combination of behavioral therapies, medications, and RSS. 

However, unlike treatments for most other medical illnesses, substance use disorder treatment has 

traditionally been provided in programs (both residential and outpatient) outside of the mainstream 

health care system. The intensity of the treatment regimens offered can vary substantially across 

program types. The American Society of Addiction Medicine (ASAM) has categorized these programs 

into “levels” of care to guide referral based on an individual patient’s needs.93-95 
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Despite differences in care delivery and differences in 

reimbursement, substance use disorder treatments have 

approximately the same rates of positive outcomes as 

treatment for other chronic illnesses. Relapse rates for 

substance use disorders (40 to 60 percent) are comparable 

to those for chronic diseases, such as diabetes (20 to 50 

percent), hypertension (50 to 70 percent), and asthma (50 to 

70 percent).12

The general process of treatment planning and delivery for 

individuals with severe substance use disorders is described 

below, along with an explanation of the evidence-based 

therapies, medications, and RSS shown to be effective in 

treatment. 

Treatment varies depending on 

substance(s) used, severity of substance 

use disorder, comorbidities, and the 

individual’s preferences.

Treatment typically includes medications 

and counseling as well as other social 

supports such as linkage to community 

recovery groups depending on an 

individual patient’s needs and level of 

existing family and social support.

Treatment Planning

Assessment and Diagnosis

Among the first steps involved in substance use disorder treatment are assessment and diagnosis. The 

diagnosis of substance use disorders is based primarily on the results of a clinical interview. Several 

assessment instruments are available to help structure and elicit the information required to diagnose 

substance use disorders. The diagnosis of a substance use 

disorder is made by a trained professional based on 11 

symptoms defined in the Fifth Edition of the Diagnostic and 

Statistical Manual of Mental Disorders (DSM-5). These symptoms, 

which are generally related to loss of control over substance 

use,96 are presented in Table 1.52 in Chapter 1. The number of 

diagnostic symptoms present defines the severity of the disorder, ranging from mild to severe (i.e., fewer 

than 2 symptoms = no disorder; 2 to 3 symptoms = mild disorder; 4 to 5 symptoms = moderate disorder; 

6 or more symptoms = severe disorder).97

Conducting a clinical assessment is essential to understanding the nature and severity of the patient’s 

health and social problems that may have led to or resulted from the substance use. This assessment 

is important in determining the intensity of care that will be recommended and the composition of 

the treatment plan.91 Several validated assessment tools can provide information about an individual’s 

substance use disorder. Table 4.3 gives a brief overview of some of the tools that are available.

See Chapter 1 - Introduction and 

Overview.
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Table 4.3: Detailed Information on Substance Use Disorder Assessment Tools

Addiction Severity 

Index (ASI)98

Substance Abuse 

Module (SAM)99

Global Appraisal of 

Individual Needs 

(GAIN)299

Psychiatric Research 

Interview for 

Substance and Mental 

Disorders (PRISM)100

• Semi-structured 

interview. 

• Addresses seven 

potential problem 

areas in substance 

using individuals: 

medical status, 

employment and 

support, drug use, 

alcohol use, legal 

status, family/social 

status, and psychiatric 

status. 

• Provides an overview 

of problems related to 

substance, rather than 

focusing on any single 

area. 

• Used extensively for 

treatment planning 

and outcome 

evaluation. 

• A shorter, self-report 

version of the ASI 

called the ASI-Lite is 

also available. 

• Expanded and more 

detailed version of the 

substance use section 

of the Composite 

International Diagnostic 

Interview (CIDI).

• Designed to assess 

mental disorders 

as defined by the 

Diagnositic and 

Statistical Manual of 

Mental Disorders, Fourth 

Edition (DSM-IV).

• Contains four diagnostic 

sections on tobacco, 

alcohol, drugs, and 

caffeine. 

• Includes questions about 

when symptoms began 

and how recent they are, 

withdrawal symptoms, 

and the physical, social 

and psychological 

consequences of each 

substance assessed.

• Assesses the 

respondent’s impairment 

and treatment seeking. 

• Can assess substance 

use disorders quickly 

and accurately in the 

clinical setting.

• Series of measures 

(screener, standardized 

biopsychosocial intake 

assessment battery, 

follow-up assessment 

battery) which integrate 

research and clinical 

assessment.

• Contains 99 scales and 

subscales, that are 

designed to measure the 

recency, breadth, and 

frequency of problems 

and service utilization 

related to substance 

use (including diagnosis 

and course, treatment 

motivation, and relapse 

potential), physical 

health, risk/protective 

involvement, mental 

health, environment and 

vocational situation.

• Can assess change over 

time.

• Semi-structured, 

clinician-administered 

interview.

• Measures the major 

DSM-IV diagnoses 

of alcohol, drug, and 

psychiatric disorders.

• Provides clear 

guidelines for 

differentiating 

between the effects 

of intoxication and 

withdrawal, substanceinduced disorders, and 

primary disorders.

Individualized Treatment Planning 

After a formal assessment, the information is discussed with the patient to jointly develop a 

personalized treatment plan designed to address the patient’s needs.91,101 The treatment plan and 

goals should be person-centered and include strength-based approaches, or ones that draw upon an 

individual’s strengths, resources, potential, and ability to recover, to keep the patient engaged in care. 

Individualized treatment plans should consider age, gender identity, race and ethnicity, language, health 

literacy, religion/spirituality, sexual orientation, culture, trauma history, and co-occurring physical 

and mental health problems. Such considerations are critical for understanding the individual and for 

tailoring the treatment to his or her specific needs. This increases the likelihood of successful treatment 

engagement and retention, and research shows that those who participate more fully in treatment 

typically have better outcomes.102 Throughout treatment, individuals should be periodically reassessed 

to determine response to treatment and to make any needed adjustments to the treatment plan.
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Maintaining Treatment Engagement and Retention 

Treatment plans should be personalized and include engagement and retention strategies to promote 

participation, motivation, and adherence to the plan.47 Research has found that individuals who received 

proactive engagement services such as direct outreach and a specific follow-up plan are more likely to 

remain engaged in services throughout the treatment process.47,103,104

Treatment providers can improve engagement and retention in programs by building a strong 

therapeutic alliance with the patient, effectively using evidence-based motivational strategies, 

acknowledging the patient’s individual barriers, making reminder phone calls, and creating a positive 

environment.105 Further, providers who can recommend and/or provide a broad range of RSS, such as 

child care, housing, and transportation, can improve retention in treatment.106

Engaging, effective treatment also involves culturally competent care. For example, treatment programs 

that provide gender-specific and gender-responsive care are more likely to enhance women’s treatment 

outcomes.107 Tailoring treatment to involve family and community is particularly effective for certain 

groups. For example, American Indians or Alaska Natives may require specific elements in their 

treatment plan that respond to their unique cultural experiences and to intergenerational and historical 

trauma and trauma from violent encounters.108 Language and literacy (including health literacy) may 

also affect how a person responds to the treatment environment.109-112 Race and ethnicity, sexual 

orientation, gender identity, and economic status can play significant roles in treatment initiation, 

engagement, and completion.107,113,114

Substance use disorder treatment programs also have an obligation to prepare for disasters within 

their communities that can affect the availability of services. A disaster can disrupt a program’s ability 

to provide treatment services or an individual’s ability to maintain treatment. Individuals in recovery, 

for example, may relapse due to sudden discontinuation of services or stress when having to cope 

with effects of a disaster. Individuals receiving MAT could be at risk of serious withdrawal symptoms 

if medications are stopped abruptly. Others may face challenges without their treatment program’s 

support.115 Therefore, planning for disasters and other large scale emergencies is critical to prevent or 

reduce the impact of interruptions in treatment services. 

Treatment Setting and the Continuum of Care

As indicated above, the treatment of addiction is delivered in predominantly freestanding programs 

that differ in their setting (hospital, residential, or outpatient); in the frequency of care delivery (daily 

sessions to monthly visits); in the range of treatment components offered; and in the planned duration 

of care. In general, as patients progress in treatment and begin to meet the goals of their individualized 

treatment plan, they transfer from clinical management in residential or intensive outpatient programs 

to less clinically intensive outpatient programs that promote patient self-management. 
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A typical progression for someone who has a severe substance use disorder might start with 3 to 7 days in 

a medically managed withdrawal program, followed by a 1- to 3-month period of intensive rehabilitative 

care in a residential treatment program, followed by continuing care, first in an intensive outpatient 

program (2 to 5 days per week for a few months) and later in 

a traditional outpatient program that meets 1 to 2 times per 

month. For many patients whose current living situations 

are not conducive to recovery, outpatient services should be 

provided in conjunction with recovery-supportive housing.

In general, patients with serious substance use disorders are recommended to stay engaged for at least 

1 year in the treatment process, which may involve participation in three to four different programs or 

services at reduced levels of intensity, all of which are ideally designed to help the patient prepare for 

continued self-management after treatment ends.56,116 This expected trajectory of care explains why 

efforts to maintain patient motivation and engagement are important. Brief summaries of the major 

levels of the treatment continuum are discussed below.

See Chapter 5 - Recovery: The Many 

Paths to Wellness.

Medically monitored and managed inpatient care is an intensive 

service delivered in an acute, inpatient hospital setting.18

These programs are typically necessary for individuals who 

require withdrawal management, primary medical and 

nursing care, and for those with co-occurring mental and 

physical health conditions.18 Treatment is usually provided by 

an interdisciplinary team of health care professionals, available 24 hours a day, who can address serious 

mental and physical health needs.18,91

Residential services offer organized services, also in a 24-hour setting but outside of a hospital. These 

programs typically provide support, structure, and an array of evidence-based clinical services.18 Such 

programs are appropriate for physically and emotionally stabilized individuals who may not have a 

living situation that supports recovery, may have a history of relapse, or have co-occurring physical and/

or mental illnesses. 

Partial hospitalization and intensive outpatient services range from counseling and education to clinically 

intensive programming.18 Partial hospitalization programs are used as a step-down treatment option 

after completing residential treatment and are usually available 6 to 8 hours a day during the work 

week.18 These services are considered to be approximately as intensive but less restrictive than 

residential programs91 and are appropriate for patients living in an environment that supports recovery 

but who need structure to avoid relapse.

Outpatient services provide both group and individual behavioral interventions and medications when 

appropriate.91 These components of care can be offered during the day, before or after work or school, 

or in the evenings and weekends. Typically, outpatient programs are appropriate as the initial level 

of care for individuals with a mild to moderate substance use disorder or as continuing care after 

completing more intensive treatment.18 Outpatient programs are also suitable for individuals with cooccurring mental health conditions. 

See the section on “Acute Stabilization 

and Withdrawal Management” earlier in 

this chapter.
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Evidence-based Treatment: Components of Care 

Regardless of the substance for which the individual 

seeks treatment or the setting or level of care, all 

substance use disorder treatment programs are expected 

to offer an individualized set of evidence-based clinical 

components. These components are clinical practices that 

research has shown to be effective in reducing substance 

use and improving health and functioning. These include 

behavioral therapies, medications, and RSS. Treatment 

programs that offer more of these evidence-based 

components have the greatest likelihood of producing better outcomes. 

Evidence-Based Practices

Research continues to identify new effective 

components of care. SAMHSA manages the 

National Registry of Evidence-based 

Programs and Practices (NREPP) that was 

developed to inform the public and to guide 

individual choices about treatment.

Medications and Medication-Assisted Treatment

Five medications, approved by the FDA, have been developed to treat alcohol and opioid use disorders. 

Currently, no approved medications are available to treat marijuana, amphetamine, or cocaine use 

disorders.117 Table 4.4 lists these medications and they are discussed individually in the text that follows.

Table 4.4: Pharmacotherapies Used to Treat Alcohol and Opioid Use Disorders

Medication Use Dosage Form DEA 

Schedule*

Application

BuprenorphineNaloxoneOpioid 

use 

disorder

Sublingual film**:118

2mg/0.5mg, 4mg/1mg,

8mg/2mg, and 12mg/3mg

Sublingual tablet:

1.4mg/0.36mg,

2mg/0.5mg, 2.9/0.71mg, 

5.7mg/1.4mg,

8mg/2mg, 8.6mg/2.1mg, 

11.4mg/2.9mg

Buccal film: 

2.1mg/0.3mg, 4.2mg/0.7mg, 

6.3mg/1mg 

CIII Used for detoxification or 

maintenance of abstinence for 

individuals aged 16 or older. 

Physicians who wish to prescribe 

buprenorphine, must obtain a 

waiver from SAMHSA and be 

issued an additional registration 

number by the U.S. Drug 

Enforcement Administration (DEA).

Buprenorphine 

Hydrochloride

Opioid 

use 

disorder

Sublingual tablet: 

2mg, 4mg, 8mg, and 12mg

CIII This formulation is indicated for 

treatment of opioid dependence 

and is preferred for induction. 

However, it is considered the 

preferred formulation for pregnant 

patients, patients with hepatic 

impairment, and patients with 

sensitivity to naloxone. It is also 

used for initiating treatment 

in patients transferring from 

methadone, in preference to 

products containing naloxone, 

because of the risk of precipitating 

withdrawal in these patients.
TREATMENT

PAGE | 4-20

Medication Use Dosage Form DEA 

Schedule*

Application

Probuphine® implants: 

80mgx4 implants for a total 

of 320mg

For those already stable on low 

to moderate dose buprenorphine. 

The administration of the implant 

dosage form requires specific 

training and must be surgically 

inserted and removed.

Methadone Opioid 

use 

disorder

Tablet: 

5mg, 10mg

Tablet for suspension:

40mg

Oral concentrate: 

10mg/mL

Oral solution: 

5mg/5mL,

10mg/5mL

Injection:

10mg/mL

CII Methadone used for the 

treatment of opioid addiction in

detoxification or maintenance 

programs shall be dispensed only 

by Opioid Treatment Programs 

(OTPs) certified by SAMHSA and 

approved by the designated state 

authority. Under federal regulations 

it can be used in persons under 

age 18 at the discretion of an OTP 

physician.119

Naltrexone Opioid 

use 

disorder; 

alcohol 

use 

disorder

Tablets: 

25mg, 50mg, and 100mg

Extended-release injectable 

suspension: 

380mg/vial

Not 

Scheduled 

under the 

Controlled 

Substances 

Act

Provided by prescription; 

naltrexone blocks opioid 

receptors, reduces cravings, and 

diminishes the rewarding effects 

of alcohol and opioids. Extendedrelease injectable naltrexone 

is recommended to prevent 

relapse to opioids or alcohol. 

The prescriber need not be a 

physician, but must be licensed 

and authorized to prescribe by the 

state.

Acamprosate Alcohol 

use 

disorder

Delayed-release tablet:

333mg

Not 

Scheduled 

under the 

Controlled 

Substances 

Act

Provided by prescription; 

acamprosate is used in the 

maintenance of alcohol 

abstinence. The prescriber need 

not be a physician, but must 

be licensed and authorized to 

prescribe by the state.

Disulfiram Alcohol 

use 

disorder

Tablet: 

250mg, 500mg

Not 

Scheduled 

under the 

Controlled 

Substances 

Act

When taken in combination with 

alcohol, disulfiram causes severe 

physical reactions, including 

nausea, flushing, and heart 

palpitations. The knowledge that 

such a reaction is likely if alcohol 

is consumed acts as a deterrent to 

drinking.

Notes: *For more information about the DEA Schedule and classification of specific drugs, see Appendix D - Important Facts

about Alcohol and Drugs.

**This dosage form may be used via sublingual or buccal routes of administration; sublingual means placed under the tongue, 

buccal means applied to the buccal area (in the cheek).

Source: Adapted from Lee et al., (2015).120
TREATMENT

PAGE | 4-21

Like all other FDA-approved medications, those listed in Table 4.4 demonstrate “well-supported” 

experimental evidence of safety and effectiveness120 for improving outcomes for individuals with 

alcohol and opioid use disorders.117 At the same time, all of these medications have side effects; two 

(methadone and buprenorphine) have the potential to be misused, and methadone (and to a lesser extent 

buprenorphine) has the potential for overdose. For these reasons, only appropriately trained health care 

professionals should decide whether medication is needed as part of treatment, how the medication is 

provided in the context of other clinical services, and under what conditions the medication should be 

withdrawn or terminated. 

The combination of behavioral interventions and medications to treat substance use disorders is 

commonly referred to as MAT.121 MAT is a highly effective treatment option for individuals with 

alcohol and opioid use disorders. Studies have repeatedly demonstrated the efficacy of MAT at reducing 

illicit drug use and overdose deaths,122,123 improving retention in treatment,124 and reducing HIV 

transmission.122

Some medications used to treat opioid use disorders can be 

used to manage withdrawal and as maintenance treatment to 

reduce craving, lessen withdrawal symptoms, and maintain 

recovery.56 These medications are used to help a patient 

function comfortably without illicit opioids or alcohol while 

balance is gradually restored to the brain circuits that have been altered by prolonged substance use. 

Prescribed in this fashion, medications for substance use disorders are in some ways like insulin for 

patients with diabetes. Insulin reduces symptoms by normalizing glucose metabolism, but it is part 

of a broader disease control strategy that also employs diet change, education on healthy living, and 

self-monitoring. Whether treating diabetes or a substance use disorder, medications are best employed 

as part of a broader treatment plan involving behavioral health therapies and RSS, as well as regular 

monitoring. 

State agencies that oversee substance use disorder treatment programs use a variety of strategies to 

promote implementation of MAT, including education and training, financial incentives (e.g., linking 

funding to the provision of MAT), policy mandates, and support for infrastructure development.5

Nevertheless, multiple factors create barriers to widespread use of MAT. These include provider, 

public, and client attitudes and beliefs about MAT; lack of an appropriate infrastructure for providing 

medications; need for staff training and development; and legislation, policies, and regulations that limit 

MAT implementation.5

See Chapter 2 - The Neurobiology of 

Substance Use, Misuse, and Addiction.

Medication-Assisted Treatment for Opioid Use Disorders 

MAT for patients with a chronic opioid use disorder must be delivered for an adequate duration in order 

to be effective. Patients who receive MAT for fewer than 90 days have not shown improved outcomes.125

One study suggested that individuals who receive MAT for fewer than 3 years are more likely to relapse 

than those who are in treatment for 3 or more years.126 Three medications are commonly used to treat 

opioid use disorders: methadone, buprenorphine, and naltrexone.
TREATMENT

PAGE | 4-22

Methadone is a synthetic opioid agonist that has been used 

to treat the symptoms of withdrawal from heroin and other 

opioids.127 More than 40 years of research support the 

use of methadone as an effective treatment for opioid use 

disorder.121,128,129 It is also used in the treatment of patients 

with chronic, severe pain130 as a therapeutic alternative to 

morphine sulfate and other opioid analgesics.131 Any licensed 

physician can prescribe methadone for the treatment of 

pain, but methadone may only be dispensed for treatment of an opioid use disorder within licensed 

methadone treatment programs.

Long-term methadone maintenance treatment for opioid use disorders has been shown to be more 

effective than short-term withdrawal management,132 and it has demonstrated improved outcomes for 

individuals (including pregnant women and their infants) with opioid use disorders.133 Studies have also 

indicated that methadone reduces deaths, HIV risk behaviors, and criminal behavior associated with 

opioid drug seeking.134,135

The use of methadone to treat opioid use disorders has much in common with treatments for other 

substance use disorders and other chronic illnesses. However, it has one significant structural and 

cultural difference. Under regulations dating back to the early 1970s, the federal government created 

special methadone programs for adults with opioid use disorders. Originally referred to as “methadone 

treatment programs,” these treatment facilities were created to provide special management of the 

medical and legal issues associated with the use of this potent, long-acting opioid. 

The use of opioid agonist medications to treat opioid use 

disorders has always had its critics. Many people, including 

some policymakers, authorities in the criminal justice 

system, and treatment providers, have viewed maintenance 

treatments as “substituting one substance for another”85 and 

have adhered instead to an abstinence-only philosophy that 

avoids the use of medications, especially those that activate 

opioid receptors. Such views are not scientifically supported; 

the research clearly demonstrates that MAT leads to better 

treatment outcomes compared to behavioral treatments alone. Moreover, withholding medications 

greatly increases the risk of relapse to illicit opioid use and overdose death. Decades of research have 

shown that the benefits of MAT greatly outweigh the risks associated with diversion. 

Today, methadone treatment programs, now called Opioid Treatment Programs (OTPs), must be 

certified by SAMHSA and registered by the U.S. Drug Enforcement Administration (DEA). OTPs are 

predominantly outpatient programs (approximately 95 percent) that provide pharmacotherapy in 

combination with behavioral therapies and other RSS.136 OTPs incorporate principles of harm reduction 

and benefit both program participants and the community137 by reducing opioid use, mortality, 

crime associated with opioid use disorders, and infectious disease transmission. Buprenorphine and 

naltrexone may also be provided in OTPs.61

Drug diversion. A medical and legal 

concept involving the transfer of any 

legally prescribed controlled substance 

from the person for whom it was 

prescribed to another person for any 

illicit use.

Agonist. A chemical substance that 

binds to and activates certain receptors 

on cells, causing a biological response. 

Fentanyl and methadone are examples 

of opioid receptor agonists.
TREATMENT

PAGE | 4-23

Individuals receiving medication for opioid use disorders in an OTP must initially take their doses daily 

under observation.138,139 After a period of orientation, patients are typically started at a dose of 20 to 30 

mg and gradually increased to 80 mg or more per day, until craving and opioid misuse are significantly 

reduced. During this period, all dosing occurs at the OTP, but following stabilization and initially 

positive results, the stabilized patient may be given a “take-home” supply of his or her dose to selfadminister per the federal opioid treatment standard regulations 42 CFR 8.12(i). 

Buprenorphine is available as a sublingual tablet and a sublingual or buccal film. In addition, in May 

2016, an implantable formulation of buprenorphine was approved by the FDA. For individuals who are 

already on a stable low to moderate dose of buprenorphine, the implant delivers a constant low dose 

of buprenorphine for 6 months. Buprenorphine is associated with improved outcomes compared to 

placebo for individuals (including pregnant women and their infants) with opioid use disorders,140 and it 

is effective in reducing illegal opioid use.129

Buprenorphine is a partial opioid agonist, meaning that it binds to and activates opioid receptors but 

with less intensity than full agonists. As a result, there is an upper limit to how much euphoria, pain 

relief, or respiratory depression buprenorphine can produce.56,141 However, buprenorphine still may 

result in overdose if used with tranquilizers and/or alcohol, and some diversion has been reported, 

although studies suggest most diverted buprenorphine is used therapeutically (e.g., to control cravings), 

not to get high.142-144

Clinical experience and research protocols indicate that buprenorphine initiation and stabilization 

during the induction period is an important part of successful treatment for individuals with opioid 

use disorder.145 Buprenorphine can be prescribed alone or as a combination medication that includes 

naloxone, an opioid antagonist medication.145 If this combined medication is taken as prescribed, the 

naloxone has no appreciable effects. However, if the combined medication is injected, the naloxone 

component can precipitate an opioid withdrawal syndrome, and in this way serves as a deterrent to 

misuse by injection.145

Buprenorphine may be prescribed by physicians who have met the statutory requirements for a waiver 

in accordance with the Controlled Substances Act (21 U.S.C. 823(g)(2)(D)(iii)).146 However, physicians 

using the waiver are limited in the number of patients they can treat with this medication. This patient 

limit does not apply to OTPs that dispense buprenorphine on site because the OTP operating in this 

capacity is doing so under 21 U.S.C. 823(g)(1) and 42 CFR Part 8, and not under 21 U.S.C. 823(g)(2)(B). 

When they first receive their waiver, physicians can provide buprenorphine treatment for only up to 

30 individuals. After the first year they can request to treat up to 100.147 However, lack of physician 

availability to prescribe buprenorphine has been a significant limitation on access to this effective 

medication. Although approximately 435,000 primary care physicians practice medicine in the United 

States,148 only slightly more than 30,000 have a buprenorphine waiver,149 and only about half of those 

are actually treating opioid use disorders.150 To address this limitation and narrow the treatment gap, a 

final rule was published on July 8, 2016, expanding access to MAT by allowing eligible practitioners to 

request approval to treat up to 275 patients.147
TREATMENT

PAGE | 4-24

Additionally, on July 22, 2016, the Comprehensive Addiction 

and Recovery Act (CARA) was signed into law. CARA 

temporarily expands eligibility to prescribe buprenorphinebased drugs for MAT for substance use disorders to 

qualifying nurse practitioners and physician assistants 

through October 1, 2021. 

See the section on “Comprehensive 

Addiction and Recovery Act (CARA)” in 

Chapter 6 - Health Care Systems and 

Substance Use Disorders.

Naltrexone is an opioid antagonist that binds to opioid receptors and blocks their activation; it produces 

no opioid-like effects and is not abusable. It prevents other opioids from binding to opioid receptors 

so that they have little to no effect. It also interrupts the effects of any opioids in a person’s system, 

precipitating an opioid withdrawal syndrome in opioid-dependent patients, so it can be administered 

only after a complete detoxification from opioids. There is also no withdrawal from naltrexone when 

the patient stops taking it. Naltrexone may be appropriate for people who have been successfully 

treated with buprenorphine or methadone who wish to discontinue use but still be protected from 

relapse; people who prefer not to take an opioid agonist; people who have completed detoxifications 

and/or rehabilitation or are being released from incarceration and expect to return to an environment 

where drugs may be used and wish to avoid relapse; and adolescents or young adults with opioid 

dependence.151

Because naltrexone is not a controlled substance, it can be prescribed or administered by any physician, 

nurse practitioner, or physician assistant with prescribing authority. Naltrexone comes in two 

formulations: oral and extended-release injectable. Oral naltrexone can be effective for those individuals 

who are highly motivated and/or supported with observed daily dosing. Extended-release injectable 

naltrexone, which is administered on a monthly basis, addresses the poor compliance associated 

with oral naltrexone since it provides extended protection from relapse and reduces cravings for 30 

days.152,153

Medication-Assisted Treatment for Alcohol Use Disorders 

A number of factors should be weighed in determining the need for medication when treating an 

individual for an alcohol use disorder, such as the patient’s motivation for treatment, potential for 

relapse, and severity of co-existing conditions.120 Three FDA-approved medications are currently 

available to treat alcohol use disorder: disulfiram, naltrexone, and acamprosate.117 None of these 

medications carries a risk of misuse or addiction, and thus none is a DEA-scheduled substance. Each 

has a distinct effectiveness and side effect profile. Prescribing health care professionals should be 

familiar with these side effects and take them into consideration before prescribing.154 Providers can 

obtain additional information from materials produced by the National Institute on Alcohol Abuse and 

Alcoholism (NIAAA) and SAMHSA.155,156 

Research studies on the efficacy of medications to treat alcohol use disorders have demonstrated 

that most patients show benefit, although individual response can be difficult to predict.154,157 MAT 

interventions for alcohol use disorders can be provided in both non-specialty and specialty care settings 

and are most beneficial when combined with behavioral interventions and brief support.154
TREATMENT

PAGE | 4-25

Disulfiram is a medication that inhibits normal breakdown of acetaldehyde which is produced by the 

metabolism of alcohol, thus rapidly increasing acetaldehyde in the blood which produces an aversive 

response. Thus, once disulfiram is taken by mouth, any alcohol consumed results in rapid buildup of 

acetaldehyde and a negative reaction or sickness results. The intensity of this reaction is dependent 

on the dose of disulfiram and the amount of alcohol consumed.158 Effects from a disulfiram-alcohol 

reaction include warmth and flushing of the skin, increased heart rate, palpitations, a drop in blood 

pressure, nausea and/or vomiting, sweating, dizziness, and headache.159 In this way, disulfiram 

essentially punishes alcohol consumption and indirectly rewards abstinence.117

Disulfiram was the first medication approved by the FDA to treat alcohol use disorder and its efficacy 

has been widely studied.160 Most studies have demonstrated that disulfiram, when given under 

supervision, is more effective than placebo in treating alcohol use disorders.154 A major limitation 

of disulfiram is adherence, which is typically poor, thereby reducing the medication’s effectiveness. 

Disulfiram is most effective when its use is supervised or observed, which has been found to increase 

compliance.154,159 Negotiating with the patient to have a spouse or significant other provide supervision 

offers both the incentive to take the medication and the documentation that the medication is being 

taken.161 The best candidates for disulfiram are patients with motivation for treatment and a desire 

to be abstinent. Thus, an individual who wants to reduce, but not stop, drinking is not a candidate for 

disulfiram. Disulfiram should also be avoided in individuals with advanced liver disease.162

Naltrexone is the opioid antagonist described above that is used to treat opioid use disorder. Because it 

blocks some opioid receptors, naltrexone counteracts some of the pleasurable aspects of drinking.154,159

Unlike disulfiram, naltrexone does not interact with alcohol to produce a severe reaction.163 As noted 

before, naltrexone comes in two formulations: oral and extended-release injectable. 

Many studies have examined the effectiveness of naltrexone in treating alcohol use disorders.154 Several 

research reviews have found that it reduces the risk of heavy drinking in patients who are abstinent 

for at least several days at the time treatment begins.154,160 However, as with disulfiram, medication 

compliance can be a problem with the oral formulation. Adherence to taking the medication increases 

under conditions where it is administered and observed by a trusted family member or when the 

extended-release injectable, which requires only a single monthly injection, is used.164 Naltrexone 

should not be prescribed to patients with acute hepatitis, renal failure, or liver failure.162

Acamprosate is a medication that normalizes the alcohol-related neurochemical changes in the 

brain glutamate systems and thereby reduces the symptoms of craving that can prompt a relapse 

to pathological drinking.117 Acamprosate has been found to be an effective medication when used 

concurrently with behavioral interventions and, as with other medications for alcohol use disorders, 

works best in motivated patients.117,165 Reviews show that acamprosate is effective in reducing relapse166

and effective when used to maintain abstinence from alcohol.167
TREATMENT

PAGE | 4-26

Behavioral Therapies

Behavioral therapies can be provided in individual, group, and/or family sessions in virtually all 

treatment settings.47,56 These structured therapies help patients recognize the impact of their behaviors 

– such as those dealing with stress or interacting in interpersonal relationships – on their substance 

use and ability to function in a healthy, safe, and productive manner. These therapies also teach and 

motivate patients in how to change their behaviors as a way to control their substance use disorders.56 

For evidence-based behavioral therapies to be delivered appropriately, they must be provided by 

qualified, trained providers. Despite this, many counselors and therapists working in substance use 

disorder treatment programs have not been trained to provide evidence-based behavioral therapies, 

and general group counseling remains the major form of behavioral intervention available in most 

treatment programs.168 Unfortunately, despite decades of research, it cannot be concluded that general 

group counseling is reliably effective in reducing substance use or related problems.169,170

The following sections describe behavioral therapies that have been shown to be effective in treating 

substance use disorders. These therapies have been studied extensively, have a well-supported evidence 

base indicating their effectiveness, and have been broadly applied across many types of substance use 

disorders and across ages, sexes, and racial and ethnic groups. 

Individual counseling is delivered in structured sessions to help patients reduce substance use and 

improve function by developing effective coping strategies and life skills.85,171 Individual counseling 

has been extensively studied in many specialty care settings but rarely within non-specialty settings. 

Most studies support the use of individual counseling as an effective intervention for individuals with 

substance use disorders.117,169 As indicated above, group counseling is a standard part of most substance 

use disorder treatments, but should primarily be used only in conjunction with individual counseling171

or other forms of individual therapy.85 

Cognitive-Behavioral Therapy 

 The theoretical foundation for Cognitive-Behavioral Therapy (CBT) is that substance use disorders 

develop, in part, as a result of maladaptive behavior patterns and dysfunctional thoughts.117 CBT 

treatments thus involve techniques to modify such behaviors and improve coping skills by emphasizing 

the identification and modification of dysfunctional thinking.117 CBT is a short-term approach, usually 

involving 12 to 24 weekly individual sessions. These sessions typically explore the positive and negative 

consequences of substance use, and they use self-monitoring as a mechanism to recognize cravings and 

other situations that may lead the individual to relapse. They also help the individual develop coping 

strategies.85

CBT may be the most researched and evaluated of all the therapies for substance use disorders.172,173

Research suggests that self-monitoring and craving-recognition skills can be learned during CBT 

and that those skills continue to be employed by the individual after treatment has concluded.85 CBT 

interventions have been found to be quite effective, and outcomes are enhanced when CBT is combined 

with other behavioral and/or pharmacologic components of care.174
TREATMENT

PAGE | 4-27

Research has shown that CBT is also an effective treatment for individuals with co-occurring mental 

disorders. Individuals with a substance use disorder and co-occurring mental disorder who received 

CBT had significantly improved outcomes on various measures of substance use and mental health 

symptoms as compared to those who did not receive CBT.101,175,176

Contingency Management

Behavior change involves learning new behaviors and changing old behaviors. Positive rewards or 

incentives for these changes can aid this process. Contingency management, which involves giving 

tangible rewards to individuals to support positive behavior change,85 has been found to be effective 

in treating substance use disorders.177 In this therapy, patients receive a voucher with monetary value 

that can be exchanged for food items, healthy recreational options (e.g., movies), or other sought-after 

goods or services when they exhibit desired behavior such as drug-free urine tests or participation 

in treatment activities.85 Clinical studies comparing voucher-based reinforcement to traditional 

treatment regimens have found that voucher-based reinforcement is associated with longer treatment 

engagement, longer periods of abstinence, and greater improvements in personal function.177 These 

positive findings, initially demonstrated with individuals with cocaine use disorders, have been 

reproduced in individuals with alcohol, opioid, and methamphetamine use disorders.177 

Contingency management may be combined with other therapies or treatment components. For 

example, contingency management has been shown to improve outcomes for adults with cocaine 

dependence when added to CBT.178 Similarly, contingency management improves outcomes for young 

adults with marijuana dependence when included with Motivational Enhancement Therapy (described 

below) and CBT.179 

Community Reinforcement Approach

Community Reinforcement Approach (CRA) Plus Vouchers is an intensive 24-week outpatient program 

that uses incentives and reinforcers to reward individuals who reduce their substance use.85 Individuals 

are required to attend one to two counseling sessions each week that emphasize improving relations, 

acquiring skills to minimize substance use, and reconstructing social activities and networks to support 

recovery.85 Individuals receiving this treatment are eligible to receive vouchers with monetary value if 

they provide drug-free urine tests several times per week.85 Research has demonstrated that CRA Plus 

Vouchers promotes treatment engagement and facilitates abstinence.85 Recent studies have also shown 

improvements in psychosocial functioning and abstinence among individuals who received CRA Plus 

Vouchers compared to those who received an intervention of standard care only.180

CRA without vouchers has been successfully adapted for adolescents. The Adolescent Community 

Reinforcement Approach (A-CRA) is a similar program targeting 12 to 22 year olds with substance use 

disorders. A-CRA, which has been implemented in outpatient and residential treatment settings, seeks 

to increase family, social, and educational and vocational supports to reinforce abstinence and recovery 

from substance use. The effectiveness of A-CRA has been supported in multiple randomized clinical 

trials with adolescents from different settings, sexes, and racial groups.181,182 Studies have found that 

A-CRA increased long-term abstinence from marijuana and alcohol and decreased frequency of other 

substance use.182
TREATMENT

PAGE | 4-28

Motivational Enhancement Therapy

Motivational Enhancement Therapy (MET) is a counseling approach that uses motivational interviewing 

techniques to help individuals resolve any uncertainties they have about stopping their substance use. 

MET works by promoting empathy, developing patient awareness of the discrepancy between their goals 

and their unhealthy behavior, avoiding argument and confrontation, addressing resistance, and supporting 

self-efficacy46 to encourage motivation and change.85,183 The therapist supports the patient in executing the 

behaviors necessary for change and monitors progress toward patient-expressed goals. 

MET has been shown to be an effective treatment in a range of populations and has demonstrated favorable 

outcomes such as reducing substance use and improving treatment engagement.169 As with other therapies 

reviewed, MET is often used concurrently with other behavioral interventions.184 However, the results of 

MET are mixed for people who use drugs such as heroin, cocaine, and nicotine, and for adolescents.185,186

The combination of MET and CBT has shown favorable results for adolescents for multiple substances.181

The Matrix Model

The Matrix Model is a structured, multi-component behavioral treatment that consists of evidencebased practices, including relapse prevention, family therapy, group therapy, drug education, and 

self-help, delivered in a sequential and clinically coordinated manner.85 The model consists of 16 weeks 

of group sessions held three times per week, which combine CBT, family education, social support, 

individual counseling, and urine drug testing.187 

Several randomized controlled trials over the past 20 years have demonstrated that the Matrix Model 

is effective at reducing substance misuse and associated risky behaviors.85 For example, one study 

demonstrated the model’s effectiveness in producing sustained reductions in sexual risk behaviors 

among individuals who use methamphetamines, thus decreasing their risk of getting or transmitting 

HIV.188 The Matrix Model has also been adapted to focus more on relationships, parenting, body image, 

and sexuality in order to improve women’s retention in treatment and facilitate recovery.189

Twelve-Step Facilitation Therapy

Twelve-Step Facilitation (TSF), an individual therapy 

typically delivered in 12 weekly sessions, is designed to 

prepare individuals to understand, accept, and become 

engaged in Alcoholics Anonymous (AA), Narcotics 

Anonymous (NA), or similar 12-step programs.190,191 As 

discussed in the next chapter, 12-step programs and other mutual-aid groups are not themselves medical 

treatments but fall under the category of RSS. Well-supported evidence shows that TSF interventions are 

effective in a variety of ways:

$ As a stand-alone intervention;192-194

$ When integrated with other treatments, such as CBT;190

$ As a distinct component of a multi-treatment package;191 and

$ As a modular appendage to treatment.195

See Chapter 5 - Recovery: The Many 

Paths to Wellness.
TREATMENT

PAGE | 4-29

Some substance use disorder treatment programs that employ 

TSF also typically encourage AA or NA participation through 

group counseling.123 However, TSF is quite different from 

generic group counseling, not only because it is an individual 

therapy, but also because it involves a systematic set of 

sequential sessions focused on three key ideas:85

12-Step Program. A group providing 

mutual support and fellowship for 

people recovering from addictive 

behaviors. The first 12-step program 

was Alcoholics Anonymous (AA), 

founded in 1935; an array of 12-step 

groups following a similar model have 

since emerged and are the most widely 

used mutual aid groups and steps for 

maintaining recovery from alcohol and 

drug use disorders. It is not a form of 

treatment, and it is not to be confused 

with the treatment modality called TSF. 

$ Acceptance - realizing that their substance use is part 

of a disorder, that life has become unmanageable 

because of alcohol or drugs, that willpower alone will 

not overcome the problem, and that abstinence is the 

best alternative; 

$ Surrender - giving oneself to a higher power, accepting 

the fellowship and support structure of other 

recovering individuals, and following the recovery activities laid out by a 12-step program; and

$ Active involvement in a 12-step program. 

TSF has been effective in reducing alcohol use during the first month of treatment for individuals with 

alcohol use disorders, but these effects disappeared rapidly following treatment completion.196 In one 

study, alcohol-dependent women were randomly assigned to TSF, CBT, or a standard counseling group. 

The women who received TSF and CBT over 12 weeks both had better outcomes on perceived social 

support from friends and on social functioning than those in the counseling group, and the differences 

between those receiving TSF and CBT were minimal.197

In another study, a randomized controlled trial compared a CBT treatment program alone to the 

same treatment combined with TSF. TSF in addition to CBT increased AA involvement and days of 

abstinence over a 12-month follow-up period as compared to CBT alone.190 Statistical analysis showed 

the benefits of the TSF stemmed from its ability to increase AA participation in the period after 

treatment ended. Further, another randomized controlled trial of outpatients with severe alcohol use 

disorder evaluated a treatment that aimed to change people’s social networks away from heavy drinkers 

and toward non-drinking individuals, including AA members.194 Those receiving the social network 

enhancement treatment had 20 percent more abstinent days and greater AA participation at 2-year 

follow-up than did patients assigned to receive standard case management. Again, AA participation 

and the number of abstinent friends in the social network were found to account for the treatment’s 

effectiveness.194

Project MATCH, the largest study of alcohol use disorder treatment ever conducted, found that TSF 

increased rates of continuous abstinence and sustained remission at the same rates as two other 

evidenced-based treatments—CBT and MET. All three treatments reduced the quantity and frequency 

of alcohol use immediately after treatment. Further, relative to the CBT and MET treatment conditions, 

significantly more of the patients receiving TSF treatment maintained continuous abstinence in the year 

following treatment.193 The same pattern of results was also evident at follow-up 3 years later.198 Like 

the other studies discussed, data analysis showed that the effectiveness of the TSF treatment was based 

on its differential ability to increase post-treatment participation in AA.196
TREATMENT

PAGE | 4-30

The first clinical trial of TSF for patients in treatment for stimulant use disorder was recently 

completed. Individuals randomized to TSF had higher rates of attending groups such as Crystal Meth 

Anonymous and higher rates of abstinence at follow-up as well.199

Given the common group and social orientation and the similar therapeutic factors operating across 

different mutual aid groups,200-202 participation in mutual aid groups other than AA might confer similar 

benefits at analogous levels of attendance.203,204 Yet systematic efforts to facilitate entry into non-12-

step mutual aid groups have rarely been studied.204 One exception is a clinical trial evaluating SMART 

Recovery, a cognitive-behavioral, evidence-based mutual aid group. Patients in treatment for “heavy 

drinking” were randomly assigned to receive face-to-face SMART Recovery meetings or to an online Web meeting. Both groups showed approximately equal rates of post-treatment participation in 

SMART Recovery and in abstinence.205

Family Therapies

Mainstream health care has long acknowledged the benefits of engaging family and social supports 

to improve treatment adherence and to promote behavioral changes needed to effectively treat many 

chronic illnesses.206 This is also true for patients with substance use disorders. Studies of various family 

therapies have demonstrated positive findings for both adults and adolescents.85 Family therapies 

engage partners and/or parents and children to help the individual achieve positive outcomes based on 

behavior change. Several evidence-based family therapies have been evaluated. 

Family behavior therapy (FBT) is a therapeutic approach used for both adolescents and adults that 

addresses not only substance use but other issues the family may also be experiencing, such as mental 

disorders and family conflict.85 FBT includes up to 20 treatment sessions that focus on developing 

skills and setting behavioral goals. Basic necessities are reviewed and inventoried with the client, and 

the family pursues resolution strategies and addresses activities of daily living, including violence 

prevention and HIV/AIDS prevention.207

Family therapies used specifically for treating substance use disorders in adolescents include MultiSystemic Therapy (MST), Multi-Dimensional Family Therapy (MDFT), Brief Strategic Family Therapy 

(BSFT), and Functional Family Therapy (FFT).85 Most of these therapies consist of sessions that include 

the adolescent and at least one other family member, although MDFT uses a combination of both 

individual and family sessions.85 These interventions use different approaches, ranging from addressing 

antisocial behaviors (MST) and unfavorable influences (MDFT) on adolescents to identifying patterns of 

negative behaviors and interactions within the family (BSFT and FFT).85

Perhaps the most widely studied and applied family therapy has been Behavioral Couples Therapy 

(BCT). A cardinal feature of BCT is the “daily sobriety contract” between the affected patient and 

his/her spouse in which the patient states his or her intent not to drink or use drugs, and the spouse 

expresses support for the patient’s efforts to stay abstinent. BCT also teaches communication and nonsubstance-associated positive activities for couples. Findings show that BCT produces more abstinence 

and better functioning relationships than typical individual-based treatment and that it also reduces 

social costs and intimate partner violence.208 
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Well-supported evidence demonstrates the effectiveness of substance use disorder therapies that 

engage the spouse or partner and the family in reducing substance use and/or misuse problems and 

addressing other issues, such as poor communication, neglect, conflict, and intimate partner violence. In 

a recent review of controlled studies with alcohol-dependent patients, marital and family therapy, and 

particularly behavioral couples therapy, was significantly more effective than individual treatments at 

inducing and sustaining abstinence; improving relationship functioning and reducing intimate partner 

violence; and reducing emotional problems of children.209,210 Similar findings have been shown with 

patients having opioid and cocaine use disorders208,210 and with gay and lesbian families.210

Tobacco Use Cessation Efforts in Substance Use Disorder Treatment Programs

People with mental and/or substance use disorders account for 40 percent of all cigarettes smoked in the 

United States.211 Many substance use disorder treatment facilities and programs have adopted tobaccofree policies and tobacco cessation programs. Research has shown that incorporating tobacco cessation 

programs into substance use disorder treatment does not jeopardize treatment outcomes212 and is 

associated with a 25 percent increase in the likelihood of maintaining long-term abstinence from alcohol 

and drug misuse.213

Recovery Support Services

Recovery support services (RSS), provided by both 

substance use disorder treatment programs and community 

organizations, help to engage and support individuals in 

treatment, and provide ongoing support after treatment. 

These supportive services are typically delivered by trained 

case managers, recovery coaches, and/or peers. Specific supports include help with navigating systems 

of care, removing barriers to recovery, staying engaged in the recovery process, and providing a social 

context for individuals to engage in community living without substance use.214 RSS can be effective in 

promoting healthy lifestyle techniques to increase resilience skills, reduce the risk of relapse, and help 

those affected by substance use disorders achieve and maintain recovery.56

Individuals who participate in substance use disorder treatment and RSS typically have better longterm recovery outcomes than individuals who receive either alone. Further, active recovery and social 

supports, both during and following treatment, are important in maintaining recovery.214 This has also 

been demonstrated for adolescents; the combination of behavioral treatments with assertive continuing 

care has yielded positive results for this age group, beyond treatment alone.215

See Chapter 5 - Recovery: The Many 

Paths to Wellness.
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Emerging Treatment Technologies

Telehealth. The use of digital technologies 

such as EHRs, mobile applications, 

telemedicine, and web-based tools to 

support the delivery of health care, healthrelated education, or other health-related 

services and functions.1

Telemedicine. Two-way, real-time 

interactive communication between 

a patient and a physician or other 

health care professional at a distant 

site. Telemedicine is a subcategory of 

telehealth. Telemedicine refers specifically 

to remote clinical services, whereas 

telehealth can include remote nonclinical services such as provider training, 

administrative meetings, and continuing 

medical education, and patient-focused 

technologies, in addition to clinical 

services.

Technological advancements are changing not only the face 

of health care generally, but also the treatment of substance 

use disorders. In this regard, approximately 20 percent of 

substance use disorder treatment programs have adopted 

electronic health record (EHR) systems. With the growing 

adoption of EHRs, individuals and their providers can 

more easily access and share treatment records to improve 

coordination of care.216 In turn, information sharing through 

EHRs can lead to improved quality and efficiency of service 

delivery, reduced treatment gaps, and increased cost savings 

to health systems. 

The use of telehealth to deliver health care, provide health 

information or education, and monitor the effects of care,has 

also rapidly increased.217 Telehealth can be facilitated through 

a variety of media, including smartphones, the Internet, 

videoconferencing, wireless communication, and streaming 

media. It offers alternative, cost-effective care options for 

individuals living in rural or remote areas or when physically 

travelling to a health care facility poses significant challenges. 

Technology-based interventions offer many potential advantages. They can increase access to care in 

underserved areas and settings; free up time so that service providers can care for more clients; provide 

alternative care options for individuals hesitant to seek in-person treatment; increase the chances 

that interventions will be delivered as they were designed and intended to be delivered; and decrease 

costs.218-222 Further, studies show that most individuals already have access to the necessary tools to 

engage in technology-based care; about 92 percent of United States adults own a cell phone223 and 85 

percent use the Internet.224 

Research on the effectiveness of technology-assisted care within substance use disorder treatment 

focuses on three main applications: (1) technology as an add-on to enhance standard care; (2) technology 

as a substitute for a portion of standard care; and (3) technology as a replacement for standard care.221

The current evidence base of technology-based interventions for substance use disorder treatment 

is limited, though it is growing.221,225-227 For this reason, these technologies can only be considered 

“promising” at this time. Table 4.5 shows the state of evidence supporting innovative technology-assisted 

interventions, several of which are discussed in the Electronic Treatment Interventions and Electronic 

Clinical and Recovery Support Tools sections.
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Table 4.5: Examples of Technology-Assisted Interventions

Intervention Intervention 

Overview

Sample (at pretest) 

/Ethnicity/ Setting 

Design

Summary/Results Source

Addiction–

Comprehensive 

Health 

Enhancement 

Support System 

(A-CHESS)

Smartphonebased application 

offering 

monitoring, 

information, 

communication, 

and support 

services.

N = 349 individuals with 

alcohol dependence 

entering treatment at 

residential programs

Varied settings, 

multiethnic

RCT

At 4-, 8- and 12-month followup, intervention group reported 

significantly fewer risky drinking 

days (1.39 vs. 2.75 days on 

average) and a higher likelihood 

of consistent abstinence (51.9% 

vs. 39.6%) as compared to the 

control group.

Gustafson et 

al., (2014)228

CBT4CBT Six-module 

computerbased cognitive 

behavioral 

therapy training.

N = 101 cocainedependent individuals 

maintained on 

methadone

Urban, multiethnic

RCT

After completing an 8-week 

program, participants who 

received the intervention were 

significantly more likely to attain 

3 or more consecutive weeks 

of abstinence from cocaine 

than were participants who 

did not receive the program 

(36% vs.17%). 6-month followup data indicated continued 

improvement for intervention 

group.

Carroll et al., 

(2014)229

HealthCall 60 days 

of patient 

automated 

telephone 

interactive voice 

response (IVR) 

calls to selfmonitor alcoholand other healthrelated behaviors 

as adjunct to 

motivational 

interviewing.

N = 258 HIV-positive 

individuals reporting 

alcohol misuse

Urban HIV primary care 

clinic, multiethnic

RCT

After 60 days, members 

of intervention group with 

alcohol dependence reported 

significantly fewer drinks per 

drinking day as compared 

to control group (3.55 vs. 

6.07). Lower rates of drinks 

per drinking day among 

intervention group maintained 

at 12-month follow-up.

Hasin et al., 

(2013)230

Reduce Your 

Use

Self-guided webbased treatment 

program for 

cannabis use 

disorder based 

on cognitive, 

motivational, 

and behavioral 

principles.

N = 225 individuals 

looking to reduce or 

cease cannabis use

Varied settings

RCT

After 6 weeks, the intervention 

group reported significantly 

fewer days of cannabis use in 

the past month, significantly 

lower past-month quantity of 

cannabis use, and significantly 

fewer symptoms of cannabis 

abuse compared to the control 

group. Similar results at 

3-month follow-up.

Rooke et al.,

(2013)231
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PAGE | 4-34

Intervention Intervention 

Overview

Sample (at pretest) 

/Ethnicity/ Setting 

Design

Summary/Results Source

Self-Help for 

Alcohol and 

other Drug Use 

and Depression 

(SHADE)

Nine sessions 

of computerdelivered 

motivational 

interviewing 

and cognitive 

behavior 

therapy with 

brief therapist 

assistance.

N = 274 individuals with 

comorbid depression 

and alcohol/cannabis 

misuse

Community-based, 

Australia

RCT 

At 3-month follow-up, the 

intervention group that received 

computer-delivered care 

achieved 4 times the reduction 

in alcohol consumption 

compared to the control group, 

and 2.5 times the reduction 

of the group who received 

therapist-delivered care.

Kay-Lambkin et 

al., (2011)232

Therapeutic 

Education 

System (TES)

62 computerinteractive 

modules teaching 

skills for achieving 

and maintaining 

abstinence, 

as well as 

prize-based 

motivational 

incentives based 

on abstinence 

and treatment 

adherence.

N = 507 adult men and 

women 

Outpatient addiction 

treatment programs

RCT

Compared to the control 

group, those receiving 

TES reduced dropout from 

treatment (Hazard Ratio=0.72) 

and increased abstinence 

(Odds Ratio=1.62).

Cambell et al., 

(2015)233

Note: RCT = randomized controlled trial.

Electronic Assessments and Early Intervention

Several studies have been conducted on technology-assisted screening, assessment, and brief intervention 

for substance use disorders. Many of these studies focus on Internet-based assessments and brief 

interventions for at-risk, college-age populations. Examples of evaluated tools include the Check Your 

Drinking screener,234 electronic alcohol screening and brief intervention (e-SBI),

235 Drinker’s Check-up,236

Alcohol electronic Check-Up to Go (e-CHUG,)

237and Marijuana eCHECKUP TO GO.238 Other studies assessed 

interventions that can be implemented in general health care settings, including Project QUIT, a brief 

intervention in a primary care setting that also includes follow-up coaching calls for individuals who 

have been identified through screening as engaging in risky drug use,50 and use of kiosks in emergency 

departments to screen for alcohol and drug use.239 In the latter study, patients in the emergency 

department were found to be significantly more likely to disclose their substance use at a kiosk 

compared to a health care professional or other interviewer. Other studies focus on telephone-based 

assessments and brief interventions related to alcohol and drug use, including DIAL,240 and a telephonebased monitoring and brief counseling intervention.241 Preliminary evidence shows that Web- and 

telephone-based assessments and brief interventions are superior to no treatment in reducing substance 

use, and often result in similar or improved outcomes when compared to alternative brief intervention 

options.236,241-247
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Electronic Treatment Interventions

A larger pool of research studies has assessed the effectiveness of substance use disorder treatment 

approaches (largely outpatient) that incorporate Web- and telephone-based technology. These 

interventions focus on a wider range of substances, including alcohol (e.g., Drinking Less,248 HealthCall230), 

opioids (e.g., Therapeutic Education System,226 CBT4CBT229), and marijuana (e.g., Reduce Your Use,231 SHADE232), 

and target various subpopulations, including veterans and individuals with co-occurring disorders and 

other chronic illnesses.230,232,249

Many of these technology-enhanced treatment interventions are Web-based versions of evidence-based, 

in-person treatment components such as CBT and MET. Early research suggests the value of applying 

Web-based treatment approaches for moderate levels of substance misuse and for individuals who may 

not otherwise seek face-to-face treatment.221,250 Among studies evaluating Web-based intervention 

support as an add-on to standard in-person treatment, preliminary evidence shows reduced substance 

use, better retention, and higher motivation to change among the intervention group.229,233,251,252 One 

study explored replacing traditional in-person CBT with a Web-based version and found at least 

equivalent outcomes among the intervention group, indicating great potential for these Web-based 

interventions to broaden the dissemination of evidence-based treatments.232

Recent studies of telephone-based interventions as adjuncts to or replacements for standard care 

interventions showed similarly promising results. For example, one study explored the effect of adding 

daily self-monitoring calls to an interactive voice response technology system with personalized feedback 

and compared it to standard motivational enhancement practice. Study results showed that those who 

received the intervention reduced the number of drinks they had on the days they did drink.230

Electronic Clinical and Recovery Support Tools

Several studies have examined the application of technology-assisted tools to RSS. In general, Web- and 

telephone-based recovery support tools focus on providing remote support to individuals following 

substance use disorder treatment. Examples of e-recovery support tools include: A-CHESS, a smartphone 

application that provides monitoring, information, communication, and support services to patients, 

including ways for individuals and counselors to stay in contact;228 and MORE, a Web-based recovery 

support program that delivers assessments, clinical content, and access to recovery coaching support 

online.253 Preliminary evidence shows that technology-assisted recovery support approaches may be 

effective in helping individuals to maintain their recovery.221,228,253 In 2014, a study found that OTP 

participants receiving ongoing counseling services through Web-based videoconferencing technology 

experienced comparable rates of decreased drug use and program attendance as did individuals 

receiving in-person care.227
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Considerations for Specific Populations

Culturally Competent Care

A variety of treatment approaches have been developed to address the needs of individuals with 

substance use disorders. However, disparities exist in the outcomes and effectiveness of substance use 

treatment for different populations.109,254 Research has shown that treatment needs can differ across 

various populations,255,256 suggesting that treatment interventions should be individually tailored 

and incorporate culturally competent and linguistically appropriate practices relevant to specific 

populations and subpopulation groups.257

Racial and Ethnic Groups

A study examining a culturally sensitive substance use disorder intervention program targeted at 

Hispanic or Latino and Black or African American adolescents called Alcohol Treatment Targeting 

Adolescents in Need (ATTAIN) found significant reductions in alcohol and marijuana use for all racial and 

ethnic groups.258 Cultural factors, including discrimination, acculturation, ethnic pride, and cultural 

mistrust, were associated with the pre-intervention levels of alcohol and drug use. The study concluded 

that accounting for these factors when tailoring a substance use disorder intervention is critical to 

meeting the needs of the community it is aiming to serve. 

Many of the interventions developed for substance use disorder treatment services in general have 

been evaluated in populations that included Black or African American patients, and many of these 

interventions are as effective for Black or African American patients as they are for White patients.259,260

Some motivational interventions that are aligned with the cultural values of the population have been 

found to reduce substance use among Blacks or African Americans.27,257

Dialectical Behavior Therapy (DBT) is an evidence-based therapy that teaches a skill called mindfulness. 

Multiple research studies have noted that mindfulness, an attentional exercise originally developed in 

Buddhist cultures, is potentially useful in helping people gain mastery over substance cravings.261 A 

study examining patients in a substance use disorder residential treatment center that incorporated 

DBT with specific cultural, traditional, and spiritual practices for American Indian or Alaska Native 

adolescents found that 96 percent of the adolescents in their sample either “recovered” or “improved.”262

Treatment included all aspects of comprehensive DBT and included consultation with tribal leaders 

from the governing body and a medicine man/spiritual counselor from a local tribe.

Asian patients tend to enter treatment with less severe substance misuse problems than do members of 

other racial or ethnic groups,263 place less value on substance use disorder treatment, and are less likely 

to use such services.264 Studies on Asians and Native Hawaiians and Pacific Islanders have identified 

culturally specific barriers and facilitators to entering and completing substance use treatment (e.g., 

family, peers, shame, and involvement in the criminal justice system).265 Assessing patient experience of 

shame is an important step when providing substance use disorder treatment to Asian patients because 

shame and humiliation can be significant barriers to treatment engagement for this population.266
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Combining Evidence-based Care with 

Traditional, Spiritual, and Cultural 

Beliefs 

Agency or Organization:

Desert Visions Youth Wellness Center (Desert Visions), Indian 

Health Service, Sacaton, Arizona

Purpose:

Desert Visions is a federally-operated adolescent residential 

center whose purpose is to provide substance use and 

behavioral health treatment to American Indians and Alaska 

Natives. Desert Visions offers a multi-disciplinary treatment 

that includes bio-psychosocial, health, education, and 

cultural activities. Desert Visions uses Dialectical Behavior 

Therapy (DBT) as the treatment modality, and clients are 

taught to use the DBT skills to improve their quality of life. 

Goals:

• Provide holistic care and treatment for the physical, spiritual, and emotional needs of American Indian and 

Alaska Native adolescents.

• Provide superior outcomes in treating substance use/co-occurring disorders. 

• Utilize the DBT skill of mindfulness to allow for the introduction of cultural, spiritual, and traditional practices 

into treatment while still maintaining fidelity to this evidence-based approach. In essence, the goal of using 

DBT is to combine the best of “Western-Based” interventions with traditional American Indian/Alaska Native 

interventions. 

Outcomes:

A 3-year program/statistical review of outcome data found that of 229 patients who were enrolled in the

treatment program:

• 201 met the criteria for clinically significant change, (i.e., “recovered” or “reliable change” or 

“improved”) and 10 showed no change. 

• None of the youth in treatment deteriorated during the treatment period.

• The findings represent a first investigation of the use of DBT within American Indian and Alaska Native 

populations.

“The results demonstrated by the 

outcome data far exceeded expectations. 

DBT has dramatically improved the 

care of adolescents at our facilities. A 

serendipitous benefit has been the 

enhancement of the relationship with the 

multiplicity of referral sources. Our tribal 

partners have commented positively on the 

integration of DBT with those traditional, 

cultural, and spiritual practices that are 

common to the many tribal nations.”

– Rear Admiral Vincent Berkley, USPHS, 

Retired Medical Director, Youth Treatment 

Centers of Arizona and Nevada

Lesbian, Gay, Bisexual, and Transgender Populations 

Lesbian, gay, bisexual, and transgender (LGBT) populations often enter treatment with more severe 

substance misuse problems,267 have a greater likelihood of experiencing a substance use disorder in 

their lifetime, and initiate alcohol consumption earlier than heterosexual clients;268 thus, developing 

effective treatment programs that address the specific needs of these populations is critical. For example, 

the 2013 National Health Interview Survey, conducted by the U.S. Census Bureau, found that a higher 

percentage of LGBT adults, aged 18 to 64, had five or more drinks on one day in the past year compared 

to heterosexual adults.269 Research has also shown that LGB adolescents report higher rates of substance 

use compared to heterosexual youth; on average substance use among LGB youth was 190 percent higher 
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PAGE | 4-38

than for heterosexual youth, 340 percent higher for bisexual youth, and 400 percent higher for lesbians 

and bisexual females.270 Treatment programs with specialized groups for gay and bisexual clients have 

shown better outcomes for men compared to gay and bisexual men in non-specialized programs.113

According to one analysis, a significant minority of the nation’s substance use disorder treatment 

agencies indicated that they offer treatment services tailored to LGBT populations, although only a small 

portion (7.4 percent) offered a service that they could identify as an LGBT-specialized service.271

Research has shown that treatment providers should be knowledgeable about sexuality, sexual 

orientation, and unique aspects of LGBT developmental and social experiences.272 For example, factors 

such as transphobia or homophobia (both internal and societal), violence, family issues, and social 

isolation, among other problems, may need to be addressed within the substance use disorder treatment 

environment for transgender people.273 It is also important to consider the types of treatment that have 

been shown effective with the LGBT population. Motivational interviewing, social support therapy, 

contingency management, and CBT have all demonstrated effectiveness specifically for gay or bisexual 

men with a substance use disorder.272

Veterans 

Being a veteran or an active member of the military is a unique way of life that involves experiences and 

sacrifices by the service member and the member’s family. Military service members, veterans, and their 

families have needs unlike other individuals that require culturally competent approaches to treatment 

and services. Veterans report high rates of substance misuse; between 2004 and 2006, 7.1 percent of 

all veterans met the criteria for a substance use disorder.274 Studies of female veterans have shown that 

between 4 and 37 percent of veterans reported alcohol misuse, 7 to 25 percent reported binge drinking, 

and between 3 and 16 percent reported substance use disorders.275 Much of the literature on substance 

use in the military examines the relationship between post-traumatic stress disorder (PTSD) and alcohol 

and drug use. For example, a large study examined improvement in substance use outcomes among 

12,270 veterans who were diagnosed with PTSD and a substance use disorder and treated in specialized 

intensive veterans’ treatment programs. The study found that treatment in longer-term programs, 

with prescribed psychiatric medication and planned participation in program reunions for postdischarge support, were all associated with improved outcomes.276 Reductions in substance use were 

also associated with improvements in PTSD symptoms and violent behavior. The findings suggested 

that intensive treatment combined with proper discharge planning for veterans with severe PTSD 

and a substance use disorder may result in better outcomes than traditional substance use disorder 

treatment. A study among homeless veterans with a diagnosis of a substance use disorder as well as a 

mental disorder found that those who took part in a low-intensity wrap-around intervention showed 

improvements in a number of substance use, mental health, and behavioral health outcomes from the 

beginning of the study to follow-up 12 months later.277

Criminal Justice Populations 

It has been estimated that half of the United States prison population has an active substance use 

disorder.278 Many incarcerated individuals will experience a lower tolerance for substances due to 

abstinence while in prison; upon release, many will return to dangerous use levels, not realizing their 
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tolerance is diminished.279 This is particularly important as it raises the risk of opioid overdose deaths 

after release from incarceration; one study found that 14.8 percent of all former prisoner deaths from 

1999 to 2009 were related to opioids.280 There is typically insufficient pre-release counseling and postrelease follow-up provided to this population to reduce these risks.281

In a randomized controlled trial of methadone maintenance for prisoners, participants were randomly 

assigned to counseling with passive referral to methadone maintenance treatment (MMT) after release, 

counseling with transfer to MMT, or counseling with pre-release MMT. Prisoners who received 

counseling and MMT in prison prior to release and continued with community-based MMT after 

release were significantly less likely to use opioids and engage in criminal activity post-release.282

Increased access to opioid agonist maintenance may positively impact the needs of substance use 

disorders among incarcerated individuals.283

Another randomized trial assigned some participants to extended-release naltrexone treatment 

and others to usual treatment, consisting of brief counseling and referrals to community treatment 

programs. Those who received extended-release naltrexone had a lower rate of relapse (43 percent 

vs. 64 percent), and a higher rate of opioid-negative urine samples (74 percent vs. 56 percent), and the 

average time between treatment and relapse was found to be longer—10.5 weeks, compared with 5.0 

weeks for those who received usual treatment. Importantly, positive effects diminished after treatment 

with extended-release naltrexone was discontinued.284

Drug Courts

Drug courts are a diverse group of specialized programs that focus on adult or juvenile offenders, as 

well as parents under child protective supervision who have substance use-related disorders.285 Drug 

courts provide treatment and other services, overseen by a judge, in lieu of being processed through the 

traditional justice system. By 2015, more than 3,400 drug courts were in operation across the United 

States.285 An estimated 55,000 defendants per year participate in adult drug courts,286,287 with each court 

serving a caseload of approximately 50 individuals each year.288 These interventions seek to harness 

the coercive power of the criminal justice system to persuade drug-involved offenders to cease their 

problematic drug use. 

Existing research, including randomized controlled trials, have found positive effects of drug courts, 

including high rates of treatment completion and reduced rates of recidivism, incarceration, and 

subsequent drug use.288-291 Reviews of these evaluations have concluded that the average effect of adult 

drug court participation is analogous to a drop in recidivism from 50 percent to 38 percent, and that 

this effect lasts up to 3 years.289 Evaluations of driving under the influence (DUI) drug courts generally 

find similar reductions as adult drug courts and substantially smaller effects than are found in juvenile 

drug courts.292 Larger reductions in recidivism were found in adult drug courts that had high graduation 

rates and that accepted only nonviolent offenders, suggesting that this intervention may be more 

effective among that segment of the substance-using population.

Despite the rapid expansion of drug courts, the number of defendants who pass through such programs 

remains a small proportion of the more than 1 million offenders with substance use disorders who 

pass through the United States criminal justice system each year. Capacity constraints provide the most 

important limitation.286
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Drug court programs require random drug tests and other monitoring measures. Required abstinence 

involves making sanctions certain and immediate. Hawaii’s Opportunity Probation with Enforcement (HOPE) 

program has implemented coerced abstinence for the entire probation population. Promising results 

of a randomized trial have sparked interest in broader replication.293 Observed recidivism rates were 

dramatically lower than for the prior probation population, and the treatment group was incarcerated 

for roughly half as many days as the control group. Interventions such as HOPE do not necessarily 

involve substance use disorder treatment; this reflects the reality that many drug-involved offenders do 

not meet the criteria for substance use disorders. For many individuals, regular monitoring, alongside 

the adverse consequences of a failed urine test, provide powerful motivation to abstain.294

A further example is the 24/7 Sobriety Project (24/7), a South Dakota innovative program to supervise 

individuals who were arrested in connection with alcohol-related offenses. It addresses problem 

drinking by imposing close monitoring, followed by swift, certain, yet modest sanctions when there is 

evidence of renewed alcohol use. Under 24/7, problem drinkers rearrested for DUI and selected other 

alcohol-related violations were subject to intensive monitoring and sanctions. As a condition of bail, 

participants were required to take morning and evening breathalyzer tests or wear continuous alcoholmonitoring bracelets. Between 2005 and 2010, 24/7 participants were ordered to take approximately 

3.7 million breathalyzer tests, and achieved a pass rate of approximately 99.3 percent.295 A RAND 

Corporation program evaluation found that 24/7 tangibly improved public safety in counties where the 

program was implemented at scale.295 In counties where the number of 24/7 participants reached onequarter of DUI arrests, the intervention was associated with a significant reduction in repeat DUI and 

intimate partner violence arrests. Similar results have been replicated in Montana.296

Recommendations for Research

Although the field of treatment for substance use disorders has made substantial progress, additional 

types of research are needed. Research involving early interventions and various components of 

treatment must move from rigorously controlled trials to natural delivery settings and a broader mix 

of patient types. Because rigorously controlled trials must focus on specific diagnoses and carefully 

characterized patient types, it is often the case that the samples used in these trials are not representative 

of the real-world populations who need treatment. For example, many opioid medication trials involve 

“opioid-only” populations, whereas in practice most patients with opioid use disorders also have 

alcohol, marijuana, and/or cocaine use disorders. Rigorously controlled trials are necessary to establish 

efficacy, but interventions that seem to be effective in these studies too often cannot be implemented 

in real-world settings because of a lack of workforce training, inadequate insurance coverage, and an 

inability to adequately engage the intended patient population. 

As has been documented in several chapters within this Report, the great majority of patients with 

substance use disorders do not receive any form of treatment. Nonetheless, many of these individuals 

do access primary or general medical care in community clinics or school settings and research is 

needed to determine the availability and efficacy of treatment in these settings and to identify ways 

in which access to treatment in these settings could be improved. The current failure to acknowledge 

and address substance use disorders in these settings has reduced the quality and increased the costs 
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PAGE | 4-41

of health care. Moreover, access and referral to specialty substance use disorder care from primary 

care settings is neither easy nor quick. Better integration between primary care and specialty care and 

additional treatment options within primary care are needed. Primary care physicians need to be better 

prepared to identify, assist, and refer patients, when appropriate. If treatment is delivered in primary 

care, it should be practical for delivery within these settings and attractive, engaging, accessible and 

affordable for affected patients. 

Buprenorphine or naloxone treatment for opioid misuse should also be available in emergency 

departments.297 Here, the goals of treatment would be the reduction of substance use combined 

with better engagement in and adherence to treatment for any associated medical illness. Therefore, 

treatment research outside of traditional substance use disorder treatment programs is needed. 

As of June 2016, four states, plus the District of Columbia, have legalized recreational marijuana, and 

many more have permitted medical marijuana use. The impact of the changes on levels of marijuana 

and other drug and alcohol use, simultaneous use, and related problems such as motor vehicle crashes 

and deaths, overdoses, hospitalizations, and poor school and work performance, must be evaluated 

closely. Accurate and practical marijuana screening and early intervention procedures for use in general 

and primary care settings are needed. Not only must it be determined which assessment tools are 

appropriate for the various populations that use marijuana, but also which treatments are generalizable 

from research to practice, especially in primary care and general mental health care settings.

Current research suggests that it is useful to educate and train first responders, peers, and family 

members of those who use opioids to use naloxone to prevent and reverse potential overdoserelated deaths. However, more research is needed to identify strategies to encourage the subsequent 

engagement of those who have recovered from overdose into appropriate treatment. In this work, it 

will be important to consider contextual factors such as age, gender identity, race and ethnicity, sexual 

orientation, economic status, community resources, faith beliefs, co-occurring mental or physical 

illness, and many other personal issues that can work against the appropriateness and ultimately the 

usefulness of a treatment strategy.

Opioid agonist therapies are effective in stabilizing the lives of individuals with severe opioid use 

disorders. However, many important clinical and social questions remain about whether, when, and 

how to discontinue medications and related services. This is an important question for many other 

areas of medicine where maintenance medications are continued without significant change and often 

without attention to other areas of clinical progress. 

At the same time, it is clear from many studies over the decades that detoxification following an 

arbitrary maintenance time period (e.g., 90 days, 180 days), or performed without continuing supports, 

is rarely effective in disengaging patients from opioid use disorders and may lead to relapse and 

overdose. Thus, more research is needed to explore if, when, and how patients can be transitioned from 

MAT to non-medication status within the context of “personalized medicine,” to provide both patients 

and clinical staff appropriate therapeutic guidance.
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Regarding personalized medicine, research is needed on how to implement multidisciplinary, 

collaborative, and patient-centered care for persons with opioid use disorders and chronic pain, in 

a manner effectively treating both diseases together with any psychiatric comorbidities that may 

undermine recovery. Precision medicine research is also needed on how to individually tailor such 

interventions to optimize care management for patient groups in which there is overlap between painrelated psychological distress and stress-related opioid misuse.298
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RECOVERY

PAGE | 5-1

CHAPTER 5.

RECOVERY: THE MANY PATHS 

TO WELLNESS

Chapter 5 Preview

On October 4, 2015, tens of thousands of people attended the UNITE to Face Addiction rally in 

Washington, D.C. The event was one of many signs that a new movement is emerging in America: 

People in recovery, their family members, and other supporters are banding together to decrease the 

discrimination associated with substance use disorders and spread the message that people do recover.

Much of the success of the event hinged on the growing network of recovery community organizations 

(RCOs) that have proliferated across the country, creating cultures of recovery and advancing recoverypositive attitudes, programs, and prevention strategies. Recovery advocates have created a onceunimagined vocal and visible recovery presence, as living proof that long-term recovery exists in the 

millions of individuals who have attained degrees of health and wellness, are leading productive lives, 

and making valuable contributions to society. Meanwhile, policymakers and health care system leaders 

in the United States and abroad are beginning to embrace recovery as an organizing framework for 

approaching addiction as a chronic disorder from which individuals can recover, so long as they have 

access to evidence-based treatments and responsive long-term supports.1-4

Despite the growing popularity and importance of “recovery” as a concept, many people wonder what 

the term really means and why it matters. This chapter answers these questions by first defining the 

concept of recovery from substance use disorders and then reviewing the research on the methods 

and procedures used by mutual aid groups and recovery support services (RSS) to foster and sustain 

recovery. 
RECOVERY

PAGE | 5-2

KEY FINDINGS*

• Recovery from substance use disorders has had several definitions. Although specific elements of these 

definitions differ, all agree that recovery goes beyond the remission of symptoms to include a positive 

change in the whole person. In this regard, “abstinence,” though often necessary, is not always sufficient 

to define recovery. 

• Remission from substance use disorders—the reduction of key symptoms below the diagnostic 

threshold—is more common than most people realize. “Supported” scientific evidence indicates that 

approximately 50 percent of adults who once met diagnostic criteria for a substance use disorder—or 

about 25 million people—are currently in stable remission (1 year or longer). Even so, remission from a 

substance use disorder can take several years and multiple episodes of treatment, RSS, and/or mutual 

aid.

• There are many paths to recovery. People will choose their pathway based on their cultural values, their 

socioeconomic status, their psychological and behavioral needs, and the nature of their substance use 

disorder.

• Mutual aid groups and newly emerging recovery support programs and organizations are a key part 

of the system of continuing care for substance use disorders in the United States. A range of recovery 

support services have sprung up all over the United States, including in schools, health care systems, 

housing, and community settings.

• The state of the science is varied in the recovery field. 

 Well-supported scientific evidence demonstrates the effectiveness of 12-step mutual aid groups focused on alcohol and 12-step facilitation interventions.

 Evidence for the effectiveness of other recovery supports (educational settings, drug-focused mutual 

aid groups, and recovery housing) is promising. 

 Many other recovery supports have been studied little or not at all. 

*The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence as: “Well-supported”: 

when evidence is derived from multiple controlled trials or large-scale population studies; “Supported”: when 

evidence is derived from rigorous but fewer or smaller trials; and “Promising”: when evidence is derived from a 

practical or clinical sense and is widely practiced.6

Recovery Definitions, Values, and Controversies 

“Recovery” Has Many Meanings 

The word “recovery” is used to mean a range of different things.4,7 For example, members of Alcoholics 

Anonymous (AA) may say they are “in recovery” or are “recovering alcoholics.” Substance use treatment 

program directors sometimes speak of their “recovery rate,” meaning the proportion of patients who 

have graduated and remained abstinent. Some activists describe themselves as being part of a “recovery 

movement.” One simple way to make sense of these different definitions of recovery is to divide them 

into those that describe individual people and their experience and those that describe a set of recovery 

values and beliefs that could be embraced by individuals, organizations, and activist movements.
RECOVERY

PAGE | 5-3

Recovery as a Term for Individuals 

Like any other chronic health condition, substance use 

disorders can go into remission. Among individuals with 

substance use disorders, this commonly involves the person 

stopping substance use, or at least reducing it to a safer level—

for example, a student who was binge drinking several nights 

a week during college but reduced his alcohol consumption 

to one or two drinks a day after graduation. In general health 

care, treatments that reduce major disease symptoms to normal or “sub-clinical” levels are said to 

produce remission, and such treatments are thereby considered effective. However, serious substance 

use disorders are chronic conditions that can involve cycles of abstinence and relapse, possibly over 

several years following attempts to change.4,8-11 Thus, sustaining remission among those seriously 

affected typically requires a personal program of sustained recovery management.12

For some people with substance use disorders, especially those whose problems are not severe, 

remission is the end of a chapter in their life that they rarely think about later, if at all. But for others, 

particularly those with more severe substance use disorders, remission is a component of a broader 

change in their behavior, outlook, and identity. That change process becomes an ongoing part of how 

they think about themselves and their experience with substances. Such people describe themselves as 

being “in recovery.” 

Various definitions of individual recovery have been offered nationally and internationally.13-17 Although 

they differ in some respects, all of these recovery definitions describe personal changes that are well 

beyond simply stopping substance use. As such, they are conceptually broader than “abstinence” or 

“remission.” For example, the Betty Ford Institute Consensus Panel defined recovery as “a voluntarily 

maintained lifestyle characterized by sobriety, personal health, and citizenship.”13 Similarly, the 

Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as “a process 

of change through which individuals improve their health and wellness, live a self-directed life, and 

strive to reach their full potential.”16

The specific meaning of recovery can also vary across cultures and communities. Among some 

American Indians, recovery is inherently understood to involve the entire family18 and to draw upon 

cultural and community resources (see, for example, the organization White Bison). On the other hand, 

European Americans tend to define recovery in more individual terms. Blacks or African Americans 

are more likely than individuals of other racial backgrounds to see recovery as requiring complete 

abstinence from alcohol and drugs.19 Within some communities, recovery is seen as being aligned with 

a particular religion, yet in other communities such as the AA fellowship, recovery is explicitly not 

religious but is instead considered spiritual. Still other communities, such as LifeRing Secular Recovery, 

SMART Recovery, and Secular Organization for Sobriety, view recovery as an entirely secular process.

Adding further to the diversity of concepts and definitions associated with recovery, in recent years 

the term has been increasingly applied to recovery from mental illness. Studies of people with 

schizophrenia, some of whom have co-occurring substance use disorders, have found that recovery is 

often characterized by increased hope and optimism, and greater life satisfaction.20 This same research 

Remission. A medical term meaning 

that major disease symptoms are 

eliminated or diminished below a predetermined, harmful level.
PAGE | 5-4

revealed that whether someone experienced such benefits was strongly related to their experience with 

broader recovery benefits, such as improved health, improved finances, and a better social life.21

Recovery-Related Values and Beliefs

When people talk about the recovery movement, they often invoke a set of values and beliefs that may 

be embraced by individuals with substance use disorders, families, treatment professionals, and even 

entire health care systems. Some examples of these values and beliefs include:22

$ People who suffer from substance use disorders (recovering or not) have essential worth and 

dignity.

$ The shame and discrimination that prevents many individuals from seeking help must be 

vigorously combated.

$ Recovery can be achieved through diverse pathways and should be celebrated.

$ Access to high-quality treatment is a human right, although recovery is more than treatment.

$ People in recovery and their families have valuable experiences and encouragement to offer 

others who are struggling with substance use.

Conceptual Controversies in Recovery 

Most people who define themselves as being “in recovery” have experience with 12-step-oriented 

mutual aid groups such as AA and Narcotics Anonymous (NA), but many others enter recovery through 

professional treatment services, non-12-step mutual aid groups, or other routes of support, such as 

family, friends, or faith-based organizations.7 The diversity in pathways to recovery has sometimes 

provoked debate about the value of some pathways over others. 

For example, people who achieve recovery with the support of medications (e.g., methadone, 

buprenorphine, disulfiram, acamprosate, naltrexone, or even antidepressants) have sometimes been 

denounced by those who do not take medications, based on assumptions that using medication is 

inconsistent with recovery principles or a form of drug substitutions or replacement. Nonetheless, 

members of the National Alliance for Medication Assisted Recovery or Methadone Anonymous refer to 

themselves as practicing medication-assisted recovery.23

Finally, some people who have had severe substance use disorders in the past but no longer meet criteria 

for a substance use disorder do not think of themselves as operating from a recovery perspective or 

consider themselves part of a recovery movement, even if they endorse some or all of the beliefs and 

values associated with recovery.

Perspectives of Those in Recovery

The most comprehensive study of how people define recovery recruited over 9,000 individuals with 

previous substance use disorders from a range of recovery pathways. Almost all (98 percent) reported 

characteristics that met formal medical criteria for a severe substance use disorder and three-quarters 
PAGE | 5-5

labeled themselves as being “in recovery.”7 The study results shed light on how people vary in their 

understanding of recovery: 

$ Abstinence: 86.0 percent saw abstinence as part of their recovery. The remainder either did not 

think abstinence was part of recovery in general or felt it was not important for their recovery.7

Endorsement of abstinence as “essential” was most common among those who were affiliated 

with 12-step mutual aid groups.24 This finding was consistent with previous research showing 

that the great majority of people (about 6 in 7) who have experienced serious substance use 

disorders consider abstinence essential for recovery.19

$ Personal growth: “Being honest with myself” was endorsed as part of recovery by 98.6 percent of 

participants.7 Other almost universally-endorsed elements included “handling negative feelings 

without using alcohol or drugs” and “being able to enjoy life without alcohol or drugs.” Almost 

all study participants viewed their recovery as a process of growth and development, and about 

two-thirds saw it as having a spiritual dimension.

$ Service to others: Engaging in service to others was another prominent component of how 

study participants defined recovery, perhaps because during periods of heavy substance use, 

individuals often do damage to others that they later regret. Importantly, service to others has 

evidence of helping individuals maintain their own recovery.25,26 A survey of more than 3,000 

people in recovery indicated that fulfilling important roles and being civically engaged, such as 

paying taxes, holding a job, and being a responsible parent and neighbor, became much more 

common after their substance use ended.27

Estimating the Number of People “In Recovery” 

How much recovery one sees in the world depends on where 

one looks. Substance use disorders are highly variable in 

their course, complexity, severity, and impact on health and 

well-being. In the general population, many people who once 

met diagnostic criteria for low-severity, “mild” substance use 

disorders but who later drink or use drugs without related problems do not define themselves as being 

in recovery. This reality has two implications: 

See Chapter 1 - Introduction and 

Overview.

$ First, the number of people who are in remission from a substance use disorder is, by definition, 

greater than the number of people who define themselves as being in recovery.

$ Second, depending on how survey questions are asked and interpreted by respondents, estimates 

of recovery prevalence may differ substantially. Someone who once met formal criteria for a 

substance use disorder but no longer does may respond “Yes” to a question asking whether they 

had “ever had a problem with alcohol or drugs,” but may say “No” when asked “Do you consider 

yourself as being in recovery?” 

Perhaps because of this definitional complexity, most clinical outcome studies and community studies 

of substance use disorders over the years have not included “recovery” as an outcome measure. Instead, 

abstinence or remission are usually the outcomes that are considered to indicate recovery.28
PAGE | 5-6

Summarizing data from six large studies, one analysis estimated that the proportion of the United States 

adult population that is in remission from a substance use disorder of any severity is approximately 10.3 

percent (with a range of 5.3 to 15.3 percent).29 This estimate is consistent with findings from a different 

national survey, which found that approximately 10 percent, or 1 in 10, of United States adults say, “Yes,” 

when asked, “Did you once have a problem with drugs or alcohol but no longer do?” These percentages 

translate to roughly 25 million United States adults being in remission.29 It is not yet known what 

proportion of adolescents defines themselves as being in recovery. 

Despite negative stereotypes of “hopeless addicts,” rigorous follow-up studies of treated adult 

populations, who tend to have the most chronic and severe disorders, show more than 50 percent 

achieving sustained remission, defined as remission that lasted for at least 1 year.29 Latest estimates from 

national epidemiological research using the Fifth Edition of the Diagnostic and Statistical Manual of Mental 

Disorders (DSM-5) criteria for substance use disorder show similar rates of remission.30,31 Despite these 

findings, widely held pessimistic views about the chances of remission or recovery from substance use 

disorders may continue to affect public opinion in part because sustained recovery lasting a year or 

longer can take several years and multiple episodes of treatment, recovery support, and/or mutual aid 

services to achieve. By some estimates, it can take as long as 8 or 9 years after a person first seeks formal 

help to achieve sustained recovery.32,33

In studies published since 2000, the rate of sustained remission following substance use disorder 

treatment among adolescents is roughly 35 percent. This estimate is provisional because most studies 

used small samples and/or had short follow-up durations.29 Despite the potentially lower remission rate 

for adolescents, early detection and intervention can help a young person get to remission faster.29

Recovery-oriented Systems of Care 

Increasingly, RSS are being organized into a framework for infusing the entire health and social service 

system with recovery-related beliefs, values, and approaches.34 This transformation has been described 

as:

...a shift away from crisis-oriented, deficit-focused, and professionally-directed models of care to a 

vision of care that is directed by people in recovery, emphasizes the reality and hope of long-term 

recovery, and recognizes the many pathways to healing for people with addiction and mental 

health challenges.35

Recovery-oriented Systems of Care (ROSC) embrace the idea that severe substance use disorders 

are most effectively addressed through a chronic care management model that includes longer term, 

outpatient care; recovery housing; and recovery coaching and management checkups.36 Recoveryoriented systems are designed to be easy to navigate for people seeking help, transparent in their 

operations, and responsive to the cultural diversity of the communities they serve.36 Treatment in 

recovery-oriented systems is offered as one component in a range of other services, including recovery 

supports. Treatment professionals act in a partnership/consultation role, drawing upon each person’s 

goals and strengths, family supports, and community resources. On a systems level, outcomes from 

Connecticut’s Department of Mental Health and Addiction Services (DMHAS) ROSC initiative have 
PAGE | 5-7

demonstrated a 46 percent increase in individuals served, with 40 percent using outpatient care at lower 

costs, resulting in a decrease of 25 percent annual cost per client and a 24 percent decrease in overall 

treatment expenses.36

An example of a successful municipal ROSC has been evolving since 2004 in Philadelphia’s Department 

of Behavioral Health and Intellectual disAbility Services (DBHIDS). Three focus areas were aligned to 

achieve a complete systems transformation in the design and delivery of recovery-oriented services: 

a change in thinking (concept); a change in behavior (practice); and a change in fiscal, policy, and 

administrative functions (context). To achieve successful implementation, DBHIDS conducted ongoing 

activities with a variety of stakeholders including individuals in recovery and their family members, 

peer and professional providers, administrators and fiscal agents, and agency staff and leadership.37

SAMHSA has been instrumental in setting the stage for the emergence of the organized recovery 

community and its role in the development of ROSC, as well as peer and other RSS. Beginning with 

the Recovery Community Support Program (RCSP) in 1998, SAMHSA’s Center for Substance Abuse 

Treatment introduced a number of grant initiatives that support recovery, such as Access to Recovery 

and Targeted Capacity Expansion grants for ROSC and Peer-to-Peer programs. These grants have given 

states, tribes, and community-based organizations resources and opportunities to create innovative 

practices and programs that address substance use disorders and promote long-term recovery. Valuable 

lessons from these grants have been applied to enhance the field, creating movement towards a strong 

recovery orientation, and highlight the need for rigorous research to identify evidence-based practices 

for recovery.

In 2010, SAMHSA rolled out Recovery Supports as one of its Strategic Initiatives, highlighting the 

importance of recovery as a valuable component in the continuum of care. Directly following the 

establishment of the Recovery Support Strategic Initiative, SAMHSA developed a five-year technical 

assistance contract to support recovery, known as BRSS-TACS (Bringing Recovery Supports to Scale 

– Technical Assistance Center Strategy). Through a series of actions and activities, this initiative has 

served to conceptualize and implement recovery-oriented services and systems across the country; 

examined the scope and depth of existing and needed recovery supports; supported the growth and 

quality of the peer workforce; enhanced and extended local, regional, and state recovery initiatives; and 

supported collaborations and capacity within the recovery movement.

Recovery Supports 

Even after a year or 2 of remission is achieved—through treatment or some other route—it can take 

4 to 5 more years before the risk of relapse drops below 15 percent, the level of risk that people in the 

general population have of developing a substance use disorder in their lifetime.29 As a result, similar 

to other chronic conditions, a person with a serious substance use disorder often requires ongoing 

monitoring and management to maintain remission and to provide early re-intervention should 

the person relapse.10,32 Recovery support services refer to the collection of community services that 

can provide emotional and practical support for continuing remission as well as daily structure and 

rewarding alternatives to substance use. 
PAGE | 5-8

Just as the development of a substance use disorder involves profound changes in the brain, behavior, 

and social functioning,38,39 the process of recovery also involves changes in these and other areas. These 

changes are typically marked and promoted by acquiring healthy life resources—sometimes called 

“recovery capital.”14,40-42 These recovery resources include housing, education, employment, and social 

resources, as well as better overall health and well-being. Recovery support services have been evaluated 

for effectiveness and are reviewed in the following sections.

Mutual Aid Groups

Mutual aid groups, such as 12-step groups, are perhaps the best known type of RSS, and they share a 

number of features. The members share a problem or status and they value experiential knowledge—

learning from each other’s experiences is a central element—and they focus on personal-change goals. 

The groups are voluntary associations that charge no fees and are self-led by the members.43

Mutual aid groups focused on substance use differ from other RSS in important respects. First, they 

have been in existence longer, having originally been created by American Indians in the 18th century 

after the introduction of alcohol to North America by Europeans.44 The best-known mutual aid 

group today, AA, was founded in 1935. Other more recent RSS innovations and have yet to be studied 

extensively.45 Second, mutual aid groups advance specific pathways to recovery, in contrast to the 

general supports provided by other RSS. They have been studied extensively for problems with alcohol, 

but not with illicit drugs. For example, an experienced AA member will help new members learn and 

incorporate AA’s specific approach to recovery. In contrast, recovery coaches will support a variety 

of recovery options and support services, of which AA may be one of many. Third, mutual aid groups 

have their own self-supporting ecosystem that interacts with, but is fundamentally independent of, 

other health and social service systems. In contrast, other RSS are often part of formal health and social 

service systems. 

12-Step Mutual Aid Groups

Mutual aid groups such as AA, Women for Sobriety, SMART 

Recovery, and many others are the historical precursors of 

RSS.33,46 Most mutual aid group research has been conducted 

on AA, because AA is the most widely accessed and bestknown form of help for alcohol problems in the United 

States.46 Research on AA includes systematic reviews of its effectiveness and randomized controlled 

trials on AA-oriented interventions that actively link individuals with substance use disorders to mutual 

aid groups.47-53 Research suggests that professional treatment programs that facilitate involvement in AA 

and NA lower health care costs by reducing relapses and need for further treatment.54,55

Beginning in the 1950s, the AA approach was adapted to illegal drugs by the founders of NA, and in 

later decades it was adapted to other drugs as well (e.g., Cocaine Anonymous, Marijuana Anonymous, 

Crystal Meth Anonymous). Alcoholics Anonymous and its derivative programs share two major 

components: A social fellowship and a 12-step program of action that was formulated based on 

members’ experiences of recovery from severe alcohol use disorders. These 12 steps are ordered in a 

logical progression, beginning with accepting that one cannot control one’s substance use, followed 

See Chapter 1 - Introduction and 

Overview.
PAGE | 5-9

by abstaining from substances permanently, and transforming one’s spiritual outlook, character, and 

relationships with other people. 

Members of 12-step mutual aid groups tend to have a history of chronic and severe substance use 

disorders and participate in 12-step groups to support their long-term recovery. About 50 percent of 

adults who begin participation in a 12-step program after participating in a treatment program are still 

attending 3 years later.56 Rates of continued attendance for individuals who seek AA directly without 

first going to treatment are also high, with 41.6 percent of those who start going to meetings still 

attending 9 to 16 years later.57

In the years since the Institute of Medicine called for more 

rigorous research on AA’s effects and mechanisms in its 1990 

report Broadening the Base of Treatment for Alcohol Problems,

58

research has moved from correlational studies with no 

control groups to carefully conducted randomized controlled 

trials. The most rigorous of these clinical trials have 

compared treatments that link patients to 12-step mutual aid 

groups to the same treatments without the AA linkage. Most 

of these trials have focused exclusively on AA, but some have 

involved mutual aid groups for drug use disorder as either an 

alternative or a supplement to AA.52,59,60 A substantial body of 

research indicates AA is an effective recovery resource;61-65

NA has been studied less extensively than AA, but evidence 

on its effectiveness is promising.43

Research studying 12-step mutual aid groups, specifically 

those focused on alcohol, has shown that participation in the groups promotes an individual’s recovery 

by strengthening recovery-supportive social networks; increasing members’ ability to cope with 

risky social contexts and negative emotions; augmenting motivation to recover; reducing depression, 

craving, and impulsivity; and enhancing psychological and spiritual well-being.66-69 Thus, with perhaps 

the exception of spirituality, many of the same mechanisms of behavior change thought to operate in 

professional treatments also appear to be important benefits of AA participation.70 

A strength of 12-step mutual aid group research is that it has included many studies involving people of 

diverse racial backgrounds, as well as studies focused exclusively on women.43 For example, American 

Indian and Alaskan Native groups have adapted AA to incorporate Native spirituality and to allow 

attendance by entire families. These groups do not limit talking time and incorporate cultural traditions 

and languages.71 A culturally appropriate variation of AA72 includes The Red Road to Wellbriety, a Native 

adaptation of the basic text of AA.18 Similarly, AA adaptations by Latino immigrants incorporate languages 

and interaction styles from members’ countries of origin.73,74 Chapters focused on serving Black or African 

American or gay and lesbian participants also tailor 12-step mutual aid groups to a style that fits the 

culture of the participants.46,75 This cultural adaptability, combined with the fact that 12-step groups are 

easily available, free of charge, and require no paperwork or insurance company documentation to attend, 

helps explain why these groups are attractive to a remarkably diverse range of people.76

Clinical trial. Any research study that 

prospectively assigns human participants 

or groups of participants to one or more 

health-related interventions to evaluate 

the effects on health outcomes.

Randomized controlled trial. A clinical 

trial of an intervention in which people 

are randomly assigned either to a group 

receiving the intervention being studied 

or to a control group receiving a standard 

intervention, a placebo (a medicine with 

no therapeutic effect), or no intervention. 

At the end of the study, the results from 

the different groups are compared.
PAGE | 5-10

Even though mutual aid groups are run by peers, professionals can and should play an important role 

in helping patients engage and participate. Multiple clinical trials have demonstrated that several 

clinical procedures are effective in increasing participation in mutual aid groups, and increase the 

chances for sustained remission and recovery. Health care professionals who help link patients with 

members of a mutual aid group can significantly increase the likelihood that the patients will attend the 

group.50,52,59,77,78 Also, the more time health care professionals spend introducing, explaining, discussing, 

and encouraging mutual aid group participation during treatment sessions, the more likely the patients 

will engage, stay involved, and benefit.47-49,51,53,79-81

Non-12-step mutual aid group meetings are far less available than are 12-step mutual aid group 

meetings.43 This points to a need for more groups aimed at those not comfortable with the 12-step 

approach,82 as well as studies assessing their effectiveness.

Al-Anon Family Groups

Friends and family members often suffer when a loved one has a substance use disorder. This may 

be due to worry about the loved one experiencing accidents, injuries, negative social and legal 

consequences, diseases, or death, as well as fear of the loved one engaging in destructive behavior, such 

as stealing, manipulating, or being verbally or physically aggressive. Consequently, a number of mutual 

aid groups have emerged to provide emotional support to concerned significant others and families and 

to help them systematically and strategically alter their own unproductive behaviors that have emerged 

in their efforts to deal with the substance use problems of their affected loved one. 

Al-Anon is a mutual aid group commonly sought by families dealing with substance use in a loved 

one. Like AA, Al-Anon is based on a 12-step philosophy83 and provides support to concerned family 

members, affected significant others, and friends through a network of face-to-face and online 

meetings, whether or not their loved one seeks help and achieves remission or recovery. More than 80 

percent of Al-Anon members are women.84 The principal goal of Al-Anon is to foster emotional stability 

and “loving detachment” from the loved one rather than coaching members to “get their loved one into 

treatment or recovery.” Al-Anon includes Alateen, which focuses on the specific needs of adolescents 

affected by a parent’s or other family member’s substance use.

Clinical trials and other studies of Al-Anon show that participating family members experience reduced 

depression, anger, and relationship unhappiness, at rates and levels comparable to those of individuals 

receiving psychological therapies.85-89 Descriptive research suggests that about half of the newcomers to 

Al-Anon are still attending 6 months later.90 Many other family-focused mutual aid groups, such as NarAnon, Co-Anon, and Grief Recovery After Substance Passing, have not been researched.

Recovery Coaching 

Voluntary and paid recovery coach positions are a new development in the addiction field. Coaches do 

not provide “treatment” per se, but they often help individuals discharging from treatment to connect to 

community services while addressing any barriers or problems that may hinder the recovery process.91

A recovery coach’s responsibilities may include providing strategies to maintain abstinence, connecting 

people to recovery housing and social services, and helping people develop personal skills that maintain 

recovery.92 Recovery coaches may or may not be in recovery themselves, but in either case they do not 
PAGE | 5-11

presume that the same path toward recovery will work for everyone they coach. Some community-based 

recovery organizations offer training programs for recovery coaches,93 but no national standardized 

approach to training coaches has been developed. Because of the role that recovery coaches play in linking 

patients to RSS, they are increasingly becoming a part of formal clinical treatment teams.94

Recovery coaching has the potential to become an important 

part of RSS and the recovery process. A descriptive study of 

56 recently homeless veterans with substance use disorder 

suggested that supplementing psychotherapy with recovery 

coaching increased length of abstinence at follow-up 6 

months later.95 Recovery coaches may complement, although 

not replace, professional case management services in the 

child welfare, criminal justice, and educational systems.91

One large randomized trial showed that providing recovery 

coaches to mothers with a substance use disorder who were involved in the child welfare system 

reduced the likelihood of the mother’s child being arrested by 52 percent.96 Other rigorous studies have 

found that providing recovery coaches for mothers with substance use disorder reduces subsequent 

births with prenatal substance exposure97 and also increases rates of family reunification.98

Case management. A coordinated 

approach to delivering general health 

care, substance use disorder treatment, 

mental health, and social services. This 

approach links clients with appropriate 

services to address specific needs and 

goals.

Recovery Housing 

Recovery-supportive houses provide both a substance-free environment and mutual support from 

fellow recovering residents. Many residents stay in recovery housing during and/or after outpatient 

treatment, with self-determined residency lasting for several months to years. Residents often 

informally share resources with each other, giving advice borne of experience about how to access 

health care, find employment, manage legal problems, and interact with the social service system. Some 

recovery houses are connected with affiliates of the National Alliance of Recovery Residences, a nonprofit organization that serves 25 regional affiliate organizations that collectively support more than 

25,000 persons in recovery across over 2,500 certified recovery residences.

A leading example of recovery-supportive houses is Oxford Houses, which are peer-run, self-sustaining, 

substance-free residences that host 6 to 10 recovering individuals per house and require that all 

members maintain abstinence.99 They encourage, but do not require, participation in 12-step mutual aid 

groups. A randomized controlled trial found that people with severe substance use disorders who were 

randomly assigned to live in an Oxford House after substance use disorder treatment were two times 

more likely to be abstinent and had higher monthly incomes and lower incarceration rates at followup 2 years later than similar individuals assigned to receive standard continuing care.99 Despite high 

intervention costs, the net cost benefit to the health care and criminal justice systems from the Oxford 

House assignment relative to standard care was estimated at approximately $29,000 per person over 

the 2-year follow-up period.100 Such beneficial effects of recovery housing may be further enhanced for 

patients with high levels of 12-step mutual aid group participation.101,102

Sober living homes are another type of substance-free living environment.103 Many of these have 

a house manager or leader and mandate attendance by residents at 12-step mutual aid groups. An 

18-month descriptive study found that residents in sober living homes reduced their alcohol and other 
PAGE | 5-12

PEER RECOVERY COACHES: WHAT THEY ARE AND WHAT THEY ARE NOT

While some RSS described in this chapter can be delivered by people who are not in recovery, peer recovery 

coaches identify as being in recovery and use their knowledge and lived experience to inform their work. 

Although research on peer RSS is limited, results so far are promising.5

 The following are some important 

distinctions regarding peer recovery coaches.

Peer recovery coaches are...

• Individuals in recovery who help others with substance use disorders achieve and maintain recovery using 

four types of support: 

 Emotional (empathy, caring, concern);

 Informational (practical knowledge and vocational assistance); 

 Instrumental (concrete assistance to help individuals gain access to health and social services); 

 Affiliational (introductions to healthy social contacts and recreational pursuits). 

• Embedded in the community in a variety of settings, including recovery community organizations; 

community health, mental health, or addiction clinics; sober living homes and recovery residences; and 

recovery high school and collegiate recovery programs. 

• Peer workers in various treatment and recovery contexts including primary care, emergency departments, 

mental health clinics, criminal justice, child welfare, homeless agencies, and crisis outreach teams. 

They are not...

• Substance use disorder treatment counselors. They do not diagnose or provide formal treatment. Rather, 

they focus on instilling hope and modeling recovery through the personal, lived experience of addiction and 

recovery. 

• Case managers. Case management typically involves professional or patient service delivery models. The 

terms “peer” and “recovery coach” are used purposely to reflect a mutual, peer-based collaboration to help 

people achieve sustained recovery.90

• AA or NA sponsors. Peer recovery coaches do not espouse any specific recovery pathway or orientation but 

rather facilitate all pathways to recovery. 

• Nationally standardized, with manuals describing their activities. Peer recovery coaches vary around the 

country. This stems from the newness of this practice and the diversity of the populations that recovery 

coaches serve. As use of this type of support expands, some national norms of practice and behavior will 

likely form over time, but with significant flexibility to enable sensitivity to local realities.

drug use as well as increased employment over time.104,105 However, unlike the clinical trial of Oxford 

House, this study had no comparison group, and individuals chose whether to reside in sober living 

homes rather than being randomly assigned to one. Therefore, residence in the sober living home 

cannot be assumed to have caused the better outcomes observed. 

Taken together, these studies provide promising evidence to suggest that recovery-supportive housing 

can be both cost-effective and effective in supporting recovery. 
PAGE | 5-13

RECOVERY HOUSING

Agency or Organization:

Oxford House, Inc. - Silver Spring, Maryland

Purpose:

Oxford House, Inc. is a publicly-supported, nonprofit 

umbrella organization that provides an oversight 

network connecting Oxford Houses in 43 states and 

the District of Columbia. Each Oxford House is a 

self-supporting and democratically-run substance-free 

residence.

Goals:

• Provide substance-free housing to individuals in 

recovery as an effective cost-efficient model.

• Ensure that houses are self-governed and run 

according to Oxford House standards and 

guidelines.

• Implement infrastructure to oversee existing houses and establish new houses in areas of need.

Outcomes:

• An 87 percent abstinence rate at the end of a 2-year period living in an Oxford House, four to five times 

greater than typical outcomes following detoxification and treatment. 

• Comparisons between a group living in Oxford House and going to AA/NA versus a similar group that only 

goes to AA/NA show that the group living in an Oxford House had higher and more positive rates of selfefficacy and self-mastery.

• In a comparison study between Oxford House residents and a group that was assigned usual aftercare 

services, the Oxford House group had significantly lower substance use (31.3 percent vs. 64.8 percent), 

higher monthly income ($989 vs. $440), and lower incarceration rates (3 percent vs. 9 percent).

“Living in an Oxford House reinforced and 

reestablished a lot of things that I was not able 

to do or unwilling to do when I was using. 

Things like paying rent and working. Things 

like learning how to live without using drugs. 

Things like becoming a responsible person. 

Things like developing healthy relationships. 

While I resided at an Oxford House, I started 

working for Oxford House, Inc. As a result, I 

was willing to help open more Oxford Houses, 

especially for women.”

– Debbie D., former Oxford House resident

Recovery Management

Recovery-oriented care often use long-term recovery management protocols, such as recovery 

management check-ups (RMCs),106 and telephone case monitoring.107,108 These models have only been 

studied with professionals, but similar protocols are also being used in peer-directed RSS, where they 

have yet to be formally evaluated. 

Recovery Management Check-ups

The RMC model for substance use disorders draws heavily from monitoring and early re-intervention 

protocols used for other chronic diseases, such as diabetes and hypertension. With the core components 

of tracking, assessment, linkage, engagement, and retention, patients are monitored quarterly for several 

years following an initial treatment. If a relapse occurs, the patient is connected with the necessary 

services and encouraged to remain in treatment. The main assumption is that early detection and 

treatment of relapse will improve long-term outcomes.109 
PAGE | 5-14

A clinical trial showed that, compared with patients assigned to usual care, individuals receiving RMCs 

returned to treatment sooner after relapses, had fewer misuse problems, had more days of abstinence, 

and were less likely to need treatment at follow-up 2 and 4 years later.106,110 Recovery management 

check-ups have also been shown to be effective for people who have co-occurring substance use 

disorders and mental illnesses111 and for women with substance use disorders who have been released 

from jail.112 RMCs are also cost-effective.113 Although the check-ups add somewhat to annual care costs, 

a randomized study showed that they produce greater reductions in costs associated with health care and 

criminal justice.113

Telephone Case Monitoring

Telephone case monitoring is another long-term recovery management and monitoring method for 

maintaining contact with patients without requiring an in-person appointment. It can be provided by 

professionals or by peers, although only the former approach has been rigorously studied. One example 

is an extended case monitoring intervention, which consisted of phone calls on a tapering schedule over 

the course of several years, with contact becoming more frequent when needed, such as when risk of 

relapse was high. This intervention was designed to optimize the cost-effectiveness of alcohol treatment 

through long-term engagement with clients beyond the relatively short treatment episodes.108

In a randomized clinical trial, patients receiving telephone case monitoring were half as likely as 

those not receiving it to drink heavily at 3-year follow-up. Case monitoring also reduced the costs of 

subsequent outpatient treatment by $240 per person at 1-year follow-up, relative to patients who did 

not receive the telephone monitoring.114 Another clinical trial compared weekly telephone monitoring 

plus brief counseling with two other treatments: standard continuing care and individualized relapse 

prevention. Telephone monitoring produced the highest rates of abstinence from alcohol at followup 12 months later.115 Furthermore, at 24 months, participants who received telephone monitoring 

continued to have significantly higher rates of total abstinence than those in standard care.116 Adding 

telephone monitoring and counseling to intensive outpatient treatment also has been shown to improve 

alcohol use outcomes in a randomized clinical trial.117 

Recovery Community Centers 

To further distinguish the peer-led services of these centers from professional treatment services, 

individuals using the center are referred to as “peers” or “members” and center staff hold positions such 

as “peer leaders” or “recovery mentors.”92,94

These centers may host mutual aid group meetings and offer recovery coaching, recovery-focused 

educational and social events; access to resources, including housing, education, and employment; 

telephone-based recovery services; and additional recovery community education, advocacy, and service 

events.33,118 Some recovery community centers are sites in which community members can engage in 

advocacy to combat negative public attitudes, educate the community, and improve supports for recovery 

in the community. Many recovery community centers are typically operated by recovery community 

organizations.119

Recovery community centers have yet to be studied in a rigorous fashion; therefore it is not possible 

to estimate their effectiveness. Evaluation studies currently underway may provide a more conclusive 
PAGE | 5-15

judgment of whether and how recovery community centers benefit their members. Recovery 

community centers are different from professionally-operated substance use disorder treatment 

programs because they offer support beyond the clinical setting.

Recovery-based Education 

High school and college environments can be difficult for students in recovery because of perceived and 

actual high levels of substance use among other students, peer pressure to engage in substance use, and 

widespread availability of alcohol and drugs.120,121 The emergence of high school and collegiate recovery 

support programs is an important response to this challenge in that they provide recovery-supportive 

environments, recovery norms, and peer engagement with other students in recovery. 

Recovery High Schools 

Recovery high schools help students in recovery focus on academic learning while simultaneously 

receiving RSS. Such schools support abstinence and student efforts to overcome personal issues that 

may compromise academic performance or threaten continued recovery.122 The earliest known program 

opened in 1979, and the number slowly increased to approximately 35 schools in 15 states by 2015.123

A study of 17 recovery high schools found that most had small and rapidly changing enrollments, ranging 

from 12 to 25 students. Rates of abstinence from “all alcohol and other drugs” increased from 20 percent 

during the 90 days before enrolling to 56 percent since enrolling. Students’ opinions of the schools were 

positive, with 87 percent reporting overall satisfaction.124 A study of graduates from one recovery high 

school found that 39 percent reported no drug or alcohol use in the past 30 days and more than 90 percent 

had enrolled in college.125 These results are promising, pointing to the need for more research. A rigorous 

outcomes study is nearing completion that will give a better idea of the impact of recovery high schools. 

Recovery in Colleges 

Collegiate recovery support programs vary in number and type of RSS. Most provide some combination 

of recovery residence halls or recovery-specific wings, counseling services, on-site mutual aid group 

meetings, and other educational and social supports. These services are provided within an environment 

that facilitates social role modeling of sobriety and connection among recovering peers. The programs 

often require participants to demonstrate 3 to 6 months with no use of alcohol and drugs as a 

requirement for admission. Recovering college peers may help these new students effectively manage the 

environmental risks present on many college campuses.126

Participants in collegiate recovery programs often have significant accompanying mental health 

problems, such as depression or an eating disorder, in addition to their substance use disorder, which 

can complicate recovery.127 Nevertheless, observational data from two model programs suggest that rates 

of return to use (defined as any use of alcohol or other substance) are only 4 to 13 percent in any given 

semester.126,128,129 Further, the academic achievement (grade point average and graduation rates) of students 

in collegiate recovery support programs is better than that of the rest of the undergraduates at the same 

institution.127,128,130 Although these results are promising, more research is needed on these programs131 to 

fully evaluate their effectiveness.126
PAGE | 5-16

Social and Recreational Recovery Infrastructures 

and Social Media

In keeping with the need to support long-term remission and recovery from substance use disorders, 

social and recreational entities are emerging that make it easier for people in recovery to enjoy activities 

and social interaction that do not involve alcohol or drugs. Examples include recovery cafes and 

clubhouses, recovery sports leagues and other sporting activities, and a variety of recovery-focused 

creative arts, including music and musicians’ organizations, visual arts, and theatre and poetry events.33

Providing these positive alternatives is intended to support recovery as well as provide access to healthy, 

enjoyable activities. However, no research has yet examined whether participation in these activities 

produces a significant benefit beyond what might be obtained from other RSS. 

Social media, mobile health applications, and recovery-specific online social networking and support 

sites are growing platforms for providing both intervention and long-term RSS for individuals with 

substance use disorders, as well as social interaction, friendship, and humor. These are easily accessible 

and have wide reach. Although research on the impact of these new tools is limited, studies are 

beginning to show positive benefits, particularly in preventing relapse and supporting recovery.132,133

Social media supports appear to be especially helpful for young people in particular.132

Specific Populations and Recovery

As mentioned earlier, practice and research in the recovery field are relatively new. This has 

disadvantages in terms of how much is known from scientific research, but it has a compensating 

advantage: Most studies have been conducted recently and usually with diverse populations. Indeed, 

the majority of participants in many of the studies cited in this chapter have included Blacks or African 

Americans, Hispanics or Latinos, and American Indians or Alaska Natives.

Recovery-oriented policies have also supported diverse populations. For example, SAMHSA’s Recovery 

Community Services Program made advancing recovery in diverse communities a central goal and 

helped support organizations serving a broad range of ethnic, racial, and sexual minority communities. 

Further, 12-step fellowships such as AA and NA have a long history of supporting meeting spaces that 

are specific to women; Lesbian, Gay, Bisexual, and Transgender (LGBT) populations; young people; and 

other groups, including meetings that are conducted in other languages.

For all these reasons, the research and practice conclusions of this chapter can be assumed to be broadly 

applicable to a range of populations. However, not every single population has received comparable 

attention:

$ Blacks or African Americans have been well represented in recovery research, including in the 

studies of ROSC, mutual aid groups, and recovery housing discussed in this chapter.

$ American Indians or Alaska Natives have maintained recovery movements for centuries. More 

recently culturally-specific adaptations of recovery approaches (e.g., The Red Road to Wellbriety) 

have been developed. Hispanic or Latino adaptations of AA have been studied, and ROSC have 

been studied in areas with significant Hispanic or Latino populations (e.g., Philadelphia).
PAGE | 5-17

$ Native Hawaiians or Other Pacific Islanders have not been studied by recovery researchers, 

probably because of their small number (one tenth of one percent of the population). They are a 

population that should be studied in the future. 

$ Asian-tailored recovery interventions have not been extensively studied and remain an 

important focus for future research.

$ Research on the effectiveness of various recovery pathways within LGBT communities has been 

limited in quantity and comparability across studies.

Recommendations for Research

Health and social service providers, funders, policymakers, and most of all people with substance use 

disorders and their families need better information about the effectiveness of the recovery options 

reviewed in this chapter. Thus, a key research goal for the future is to understand and evaluate the 

effectiveness, and cost effectiveness, of the emerging range of mutual aid groups and RSS, particularly 

peer recovery support services and practices and recovery coaches. Another focus of research is new, 

culturally specific adaptations of long-existent recovery supports, such as AA and NA, as they evolve 

to meet the needs of an increasingly diverse membership. Such research could increase public and 

professional awareness of these potentially cost-effective recovery strategies and resources. 

Research is also needed on how health care systems themselves can work best with RSS and the 

workforce that provides RSS. Professional and formal treatment services and RSS have different roots 

and represent different cultures historically. Creating a fluid, responsive, and more effective recoveryoriented “system” will require greater sensitivity and understanding of the strengths and benefits 

of each, including rigorous cross-site evaluations for professional RSS strategies. Research should 

determine the efficacy of peer supports including peer recovery support services, recovery housing, 

recovery chronic disease management, high school and collegiate recovery programs, and recovery 

community centers through rigorous, cross-site evaluations.

Although the professionally-led health and social service system should engage with peer-led service 

organizations, maintaining the informal, grassroots nature of many RSS may be central to their appeal 

and quite possibly their effectiveness. Thus, a diverse group of stakeholders in the recovery field should 

come together to create a strategic research agenda that includes:

$ The establishment of recovery outcomes and measures;

$ The development of a credible methodology for estimating the prevalence of those in recovery;

$ Protocols on initiating, stabilizing, and sustaining long-term recovery; and

$ Measuring the value of ROSC.
PAGE | 5-18

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125. Lanham, C. C., & Tirado, J. A. (2011). Lessons in sobriety: An exploratory study of graduate 

outcomes at a recovery high school. Journal of Groups in Addiction & Recovery, 6(3), 245-263.

126. Laudet, A., Harris, K., Kimball, T., Winters, K. C., & Moberg, D. P. (2014). Collegiate recovery 

communities programs: What do we know and what do we need to know? Journal of Social Work 

Practice in the Addictions, 14(1), 84-100.

127. Laudet, A. B., Harris, K., Kimball, T., Winters, K. C., & Moberg, D. P. (2015). Characteristics of 

students participating in collegiate recovery programs: A national survey. Journal of Substance 

Abuse Treatment, 51, 38-46.

128. Cleveland, H. H., Harris, K. S., Baker, A. K., Herbert, R., & Dean, L. R. (2007). Characteristics of 

a collegiate recovery community: Maintaining recovery in an abstinence-hostile environment. 

Journal of Substance Abuse Treatment, 33(1), 13-23.

129. Harris, K. S., Baker, A. K., Kimball, T. G., & Shumway, S. T. (2008). Achieving systems-based 

sustained recovery: A comprehensive model for collegiate recovery communities. Journal of 

Groups in Addiction & Recovery, 2(2-4), 220-237.

130. Laudet, A. B., & White, W. L. (2008). Recovery capital as prospective predictor of sustained 

recovery, life satisfaction, and stress among former poly-substance users. Substance Use and 

Misuse, 43(1), 27-54.

131. Dickard, N., Downs, T., & Cavanaugh, D. (2011). Recovery/relapse prevention in educational settings 

for youth with substance use & co-occurring mental health disorders: 2010 consultative sessions report. 

Washington, DC: U.S. Department of Education, Office of Safe and Drug-Free Schools.

132. Dennis, M. L., Scott, C. K., Funk, R. R., & Nicholson, L. (2015). A pilot study to examine the 

feasibility and potential effectiveness of using smartphones to provide recovery support for 

adolescents. Substance Abuse, 36(4), 486-492.

133. Elison, S., Humphreys, L., Ward, J., & Davies, G. (2014). A pilot outcomes evaluation for 

computer assisted therapy for substance misuse—An evaluation of Breaking Free Online. Journal 

of Substance Use, 19(4), 313-318.
HEALTH CARE SYSTEMS

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CHAPTER 6.

HEALTH CARE SYSTEMS AND 

SUBSTANCE USE DISORDERS

Chapter 6 Preview

Services for the prevention and treatment of substance misuse and substance use disorders have traditionally 

been delivered separately from other mental health and general health care services. Because substance misuse 

has traditionally been seen as a social or criminal problem, prevention services were not typically considered 

a responsibility of health care systemsi; and people needing care for substance use disorders have had access 

to only a limited range of treatment options that were generally 

not covered by insurance. Effective integration of prevention, 

treatment, and recovery services across health care systems is 

key to addressing substance misuse and its consequences and 

it represents the most promising way to improve access to and 

quality of treatment. Recent health care reform laws, as well as 

a wide range of other trends in the health care landscape, are 

facilitating greater integration to better serve individual and 

public health, reduce health disparities, and reduce costs to society. 

This chapter describes the key components of health care 

systems; historical reasons substance use and its consequences have been addressed separately from 

other health problems; the key role that health care systems can play in providing prevention, treatment, 

and recovery support services (RSS) for substance use disorders; and the recent developments that are 

leading to improved integration of substance use-related care with the rest of medicine. This chapter 

also describes the challenges to effective integration, as well as promising trends, such as in health 

information technology (health IT) that will facilitate it. Because these changes are still underway, much 

Integration. The systematic coordination 

of general and behavioral health care. 

Integrating services for primary care, 

mental health, and substance userelated problems together produces the 

best outcomes and provides the most 

effective approach for supporting wholeperson health and wellness.3

i The World Health Organization defines a health care system as (1) all the activities whose primary purpose is to 

promote, restore, and/or maintain health, and (2) the people, institutions, and resources, arranged together in 

accordance with established policies, to improve the health of the population they serve.1

 Health care systems 

may provide a wide range of clinical services, from primary through subspecialty care and be delivered in offices, 

clinics, and hospitals. They can be run by private, government, non-profit, or for-profit agencies and organizations.
HEALTH CARE SYSTEMS

PAGE | 6-2

of the relevant research is still formative and descriptive; information presented in this chapter often 

derives from reports and descriptive papers. 

KEY FINDINGS*

• Well-supported scientific evidence shows that the traditional separation of substance use disorder 

treatment and mental health services from mainstream health care has created obstacles to successful 

care coordination. Efforts are needed to support integrating screening, assessments, interventions, use 

of medications, and care coordination between general health systems and specialty substance use 

disorder treatment programs or services. 

• Supported scientific evidence indicates that closer integration of substance use-related services in 

mainstream health care systems will have value to both systems. Substance use disorders are medical 

conditions and their treatment has impacts on and is impacted by other mental and physical health 

conditions. Integration can help address health disparities, reduce health care costs for both patients 

and family members, and improve general health outcomes. 

• Supported scientific evidence indicates that individuals with substance use disorders often access the 

health care system for reasons other than their substance use disorder. Many do not seek specialty 

treatment but they are over-represented in many general health care settings. 

• Promising scientific evidence suggests that integrating care for substance use disorders into mainstream 

health care can increase the quality, effectiveness, and efficiency of health care. Many of the health home 

and chronic care model practices now used by mainstream health care to manage other diseases could 

be extended to include the management of substance use disorders. 

• Insurance coverage for substance use disorder services is becoming more robust as a result of the 

Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) and the 

Affordable Care Act. The Affordable Care Act also requires non-grandfathered individual and small 

group market plans to cover services to prevent and treat substance use disorders. 

• Health care delivery organizations, such as health homes and accountable care organizations (ACOs), 

are being developed to better integrate care. The roles of existing care delivery organizations, such 

as community health centers, are also being expanded to meet the demands of integrated care for 

substance use disorder prevention, treatment, and recovery.

• Use of Health IT is expanding to support greater communication and collaboration among providers, 

fostering better integrated and collaborative care, while at the same time protecting patient privacy. 

It also has the potential for expanding access to care, extending the workforce, improving care 

coordination, reaching individuals who are resistant to engaging in traditional treatment settings, and 

providing outcomes and recovery monitoring. 

• Supported evidence indicates that one fundamental way to address racial and ethnic disparities in 

health care is to increase the number of people who have health insurance coverage.

• Well-supported evidence shows that the current substance use disorder workforce does not have the 

capacity to meet the existing need for integrated health care, and the current general health care 

workforce is undertrained to deal with substance use-related problems. Health care now requires a new, 

larger, more diverse workforce with the skills to prevent, identify, and treat substance use disorders, 

providing “personalized care” through integrated care delivery. 

*The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence as: “Well-supported”: 

when evidence is derived from multiple controlled trials or large-scale population studies; “Supported”: when 

evidence is derived from rigorous but fewer or smaller trials; and “Promising”: when evidence is derived from a 

practical or clinical sense and is widely practiced.5
HEALTH CARE SYSTEMS

PAGE | 6-3

Key Components of Health Care Systems

In 2015, 20.8 million Americans had a substance use disorder. As discussed in Chapter 1 - Introduction 

and Overview, these disorders vary in intensity and may respond to different intensities of intervention. 

Diverse health care systems have many roles to play in addressing our nation’s substance misuse and 

substance use disorder problems, including:

$ Screening for substance misuse and substance use disorders;

$ Delivering prevention interventions to prevent substance misuse and related health 

consequences; 

$ Early intervention to prevent escalation of misuse to a substance use disorder;

$ Engaging patients with substance use disorders into treatment;

$ Treating substance use disorders of all levels of severity;

$ Coordinating care across both health care systems and social services systems including 

criminal justice, housing and employment support, and child welfare; 

$ Linking patients to RSS; and

$ Long-term monitoring and follow-up.

There is a great diversity of health care systems across the United States, with varying levels of 

integration across health care settings and wide-ranging workforces that incorporate diverse structural 

and financing models and leverage different levels of technology. 

Health Care Settings

Health care systems are made up of diverse health care organizations ranging from primary care, 

specialty substance use disorder treatment (including residential and outpatient settings), mental 

health care, infectious disease clinics, school clinics, community health centers, hospitals, emergency 

departments, and others. 

It is known that most people with substance use disorders do not seek treatment on their own, many 

because they do not believe they need it or they are not ready for it, and others because they are not 

aware that treatment exists or how to access it. But individuals with substance use disorders often do 

access the health care system for other reasons, including acute health problems like illness, injury, or 

overdose, as well as chronic health conditions such as HIV/AIDS, heart disease, or depression. Thus, 

screening for substance misuse and substance use disorders in diverse health care settings is the first 

step to identifying substance use problems and engaging patients in the appropriate level of care. 

Mild substance use disorders may respond to brief counseling sessions in primary care, while severe 

substance use disorders are often chronic conditions requiring substance use disorder treatment like 

specialty residential or intensive outpatient treatment as well as long-term management through 

primary care. A wide range of health care settings is needed to effectively meet the diverse needs of 

patients. 
HEALTH CARE SYSTEMS

PAGE | 6-4

Workforce

Just as a diversity of health care settings is needed to meet the needs of patients, a diversity of health 

care professionals is also critical. Health care services can be delivered by a wide-range of providers 

including doctors, nurses, nurse practitioners, psychologists, licensed counselors, care managers, 

social workers, health educators, peer workers, and others. With limited resources for prevention and 

treatment, matching patients to the appropriate level of care, delivered by the appropriate level of 

provider, is crucial for extending those resources to reach the most patients possible. 

Structural and Financing Models

A range of promising health care structures and financing 

models are currently being explored for integrating general 

health care and substance use disorder treatment within 

health care systems, as well as integrating the substance 

use disorder treatment system with the overall health care 

system. As part of ongoing health reform efforts, both federal 

and state governments are investing in models and innovations ranging from health homes and ACOs, 

to managed care and Coordinated Care Organizations (CCOs), to pay-for-performance and sharedsavings models. These new models are developing and testing strategies for effectively and sustainably 

financing high-quality care that integrates behavioral health and general health care.

See the sections on “Health Homes” 

and “Accountable Care Organizations”

later in this chapter. 

Technology Integration

Technology can play a key role in supporting these 

integrated care models. Electronic health records (EHRs), 

telehealth, health information exchanges (HIE), patient 

registries, mobile applications, Web-based tools, and other 

innovative technologies have the potential to extend the 

reach of the workforce; support quality measurement and 

improvement initiatives to drive a learning health care 

system; electronically deliver prevention, treatment, and 

recovery interventions; efficiently monitor patients; identify 

population health trends and threats; and engage patients 

who are hesitant to participate in formal care.

Learning Health Care System. As 

described by the Institute of Medicine 

(IOM), a learning health care system 

is “designed to generate and apply 

the best evidence for the collaborative 

healthcare choices of each patient 

and provider; to drive the process of 

discovery as a natural outgrowth of 

patient care; and to ensure innovation, 

quality, safety, and value in health care.”4

The Promise of Integration

When health care is not well integrated and coordinated across systems, too many patients fall through the 

cracks, leading to missed opportunities for prevention or early intervention, ineffective referrals, incomplete 

treatment, high rates of hospital and emergency department readmissions, and individual tragedies that 

could have been prevented. For example, a recent study found that doctors continue to prescribe opioids 

for 91 percent of patients who suffered a non-fatal overdose, with 63 percent of those patients continuing 

to receive high doses; 17 percent of these patients overdosed again within 2 years.6 Effective coordination 

between emergency departments and primary care providers can help to prevent these tragedies. 
HEALTH CARE SYSTEMS

PAGE | 6-5

Other tragedies occur when patients complete treatment and 

the health care system fails to provide adequate follow-up 

and coordination of the wrap-around services or recovery 

supports necessary to help them maintain their recovery, 

leading to relapse. The risk for overdose is particularly high 

after a period of abstinence, due to reduced tolerance—

patients no longer know what a safe dose is for them—and 

this all too often results in overdose deaths. This is a common 

story when patients are released from prison without a 

coordinated plan for continuing treatment in the community. 

One study from the Washington State Department of 

Corrections found that during the first 2 weeks after release, the risk of death among former inmates 

was 12.7 times higher than among state residents of the same age, sex, and race. Health care systems 

play a key role in providing the coordination necessary to avert these tragic outcomes.7

Wrap-Around Services. Wrap-around 

services are non-clinical services that 

facilitate patient engagement and 

retention in treatment as well as their 

ongoing recovery. This can include 

services to address patient needs related 

to transportation, employment, childcare, 

housing, and legal and financial 

problems, among others.

Substance Use Disorder Services Have Traditionally 

Been Separate From Mental Health and General 

Health Care 

The separation of the treatment systems for substance use disorders, mental illness, and general 

health care has historical roots.8-10 For example, Alcoholics Anonymous (AA) was founded in 1935 in 

part because mainstream psychiatric and general medical providers did not attend to substance use 

disorders. If treated at all, alcoholism was most often treated in asylums, separate from the rest of 

health care. The separation of substance use disorder treatment and general health care was further 

influenced by social and political trends of the 1970s. At that time, substance misuse and addiction were 

generally viewed as social problems best dealt with through civil and criminal justice interventions 

such as involuntary commitment to psychiatric hospitals, prison-run “narcotic farms,” or other forms of 

confinement.11 However, when many college students and returning Vietnam veterans were misusing 

alcohol, using drugs, and/or becoming addicted to illicit substances, high numbers of arrests and other 

forms of punishment became politically and economically infeasible. At this time, there was a major 

push to significantly expand substance misuse prevention and treatment services.

Despite the compelling national need for treatment, the 

existing health care system was neither trained to care for, 

nor especially eager to accept, patients with substance use 

disorders. For these reasons, new substance use disorder 

treatment programs were created, ultimately expanding to 

programs in more than 14,000 locations across the United 

States. This meant that with the exception of withdrawal management in hospitals (detoxification), 

virtually all substance use disorder treatment was delivered by programs that were geographically, 

financially, culturally, and organizationally separate from mainstream health care. 

See Chapter 4 - Early Intervention, 

Treatment, and Management of 

Substance Use Disorders.
HEALTH CARE SYSTEMS

PAGE | 6-6

Even though these programs were separate from the rest of health care, these new delivery sites were a 

critical step toward better addressing the growing problems related to substance misuse and substance use 

disorders. One positive consequence was the initial development of effective and inexpensive behavioral 

change strategies rarely used in the treatment of other chronic illnesses. However, the separation of 

substance use disorder treatment from general health care also created unintended and enduring 

impediments to the quality and range of care options available to patients in both systems. For example, it 

tended to reinforce the notion that substance use disorders were different from other medical conditions. 

Despite numerous research studies documenting high prevalence rates of substance use disorders among 

patients in emergency departments, hospitals, and general medical care settings, mainstream health care 

generally failed to recognize or address substance use-related health problems.8,12-15

The continued separation of substance use and general health 

care services has been costly, often harmful, and for some 

individuals even fatal. A recent study of world health settings 

showed that the presence of a substance use disorder often 

doubles the odds that a person will develop another chronic 

and costly medical illness, such as arthritis, chronic pain, 

heart disease, stroke, hypertension, diabetes, or asthma.16 Yet 

despite the impact of substance use on physical health, few 

medical, nursing, dental, or pharmacy schools teach their 

students how to identify, prevent, and treat substance use disorders;17-19 and, until recently, few insurers 

offered comparable reimbursement for substance use disorder treatment services.20-23

Even now, there are health care professionals who continue to be hesitant to provide patients with 

medication-assisted treatment (MAT), especially maintenance medications (methadone and buprenorphine) 

for opioid use disorders, because of deeply ingrained but erroneous misconceptions about these treatments, 

such as the idea that they “substitute one addiction for another.”24 This has hindered the adoption of these 

effective medications even by substance use disorder treatment facilities; and when they are used by 

substance use disorder treatment providers, they are often prescribed at insufficient doses, for insufficient 

durations, contributing to treatment failure and reinforcing a belief that they are not effective.25,26 In fact, 

ample research shows that, when used correctly, MAT can reduce or eliminate illicit drug use and associated 

criminality and infectious disease transmission and restore patients to healthy functioning.25,27,28

Inpatient treatment. Intensive, 

24-hour-a-day services delivered in a 

hospital setting. 

Residential treatment. Intensive, 

24-hour-a-day services delivered in 

settings other than a hospital.

A Growing Impetus for Integration

An integrated system of prevention, early intervention, 

treatment, and recovery that can address the full spectrum 

of substance use-related health problems is a logical and 

necessary shift that our society must make to prevent 

substance misuse and its consequences and meet the needs of 

individuals with substance use disorders. Providing services 

to people with mild and moderate substance use disorders—by far the largest proportion of all those 

diagnosed—in general health care settings will likely lessen the need for intensive and costly substance 

See Chapter 4 - Early Intervention, 

Treatment, and Management of 

Substance Use Disorders.
HEALTH CARE SYSTEMS

PAGE | 6-7

use disorder treatment services later, even though specialty care is still essential for people with serious 

substance use disorders, just as it is for patients with other severe diseases and conditions. 

Beginning in the 1990s, a number of events converged to lay the foundation for integrated care. 

First, a number of IOM reports and other major articles established that substance use disorders are 

inherently health conditions that require a collaboration between general health care settings and 

specialty care29 to improve treatment30 and reduce gaps in quality for health care broadly31 and for 

mental disorders and substance use disorders in particular.29,32 This was followed, in more recent years, 

by legislation that aims to transform the way services are provided and to facilitate access to prevention 

and treatment services through expanded insurance coverage. The Paul Wellstone and Pete Domenici 

Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires the financial requirements 

and treatment limitations imposed by most health plans and insurers for substance use disorders be no 

more restrictive than the financial requirements and treatment limitations they impose for medical and 

surgical conditions. 

Further, the Affordable Care Act, passed in 2010, requires that non-grandfathered health care plans 

offered in the individual and small group markets both inside and outside insurance exchanges provide 

coverage for a comprehensive list of 10 categories of items and services, known as “essential health 

benefits.” One of these essential health benefit categories is mental health and substance use disorder 

services, including behavioral health treatment. This requirement represents a significant change in 

the way many health insurers respond to these disorders. The Affordable Care Act also reaffirmed 

MHPAEA by requiring that mental health and substance use disorder benefits covered by plans offered 

through the exchanges be offered consistent with the parity requirements under MHPAEA. 

A major goal of the Affordable Care Act is to expand insurance coverage and reduce the number of 

uninsured individuals.33 As of March 2016, more than 20 million previously uninsured individuals 

(including children on parents’ plans) had new benefits under the Affordable Care Act.34 These 

enrollment figures include those who were previously uninsured, as well as 1 million who previously had 

employer-based coverage and 3 million who previously had non-group and other insurance coverage.33

Individuals with substance use disorders are overrepresented in the newly insured population (including 

children now on parents’ plans), because they were previously disproportionately uninsured, young 

adults without dependent children. They now are eligible for coverage under the Affordable Care Act, 

which will enable them to receive substance use disorder prevention, treatment, and RSS.35

Medicaid Expansion under the Affordable Care Act

To more broadly cover uninsured individuals, the Affordable Care Act includes a provision that allows states to 

expand Medicaid coverage. In those states (“Medicaid expansion states”), individuals in households with incomes 

below 138 percent of the federal poverty level are eligible for Medicaid. Benefits include mental health and 

substance use disorder treatment services with coverage equivalent to that of general health care services.

Medicaid expansion is a key lever for expanding access to substance use treatment because many of the most 

vulnerable individuals with substance use disorders have incomes below 138 percent of the federal poverty 

level. As of fall 2015, an estimated 3 million adults have incomes that make them eligible for Medicaid under the 

Affordable Care Act but live in a state that has declined to expand Medicaid eligibility as permitted under the new 

law.36,37
HEALTH CARE SYSTEMS

PAGE | 6-8

Most recently, Congress passed the Protecting Access to Medicare Act, which, in addition to its 

Medicare provisions, funds pilot programs to increase access to, and Medicaid payment for, community 

mental health and substance use disorder treatment services. This is an important opportunity for 

integration.

Other changes, described later in this chapter, are also helping to create momentum for integration. 

These include new or improved organizational structures, such as medical homes, health homes, and 

ACOs; improved health IT, such as EHRs; clinical approaches, such as new substance use disorder 

treatment medications that can be prescribed in primary care settings; and effective approaches to 

identifying and preventing substance misuse problems. In addition, organizations including the 

American College of Physicians and the American Society of Addiction Medicine (ASAM) now 

recommend integration of substance use-related and mental health services with primary care.38 Of 

historical note, although the World Health Organization and the American Medical Association have 

long identified alcohol and drug use disorders as medical conditions, it was only in 2016 that addiction 

medicine was formally recognized as a new subspecialty by the American Board of Medical Specialties 

under the American Board of Preventive Medicine. 

Figure 6.1 summarizes a few of the key changes that are occurring as substance use disorder treatment 

services are integrated into mainstream health care. 

Figure 6.1: Substance Use Disorders Services: Past and Future

Past Future

Substance use mainly ignored in primary care Substance use screened and monitored in primary care 

Focus on the most severe problems Addresses full spectrum of problems 

Paper charts: little contact between specialty 

substance use disorders and health care 

EHR, clinical coordination, patient portals, health IT 

treatment options that focus on coordination of care 

Limited use of health IT Leveraging technologies including patient portals, 

HIEs, technology delivered treatments 

Little focus on physical health issues Addresses medical problems with focus on whole 

person wellness 

Medications seldom available Medications readily available 

Separate oversight structures and reporting Performance and outcomes measurement, ongoing 

quality improvement 

12-step programs 12-step and other RSS, social network innovations

Health care professionals are being encouraged to offer prevention advice, screen patients for substance 

misuse and substance use disorders, and provide early interventions in the form of motivational approaches, when appropriate.39,40

Primary care has a central role in this process, because it is the site for most preventive and ongoing 

clinical care for patients—the patient’s anchor in the health care system. For example, primary care 

settings can serve as a conduit to help patients engage in and maintain recovery. Also, approaches such 

as screening, brief intervention, and referral to treatment (SBIRT) provide primary care providers 

with tools for addressing patients’ substance misuse. Based upon the strength of the evidence for their 

effectiveness, the U.S. Preventive Services Task Force (USPSTF) has recommended alcohol screening 
HEALTH CARE SYSTEMS

PAGE | 6-9

and brief behavioral counseling interventions for adults in 

primary care and given the supporting evidence for these 

services a “B” grade. This is significant because under the 

Affordable Care Act, preventive services given a grade of A 

or B by the USPSTF must be covered by most health plans 

without cost-sharing.41-43 The USPSTF recommendation 

supports the expectation that primary care providers will soon routinely screen adults of all ages 

for unhealthy alcohol use as they now do for blood pressure and weight. Relatedly, the National 

Commission on Prevention Priorities of the Partnership for Prevention ranks primary care-based 

interventions to reduce alcohol misuse among the most valuable clinical preventive services.44,45

The literature on the effectiveness of drug-focused brief intervention in primary care and emergency 

departments is less clear, with some studies finding no improvements among those receiving brief 

interventions.46,47 However, at least one study found significant reductions in subsequent drug use.48

Trials evaluating different types of screening and brief interventions for drug use in diverse settings 

with a range of patient groups are lacking. The USPSTF’s current rating for illicit drug screening 

and brief intervention remains “I” for insufficient evidence to support its use as a preventive service. 

However, assessment for drug use is recommended under numerous circumstances, including treating 

any condition for which drug use might interfere with the treatment; considering potential interactions 

with prescribed medications; supporting integration of behavioral health care; and monitoring patient 

risk when prescribing opioid pain medications or sedatives/tranquilizers. 

It is also important to emphasize that brief primary care-based interventions by themselves are likely 

not sufficient to address severe substance use disorders. However, primary care providers can use 

other interventions with this population, including providing MAT, providing more robust monitoring 

and patient education,49,50 and importantly, referring individuals to specialty substance use disorder 

treatment. Effective referral arrangements that include motivating patients to accept the referral are 

critical elements to encourage individuals to engage in treatment for their substance use disorder. 

See Chapter 4 - Early Intervention, 

Treatment, and Management of 

Substance Use Disorders.

Reasons Why Integrating Substance Use Disorder Services and 

Mainstream Health Care Is Necessary

A number of strong arguments underpin the growing momentum to integrate substance use disorder 

services and mainstream health care. The main argument is that substance use disorders are medical 

conditions like any other—the overarching theme of much of this Report. Recognition of that fact means 

it no longer makes sense to keep substance use disorders segregated from other health issues. A number 

of other realities support the need for integration:63

$ Substance use, mental disorders, and other general medical conditions are often interconnected;

$ Integration has the potential to reduce health disparities;

$ Delivering substance use disorder services in mainstream health care can be cost-effective and 

may reduce intake/treatment wait times at substance use disorder treatment facilities; and

$ Integration can lead to improved health outcomes through better care coordination.
HEALTH CARE SYSTEMS

PAGE | 6-10

Health Systems and Opioids

Physician prescribing patterns, patient drug diversion (selling, sharing, or using medications prescribed 

for another person), and doctor shopping behaviors have all contributed to the ongoing opioid overdose 

epidemic.51 For example, evidence indicates that chronic pain patients with substance use disorders are 

prescribed opioids more often than other individuals with chronic pain, with the trend increasing over time.52

Also, a study in two health systems found opioid prescription rates for older persons, particularly older women,53

to be higher over time than for other individuals with long-term chronic pain. 

In March 2015, the U.S. Department of Health and Human Services (HHS) made addressing the opioid misuse 

crisis a high priority, announcing a national opioid initiative focused on three priority areas: (1) providing training 

and educational resources, including updated prescriber guidelines, to assist health professionals in making 

informed prescribing decisions; (2) increasing use of the opioid overdose reversal drug naloxone; and (3) 

expanding the use of MAT. Since then, HHS has initiated many efforts to help reduce prescription opioid misuse 

and use disorders. Improving prescribing practices is one of these important efforts.54 In March 2016, the CDC 

released the Guideline for Prescribing Opioids for Chronic Pain, which provides recommendations about the 

appropriate prescribing of opioid pain relievers and other treatment options to improve pain management and 

patient safety.55 The guideline is not intended to regulate necessary and appropriate opioid prescribing. Rather, 

the guideline is meant to inform health care professionals about some of the consequences of treatment with 

opioids for chronic pain and to consider, when appropriate, tapering and changing prescribing practices, as 

well as considering alternative pain therapies. The same month, HHS also released the National Pain Strategy, 

which outlines the federal government’s first coordinated plan for addressing chronic pain that affects so many 

Americans.56 The goals of the National Pain Strategy will be achieved through a broad effort that includes 

improved pain care and safer prescribing practices, such as those recommended by the CDC Guideline.

The National Heroin Task Force, which consisted of law enforcement, doctors, public health officials, and 

education experts, was convened to develop strategies to confront the heroin problem and decrease the 

escalating overdose epidemic and death rate.57 In 2015, the Task Force developed a report outlining the 

steps being taking to address the opioid problem. This included a multifaceted strategy of enforcement and 

prevention efforts, as well as increased access to substance use disorder treatment and recovery services. 

Although only about 4 percent of those who misuse prescription opioids transition to using heroin, concern 

is growing that tightening restrictions on opioid prescribing could potentially have unintended consequences 

resulting in new populations using heroin.58 The Task Force states that “evidence shows that some people who 

misuse opioid medications migrate to heroin because heroin is more accessible and less costly than prescription 

opioids.”59 In fact, nearly 80 percent of recent heroin initiates reported that they began their opioid use through 

the nonmedical use of prescription opioid medications.”58

The concern about opioid overdoses has also triggered efforts 

by health systems to increase access to naloxone, an opioid 

antagonist that prevents overdose fatalities by rapidly restoring 

normal respiration to a person whose breathing has slowed 

or stopped as a result of opioid use. Since 1996, communitybased organizations in many states have implemented overdose 

education and naloxone distribution programs for people who 

use heroin or misuse pharmaceutical opioids and efforts are 

underway to expand access to naloxone to patients who are prescribed opioids for pain. Expanded access 

to naloxone through large health systems could prevent overdose fatalities in broad populations of patients, 

including patients who may experience accidental overdose from misusing their medications. The Substance 

Abuse and Mental Health Services Administration (SAMHSA) has developed an easy-to-use toolkit to be 

distributed with naloxone.60 Prior research has suggested the potential to translate overdose education and 

naloxone distribution into routine primary care practice61 and examination of the perspectives of primary care 

providers on this practice revealed knowledge gaps about naloxone but also a willingness to follow standardized 

naloxone prescribing practices when they emerge.62

See Chapter 4 - Early Intervention, 

Treatment, and Management of 

Substance Use Disorders.
HEALTH CARE SYSTEMS

PAGE | 6-11

Substance Use Disorders, Mental Disorders, and Other Medical Conditions Are Interconnected

Many individuals who come to mainstream health care settings, such as primary care, obstetrics and 

gynecology, emergency departments, and hospitals, also have a substance use disorder. In a study 

within one health plan, one third of the most common and costly medical conditions were markedly 

more prevalent among patients with substance use disorders than they were among similar health 

system members who did not have a substance use disorder.64 Similarly, many individuals who present 

at specialty substance use disorder treatment programs have other medical conditions,65,66 including 

hypertension, HIV/AIDS, coronary artery disease, hepatitis, chronic liver disease, and psychiatric 

disorders.67

Because substance use complicates many other medical conditions, early identification and 

management of substance misuse or use disorders presents an important opportunity to improve 

health outcomes and reduce health care costs.68 Research shows that primary care patients with mild 

or moderate substance use have higher rates of other medical problems, including injury, hypertension, 

and psychiatric disorders, as well as higher costs.69 For example, cocaine use is associated with 

cardiovascular complications67,70,71 and neurological and psychiatric disorders,67,71 and long-term 

marijuana use has been associated with chronic bronchitis and cardiovascular problems.72-74 Alcohol 

misuse is associated with liver and pancreatic diseases; hypertension; reproductive system disorders; 

trauma; stroke;75 and cancers of the oral cavity, esophagus, larynx, pharynx, liver, colon, and rectum.76,77 

Even one drink per day may increase the risk of breast cancer. 67,76,78

In addition to the health problems faced by individuals engaged in substance use mentioned above, 

substance use can adversely affect a developing fetus. In the United States, fetal alcohol spectrum 

disorders (FASD) remain highly prevalent and problematic, even though they are preventable.79 A study 

of children in public and private schools in a Midwestern community calculated rates of FASD to be as 

high as 6 to 9 per 1,000.80 

Opioid pain reliever use among pregnant women has also become a major concern due to neonatal 

abstinence syndrome (NAS), a treatable condition that newborns experience after exposure to drugs 

while in the mother’s womb.81 NAS may cause neurological excitability, gastrointestinal dysfunction, 

and autonomic dysfunction. Newborns with NAS are more likely than other babies to also have low 

birthweight and respiratory complications. The incidence of NAS has increased dramatically in the last 

decade along with increased opioid misuse.82 In 2012, an estimated 21,732 infants were born with NAS, 

a five-fold increase since 2000. Moreover, in 2012, newborns with NAS stayed in the hospital an average 

of 16.9 days, more than eight times the number of days other newborns stay in the hospital (2.1 days).83

These newborns with NAS cost hospitals an estimated $1.5 billion, and 81 percent of these costs were 

paid by state Medicaid programs.83 These data suggest the need to develop and test measures to reduce 

newborn exposure to opioids. For women who are considering getting pregnant or are already pregnant, 

abstaining from all substances is recommended, since NAS is not exclusively caused by opioids.84

Adolescents with substance use disorders experience higher rates of other physical and mental illnesses, 

as well as diminished overall health and well-being.85-88 Sexually transmitted infections and HIV/AIDS,89

appetite changes and weight loss, dermatological problems, gastrointestinal problems, headaches,86

insomnia and chronic fatigue,90 and heart, lung, and abdominal abnormalities are only some of the 
HEALTH CARE SYSTEMS

PAGE | 6-12

problems that affect the health of young people who misuse alcohol and drugs.87 A study of adolescents 

entering specialty substance use disorder treatment—as compared with age-matched adolescent 

patients without a substance use disorder—found higher rates of clinically diagnosed sinusitis, asthma, 

abdominal pain, sleep disorders, injuries and overdoses.91

In addition to the physical health problems described above, 

mental health problems are also over-represented among 

adolescents with substance use disorders,92,93 particularly 

attention-deficit hyperactivity disorder,94-98 conduct 

disorders,99 anxiety disorders,100 and mood disorders.101-103 In 

addition, alcohol and drug use are associated with serious personal and social problems for users and 

for those around them including elevated rates of morbidity and mortality related to traffic crashes, 

intimate partner violence, risky sex, and unintentional injuries, including death from overdose.104-110

See Chapter 1 - Introduction and 

Overview.

Integration Can Lead to Improved Health Outcomes through Better Care Coordination 

Treatment of substance use disorders has historically been provided episodically, when a person experiences 

a crisis or a relapse occurs.32 This is neither good quality nor efficient care, because severe substance use 

disorders are chronic health problems, similar to other health conditions and with similar outcomes.12,111

Studies conducted over extended periods of time have found that annual primary care visits were associated 

with better outcomes and reduced health care costs following substance use disorder treatment,112-115 but 

research on models of chronic care management is only beginning and thus far no consensus has emerged 

on the best approach.116-119 These types of long-term studies will be more informative as the substance use 

disorder treatment, health care, and mental health systems become more integrated and as researchers build 

on disease management models that are effective for other medical conditions. 

In addition to chronic care management for severely affected individuals, coordinating services for 

those with mild or moderate problems is also important. Studies of various methods for integrating 

substance use services and general medical care have typically shown beneficial outcomes.66,120,121 The 

effectiveness of providing alcohol screening and brief counseling in primary care is supported by a 

robust evidence base,122 and a growing literature is showing its benefits as a first tool in managing chronic 

health conditions that may arise from, or be exacerbated by, alcohol use.123-125 Primary care-based alcohol 

use disorder case management involving pharmacotherapy and psychosocial support has been found to 

increase engagement in specialty substance use disorder treatment and to decrease heavy drinking.126

Care coordination is an essential part of quality in all health care. The Healthcare Effectiveness Data and 

Information Set (HEDIS), The Joint Commission, and organizations such as the National Committee 

for Quality Assurance emphasize coordination and accountability and the use of evidence-based care 

and performance indicators to establish and monitor quality and value. This approach to care delivery 

proceeds on the assumption that services for the range of substance use disorders should be fully 

integrated components of mainstream health care.
HEALTH CARE SYSTEMS

PAGE | 6-13

Quality and Performance Measurement and Accountability

Publicly available quality measurement information helps consumers, health care purchasers, and other groups 

make informed decisions when choosing services, providers, and care settings. Performance measurement has 

the dual purpose of accountability and quality improvement. 

A 2015 IOM study on Psychosocial Interventions for Mental and Substance Use Disorders recommended 

that the substance use disorder field develop approaches to measure quality, similar to approaches used for 

other diseases. This includes the development of performance measures, use of health IT for standardized 

measurement, and utilization of these measures to support quality improvement.127 

Measures have been proposed by a variety of organizations, including SAMHSA, as part of its 2013 National 

Behavioral Health Quality Framework; by the ASAM, as part of its development of standards of care for specialist 

addiction medicine physicians; by the Behavioral Health Steering Committee of the National Quality Forum; and 

by accrediting bodies such as The Joint Commission. Many measures are being tested by public and private 

health plans, though most have not been adopted widely for quality improvement and accountability. The single 

substance use measure included in HEDIS is “initiation and engagement of alcohol and other drug dependence 

treatment.” Although the HEDIS measure is limited, it does provide health systems a beginning benchmark for 

tracking substance use disorders. A measure of care continuity after emergency department use for substance 

use disorders is in process. 

Because substance use disorder treatment is currently not well integrated and services are often provided by 

multiple systems, it can be challenging to effectively measure treatment quality and related outcomes. The ability to 

track service delivery across these multiple environments will be critical for addressing this challenge. For example, 

community monitoring systems to assess risk and protection for adolescents are being developed.128-130

Pay-for-performance is an approach for improving quality and for incentivizing programs or health care 

professionals to produce particular outcomes (for example, treatment retention and treatment outcomes). 

It has been used more in general health care than in substance use disorder treatment. However, Delaware 

and Maine have experimented with it in their public substance use disorder treatment systems, and several 

studies have found improvement in retention and outcomes.131,132 Potential concerns with pay-for-performance 

are that treatment programs may not accept the most severe patients and that methods of risk adjustment to 

compensate programs that accept those patients are not well-established. Although pay-for-performance is a 

promising approach, more research is needed to address these concerns. 

A fundamental concept in care coordination between the health care, substance use disorder treatment, 

and mental health systems is that there should be “no wrong door.”133 This means that no matter where 

in the health care system the need for substance use disorder treatment is identified the patient will be 

effectively linked with appropriate services.

Several models of coordination have been described by researchers. In one such model, coordination 

ranges from referral agreements to co-located substance use disorder, mental health, and other health 

care services. Onsite programs had the highest rates of treatment engagement.134 A recent metaanalysis concluded that integrated treatment of adolescent substance use disorders, along with mental 

disorders and medical care, produced better outcomes than when treatment was provided separately.135

Other observational research has found that co-location of specialty substance use disorder treatment 

and mental health care is associated with better outcomes in adolescents.93 SAMHSA and the Health 

Resources and Services Administration (HRSA) have also developed a model with six levels of 

coordination (Figure 6.2). 
PAGE | 6-14

Figure 6.2: A Continuum of Collaboration between Health Care and Specialty Services

Coordinated

Key Element: Communication

Co-located

Key Element: Physical Proximity

Integrated

Key Element: Practice Change

LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5 LEVEL 6

Minimal 

Collaboration

Basic 

Collaboration at 

a Distance

Basic 

Collaboration 

Onsite

Close 

Collaboration 

Onsite with 

Some System 

Integration

Close 

Collaboration 

Approaching 

an Integrated 

Practice

Full 

Collaboration in 

a Transformed/ 

Merged 

Integrated 

Practice

Behavioral health, primary care, and other health care professionals work:

In separate 

facilities, where 

they:

In separate 

facilities, where 

they:

In same facility 

not necessarily 

same offices, 

where they:

In same space 

within the same 

facility, where 

they:

In same space 

within the same 

facility (some 

shared space), 

where they:

In same space 

within the same 

facility, sharing all 

practice space, 

where they:

• Have separate 

systems

• Communicate 

about cases 

only rarely 

and under 

compelling 

circumstances

• Communicate, 

driven by 

provider need

• May never 

meet in person

• Have limited 

understanding 

of each other’s 

roles

• Have separate 

systems

• Communicate 

periodically 

about shared 

patients

• Communicate, 

driven by 

specific patient 

issues

• May meet as 

part of a larger 

community

• Appreciate 

each other’s 

roles as 

resources

• Have separate 

systems

• Communicate 

regularly 

about shared 

patients, by 

phone or e-mail

• Collaborate, 

driven by need 

for each other’s 

services and 

more reliable 

referral

• Meet 

occasionally to 

discuss cases 

due to close 

proximity

• Feel part of a 

larger yet nonformal team

• Share some 

systems, like 

scheduling 

or medical 

records

• Communicate 

in person as 

needed

• Collaborate, 

driven by need 

for consultation 

and 

coordinated 

plans for 

difficult 

patients

• Have regular 

face-to-face 

interactions 

about some 

patients

• Have a basic 

understanding 

of roles and 

culture

• Actively 

seek system 

solutions 

together or 

develop worka-rounds

• Communicate 

frequently in 

person

• Collaborate, 

driven by 

desire to be a 

member of the 

care team

• Have regular 

team meetings 

to discuss 

overall patient 

care and 

specific patient 

issues

• Have an 

in-depth 

understanding 

of roles and 

culture

• Have resolved 

most or all 

system issues, 

functioning as 

one integrated 

system

• Communicate 

consistently 

at the system, 

team, and 

individual levels

• Collaborate, 

driven by 

shared concept 

of team care

• Have formal 

and informal 

meetings 

to support 

integrated 

model of care

• Have roles and 

cultures that 

blur or blend 

Source: Heath, et al., (2013).136

These models, as well as recovery-oriented systems of care, provide opportunities for substance use 

disorder services and mainstream health care to engage in various types of collaborative efforts to 

integrate their services at all stages: prevention, treatment, and recovery. Importantly, the models all 

emphasize the relationship between person-centered, high-quality care and fully integrated models. 

Innovative financing mechanisms now being explored also allow for formal arrangements to implement 

some of the models discussed above, including linking to off-site health professionals in specialty 
HEALTH CARE SYSTEMS

PAGE | 6-15

substance use disorder treatment settings (and vice versa) when locating multiple services at one site is 

not feasible.

Integration Can Help Address Health Disparities 

Integrating substance use services with general health care (e.g., in community health centers) provides 

opportunities to address longstanding health disparities. Prevalence of substance misuse and substance 

use disorders differs by race and ethnicity, sex, age, sexual orientation, gender identity, and disability, 

and these factors are also associated with differing rates of access to both health care and substance use 

disorder treatment. These differences are often exacerbated by socioeconomic variables.137,138 Some 

racial and ethnic groups experience disparities in entering and engaging in treatment. A study of a large 

health system found that Black or African American women but not Latina or Asian American women 

were less likely to attend substance use disorder treatment, after controlling for other factors; there 

were no ethnicity differences for men.139

In addition, an analysis of longitudinal data from the National Epidemiologic Survey on Alcohol and Related 

Conditions showed that individuals from most racial and ethnic groups were less likely to receive an 

alcohol intervention than were White individuals over a 3 year period.140 Controlling for socioeconomic 

status and clinical conditions increased the disparity, and Hispanic or Latino individuals were the 

least likely to receive services. Differences within the various racial and ethnic groups by sex were not 

studied. 

A fundamental way to address disparities is to increase the number of people who have health coverage. The 

Affordable Care Act provides several mechanisms that broaden access to coverage. As a result, more lowincome individuals with substance use disorders have gained health coverage, changed their perceptions 

about being able to obtain treatment services if needed, and increased their access to treatment.141 However, 

in states that have elected not to expand Medicaid, some low-income adults who need substance use disorder 

treatment, especially single childless adults, are unable to receive these services. Individuals whose incomes 

are too high to qualify for Medicaid but are not high enough to be eligible for qualified health plan premium 

tax credits also rarely have coverage for substance use disorder treatment.142 As Figure 6.3 shows, more Blacks 

or African Americans are in the coverage gap than other groups, and more Hispanics or Latinos are ineligible 

due to immigration status.142 One study conducted by The Pew Charitable Trusts reported that 14 percent 

of the low-income adults who are newly eligible for Medicaid under the Affordable Care Act have drug and 

alcohol addictions, compared to 10 percent in the general population. Because the new Medicaid population 

includes large numbers of young, single men—a group at much higher risk for alcohol and drug misuse—

Medicaid enrollees needing treatment could more than double, from 1.5 million prior to the 2014 Medicaid 

expansion to about 4 million in the next five years.8,143,144
HEALTH CARE SYSTEMS

PAGE | 6-16

Figure 6.3: Eligibility for Affordable Care Act Coverage Among the Nonelderly Uninsured by 

Race and Ethnicity, as of 2015

Notes: Totals may not sum to 100 percent due to rounding. Ineligible for Financial Assistance share includes those ineligible due 

to offer of employer sponsored insurance or income. Tax Credit Eligible share includes adults in MN and NY who are eligible for 

coverage through the Basic Health Plan. 

Source: Kaiser Family Foundation analysis based on 2015 Medicaid eligibility levels and 2015 Current Population Survey.142 

Another way to address disparities is to ensure that substance misuse prevention, interventions, 

treatments, and recovery services are tailored and relevant to the populations receiving them. Several 

interventions have been adapted explicitly to address differences in specific populations; they were 

either conducted within health care settings or are implementable in those settings. The list below 

provides examples of such programs that have been shown to be effective in diverse populations: 

$ An evidence-based prevention intervention focused 

on women who are at risk for an alcohol-exposed 

pregnancy because of risky drinking and not using 

contraception consistently and correctly.145 The 

program has been adapted to serve American Indian 

women of the Oglala Sioux Tribe.146 Implementation 

of this intervention in health care settings has high 

potential for improving outcomes. 

See Chapter 3 - Prevention 

Programs and Policies and Chapter 

4 - Early Intervention, Treatment, 

and Management of Substance Use 

Disorders.
HEALTH CARE SYSTEMS

PAGE | 6-17

$ A study of a computerized screening and brief intervention in both Spanish and English used 

in a public health center’s obstetrics-gynecology department was shown to be feasible and 

accepted by patients.147

$ A small trial of Latino heavy drinkers compared culturally adapted motivational interviewing to 

motivational interviewing that was not culturally adapted. The trial suggested stronger results 

for the culturally adapted program.148

$ A study comparing rural and urban differences in screening for substance use disorders in 

mental health clinics did not find significant differences in screening outcomes. However, rural 

clinics did significantly less following up for substance use problems in their patients than their 

urban counterparts. Larger rural clinics did better than small ones.149

Importantly, if health care systems systematically screen to identify individuals with risky use or potential 

substance use disorders, and respond appropriately to the level of the identified problem (with brief 

interventions, medications, and/or referral to specialty substance use disorder treatment), disparities in 

the use of treatment among those populations should lessen dramatically. In other words, it is expected 

that the number of people who seek treatment across all racial and ethnic groups will increase. 

Few studies have directly compared treatment populations by race and ethnicity. However, some studies 

have examined race and ethnicity as predictors of outcomes in analyses controlling for many other 

factors (such as age, substance use disorder severity, mental health severity, social supports), and they 

showed that after accounting for these socioeconomic factors, outcomes did not differ by race and 

ethnicity. Some examples from an integrated health system include adolescent studies comparing Blacks 

or African Americans, American Indians or Alaska Natives, Hispanics or Latinos, and Whites.150-152 The 

same is true for short-term and long-term treatment outcomes of adults.112,153-155

This body of research has some key caveats. For example, 

studies have found that matching programs and providers by 

race or ethnicity may produce better results for Hispanics or 

Latinos than for other racial and ethnic groups.156 However, 

this research also suggests that all racial and ethnic groups 

can benefit equally from substance use disorder treatment. At 

the same time, offering programs that are tailored to patient 

characteristics or that incorporate health care professionals 

who share similarities with their patients in sex, age, or race or ethnicity may improve willingness to 

enter and engage in treatment.157-159

It should also be noted that civil rights laws, such as Section 504 of the Rehabilitation Act, the Americans 

with Disabilities Act (ADA), and Section 1557 of the Affordable Care Act, protect many people with 

substance use disorders and impose requirements on substance use disorder treatment programs. These 

laws require individual assessment of a person with a disability, identifying and implementing needed 

reasonable modifications of policies and practices when necessary to provide an equal opportunity for 

a person with a disability to participate in and benefit from treatment programs. More generally, these 

laws prohibit programs from excluding individuals from treatment programs on the basis of a cooccurring disability, if the individual meets the qualifications for the program. Additionally, under Title 

See the section on “Considerations 

for Specific Populations” in Chapter 

4 - Early Intervention, Treatment, 

and Management of Substance Use 

Disorders.
HEALTH CARE SYSTEMS

PAGE | 6-18

VI of the Civil Rights Act and Section 1557 of the Affordable Care Act, providers who receive federal 

financial assistance must address the needs of people with limited English proficiency. The ADA and 

Section 504 also apply to discriminatory zoning laws and decisions that operate as a barrier to providers 

seeking to open or expand substance use disorder treatment programs.160

As the section on Electronic Health Records and Health Information Technology shows, health IT 

holds tremendous promise to provide culturally appropriate services in multiple languages and that 

incorporate health care professionals with characteristics similar to the target patients’ population. One 

example with cultural relevance is a pilot randomized trial of a computer-delivered brief intervention in 

a prenatal clinic, which matched health care professionals and patients on race/ethnicity; patients found 

the intervention to be easy to use and helpful.161 Such services have the potential to be cost-effective 

and to reach individuals in rural or urban settings and those who have difficulty attending treatment, 

including those with disabilities.

Integration Can Reduce Costs of Delivering Substance Use Services 

With scarce resources and many social programs competing for limited funding, cost-effectiveness is a 

critical aspect of substance use-related services. Over the past 20 years, several comprehensive literature 

reviews have examined the economics of substance use disorder treatment.162-165

Although the United States spends roughly $35 billion across public and private payors to treat 

substance use disorders,166,167 the social and economic costs associated with these disorders are many 

times higher: Annual costs of substance misuse and substance use disorders in the United States are 

estimated at more than $400 billion.168,169 Thus, treating substance use disorders has the potential 

for positive net economic benefits, not just in regard to treatment services but also general health 

care.162,170-172 For example, on average individuals with chronic medical conditions incur health care 

costs two to three times higher when they have a comorbid substance use disorder compared with 

individuals without this comorbidity.173 The net benefits of integrated treatment include improved 

health care outcomes and reduced health care costs, as 

well as reduced crime, improved child welfare, and greater 

employment productivity.125,174-178 Major individual and 

societal savings also stem from fewer interpersonal conflicts, 

greater workplace productivity, reduced infectious disease 

transmission, and fewer drug-related accidents, including overdoses and deaths.179

Evaluations of Medicaid expenditures for substance use disorder treatment show that the costs of 

treating substance use disorders are more than offset by the accompanying savings to Medicaid in 

reduced health care costs, such as reductions in future substance use disorder-related hospitalizations 

and residential treatment costs.188-190 For example, as discussed below, an analysis of Washington State 

Medicaid found that providing substance use disorder treatment resulted in aggregate net savings to the 

Medicaid program, in the millions of dollars.190 These and other studies point out that investments in 

engaging people into effective treatment for substance use disorders will reduce costs in many areas.

Net economic benefit. The value of 

total benefits minus total costs. 
HEALTH CARE SYSTEMS

PAGE | 6-19

Costs of Substance Use Disorders in Other Service Systems

Costs associated with substance use disorders are not limited to health care. The accumulated costs to the 

individual, the family, and the community are staggering and arise as a consequence of many direct and indirect 

effects, including compromised physical and mental health, loss of productivity, reduced quality of life, increased 

crime and violence, misuse and neglect of children, and health care costs. 

Criminal Justice System

As described elsewhere in this Report, a substance use disorder is a substantial risk factor for committing a 

criminal offense. Reduced crime is thus a key component of the net benefits associated with prevention and 

treatment interventions. Overall, within the criminal justice system, more than two thirds of jail detainees and 

half of prison inmates experience substance use disorders.180,181 Many require treatment interventions, although 

only approximately 10 percent of prison inmates receive substance use disorder treatment services.181 Applying 

inflation-adjusted estimates of the costs of in-prison care, the public sector spends approximately $400 million on 

such prison-based services, with substantial additional costs for after-care.182

Child Welfare and Related Service Systems

Substance use-related costs are also prominent within child welfare and related services. The estimated 

prevalence of substance use disorders among parents involved in the child welfare system varies across service 

populations, time, and place. One widely cited estimate is that between one-third and two-thirds of parents 

involved with the child welfare system experience some form of substance use problem.183

The National Survey of Child and Adolescent Well-Being found that caseworkers perceived substance misuse

problems in 23 percent of cases, which was correlated with significantly higher probabilities of severe harm 

to children (24 percent), compared with parents with no such indication (5 percent).184 Consistent with these 

findings, caseworker-perceived substance misuse problems were associated with more than twice the risk of 

out-of-home, or foster care, placement (38 percent vs. 16 percent) within this sample. Children of parents with 

substance use problems were more likely than others to require child protective services at younger ages, to 

experience repeated neglect and abuse from parents, and to otherwise require more intensive and intrusive 

services.183 An estimated 19 percent of adolescents served by the child welfare system have experienced some 

substance use disorder, highlighting another challenge facing these service systems.185

In fiscal year 2016, approximately $5.2 billion was proposed for Federal Title IV-B, IV-E, and child abuse 

prevention services. Substance use disorders appear to account for a large proportion of child welfare, foster 

care, and related expenditures in the United States. 

Military Health System

The United States military health system includes Department of Defense (DoD), Army, Navy, Air Force, and 

Marine Corps programs as well as health care outside the direct care system (TRICARE) for military members and 

their dependents, both in the United States and abroad. It is one of the largest health care systems in the United 

States. The IOM conducted a comprehensive study of military prevention and treatment services for substance 

use disorders.186 As found in other health systems discussed in this Report, the prevalence of alcohol problems 

is high. A study of the economic impact of alcohol misuse among beneficiaries of the DoD’s TRICARE insurance 

program found that the DoD spent approximately $1.2 billion to address problems related to alcohol use in 

2006: $425 million in medical costs and $745 million in reduced readiness and misconduct.187 In addition, opioid 

use disorders, often initiated when opioids are prescribed following injuries during deployment, are increasing at 

a high rate and are of high concern. Further, service members and veterans suffer from high rates of co-occurring 

health problems that pose significant treatment challenges, including traumatic brain injury, post-traumatic stress 

disorder, depression, and anxiety. Along with other recommendations, the IOM report recommended conducting 

routine screening, integrating substance use treatment with other health care, and implementing evidence-based 

treatments.
HEALTH CARE SYSTEMS

PAGE | 6-20

Costs of Substance Use Disorders in Other Service Systems, continued

These illustrative examples underscore that the costs associated with substance use disorders are incurred 

across diverse service systems that serve vulnerable populations. These expenditures might be reduced through 

more aggressive measures to address substance misuse problems and accompanying disorders. Moreover, 

many substance use-related services provided through criminal justice, child welfare, or other systems seek to 

ameliorate serious harms that have already occurred, and that might have been prevented with greater impact or 

cost-effectiveness through the delivery of evidence-based prevention or early treatment interventions. 

Economic Analyses can Assess the Value of Substance Use Interventions

Different kinds of economic analyses can be particularly useful in helping health care systems, community 

leaders, and policymakers identify programs or policies that will bring the greatest value for addressing their 

needs. Two commonly used types of analyses are cost-effectiveness analysis199 and cost-benefit analysis. 

Both types of studies have been used to examine substance use disorder treatment and prevention programs. 

Studies have found a number of substance use disorder treatments, including outpatient methadone, alcohol 

use disorder medications, and buprenorphine, to be cost-effective compared with no treatment.162,200-209 The 

same is true for outpatient services without MAT and residential levels of treatment. 

Cost-effectiveness Analyses

Treatment Settings and Approaches. A 2003 study estimating 

the cost-effectiveness of four different treatment modalities—

inpatient, residential, outpatient methadone, and outpatient 

without MAT—found that the treatment of substance 

use disorders is cost-effective compared to other health 

interventions, with outpatient programs without MAT being 

the most cost-effective. Estimated cost per abstinent case 

ranged from $11,411 for outpatient treatment without MAT to 

$28,256 in the inpatient setting, with an average cost across all 

modalities of $22,460 per abstinent study participant (adjusted 

to 2014 dollars).205

Methadone Maintenance versus Methadone Detoxification. A 2004 

study evaluating the incremental cost-effectiveness of sustained 

methadone maintenance relative to a 180-day methadone 

detoxification enriched with intensive psychosocial services 

followed by drug-free substance use disorder treatment found that methadone maintenance yielded better 

outcomes, including reduced opioid use and lower subsequent behavioral health care costs, and had a costeffectiveness ratio of approximately $20,000 per life year gained.203

Methadone Maintenance versus Maintenance with Other Medications. As the use of MAT options has 

grown, cost-effectiveness studies have compared alternative MAT interventions and MAT compared to 

medication-free behavioral therapies. For example, a 2015 study examining injectable, extended-release 

naltrexone compared with methadone maintenance treatment and buprenorphine maintenance treatment 

Cost-effectiveness study. A 

comparative analysis of two or more 

interventions against their health and 

economic outcomes. These outcomes 

could be lives saved, illnesses 

prevented, or years of life gained.

Cost-benefit study. A study that 

determines the economic worth of an 

intervention by quantifying its costs in 

monetary terms and comparing them 

with the benefits, also expressed in 

monetary terms. Total benefits divided 

by total costs is called a cost-benefit 

ratio. If the ratio is greater than 1, the 

benefits outweigh the costs.
HEALTH CARE SYSTEMS

PAGE | 6-21

for opioid dependence found that extended release naltrexone was more effective among patients 

remaining in treatment but also more costly than the other options,227 totaling an additional $72 per 

opioid-free day. However, extended-release naltrexone is not off-patent, and therefore these cost findings 

will likely change when it becomes generic. 

Extended Buprenorphine-Naloxone Treatment versus Brief 

Detoxification. A 2010 study of extended buprenorphinenaloxone treatment for opioid-dependent youth estimated 

that the cost-effectiveness ratio for buprenorphine compared 

to detoxification was $29,415 (outpatient treatment program 

costs for up to 12 weeks) per Quality-Adjusted Life Year 

(QALY).228 Results like this indicate that buprenorphine 

is highly cost-effective by the standard benchmarks often 

employed to evaluate clinical and population health 

interventions ($50,000 to $100,000 per QALY). 

Buprenorphine-Naloxone versus No Treatment. A 2012 study examined individuals with opioid use disorders 

who had completed 6 months of buprenorphine-naloxone treatment within a primary care setting. It 

estimated that office-based buprenorphine-naloxone treatment for clinically stable patients has a costeffectiveness ratio of $38,107 per QALY compared to no treatment after 24 months.229 The cost-effectiveness 

ratio was measured by calculating the difference in treatment costs between those receiving buprenorphinenaloxone treatment and those that did not and dividing them by the difference in patients’ health outcomes.

SBI. A 2014 review of cost-effectiveness studies for alcohol SBI in a primary care setting found 

considerable variability in the estimated cost-effectiveness ratios and cost savings across studies.230

However, almost all the studies found SBI to be cost-effective or to produce cost savings. For example, 

a 2008 analysis of alcohol SBI in primary care settings found an incremental cost-effectiveness ratio 

for SBI of $2,413 per QALY gained compared to a do-nothing scenario (in 2014 dollars).45 The authors 

compared the cost-effectiveness of alcohol SBI to 24 other preventive services that have been deemed 

effective by the USPSTF. Using that comparison, alcohol misuse screening achieved a combined score 

similar to screening for colorectal cancer, hypertension, or vision (for adults older than age 64), and 

to influenza or pneumococcal immunization. Because current levels of SBI delivery are much lower 

than desired, this service deserves special attention by health care professionals and care delivery 

systems.45 Importantly, all of the interventions that have proved to be cost-effective are appropriate for 

implementation in primary care.

Quality-Adjusted Life Year (QALY). A 

measure of the burden of disease used 

in economic evaluations of the value of 

health care interventions that accounts 

for both the years of life lived and the 

quality of life experienced during those 

years, relative to quality associated with 

perfect health.

Cost-Benefit Analyses

Interventions that prevent substance use disorders can yield an even greater economic return than the 

services that treat them. For example, a recent study of prevention programs estimated that every dollar 

spent on effective, school-based prevention programs can save an estimated $18 in costs related to 

problems later in life.231

The Washington State Institute for Public Policy has used a standardized model to estimate the cost-benefit 

of diverse prevention, early intervention, and treatment programs. Benefit-per-dollar invested ratios for 

evidence-based interventions (EBIs) include $27.48 for every dollar invested in brief intervention in primary 
HEALTH CARE SYSTEMS

PAGE | 6-22

care; $36.71 for brief intervention in a medical hospital; $9.07 

for brief intervention in an emergency department; $136.41 for 

cognitive behavior coping skills therapy; $33.71 for contingency 

management for substance use; $41.10 for motivational 

interviewing to enhance treatment engagement; $14.79 for brief 

marijuana dependence counseling; and $34.90 for brief cognitive behavioral intervention for amphetamine 

users.232 Although some of the 30 interventions studied had smaller benefit-to-cost ratios than others (e.g., 

$2.18 for methadone maintenance treatment and $1.30 for buprenorphine/buprenorphine-naloxone 

treatment), all had benefits greater than their costs.

See Chapter 3 - Prevention Programs 

and Policies.

How Much Does Alcohol or Drug Screening and Treatment Cost?

In a 2005 literature review of the economics of substance use disorder treatment, one study highlighted the 

variability in cost estimates for substance use disorder treatment delivered in specialty settings. For example, 

they reported per-patient weekly costs ranging from $90 to $208 for standard outpatient treatment; $682 to 

$936 for residential treatment; and $100 to $125 for methadone maintenance treatment.162 Another study, 

estimated service costs in 170 methadone maintenance treatment programs and found that methadone dosing 

was $33 per patient per week, individual counseling was $49 per patient per session (approximately 43 minutes 

per session), and group counseling was $12 per patient per session (approximately 77 minutes per session).191

A 2009 study estimated service costs for 70 standard outpatient programs and found that individual counseling 

was $75 per patient per hour and group counseling was $9 per patient per hour.192

A 2012 review of 17 studies on the cost of alcohol screening and brief intervention (SBI), found considerable 

variability, with costs ranging from $0.56 to $663.74 per screen and $3.76 to $268.16 per brief intervention.193

Median costs were approximately $4 per screen and $53 per brief intervention. Costs were typically lower when 

activity-based costing (assigning the cost and amount of each activity that is part of the intervention) was employed 

and when the SBI occurred in a primary care setting or was performed by a provider who was not a physician. 

Additionally, variation was attributed to the wage of the person conducting the screening and the amount of time 

the screening took. A 2015 study examined costs of SBI for illicit drug use in primary care settings; they estimated 

that per-person costs were $16.43 for screening, $40.98 for a brief negotiated interview, and $265.49 for an 

adaptation of motivational interviewing.194

In recent years, use of MAT has increased. Recent studies have examined extended-release naltrexone, 

buprenorphine, and methadone for opioid use disorder treatment.195-197 These studies found that health care costs 

were generally as low or lower for individuals receiving extended-release naltrexone compared to individuals 

receiving other treatments for opioid use disorder. Individuals with opioid use disorders who received extendedrelease naltrexone had $8,170 lower costs compared to those receiving methadone maintenance. Individuals 

receiving buprenorphine with counseling had significantly lower total health care costs than individuals receiving 

little or no treatment for their opioid use disorder ($13,578 compared to $31,055). However, those receiving 

buprenorphine plus counseling did not differ significantly in total health care costs when compared to those 

receiving only counseling (mean health care costs for those receiving counseling only were $17,017).196 It is 

important to note, however, that while some treatments may be less costly, they may also be less effective.

Another study, the Combined Pharmacotherapies and Behavioral Interventions (COMBINE) trial, examined nine 

treatment alternatives for alcohol treatment, including MAT. They reported mean per-patient cost estimates of 

$631 for a combined behavioral intervention (CBI) without MAT, $766 for naltrexone with medical management, 

and $865 for acamprosate with medical management. Combining CBI with a MAT option increased cost 

estimates to $1,183 for naltrexone plus CBI and $1,285 for acamprosate plus CBI.198 However, in the COMBINE 

study, naltrexone combined with medical management was found to be the most cost-effective treatment. While 

other treatments may be less costly, they are also somewhat less effective.

 *All costs in this sidebar are calculated in 2014 dollars.
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Financing Systems for Substance Use Disorder 

Services

In 2013, about three-quarters of all general health care purchased in the United States was paid for by 

private insurance, Medicare, or Medicaid. The rest was covered by consumers paying out-of-pocket, 

by other federal health grants, and by programs and other insurance provided by the DoD, Department 

of Veterans Affairs, and other state and local programs.211 In the case of treatment for substance use 

disorders, only about 45 percent of spending was through private insurance, Medicare, or Medicaid. In 

2014, the largest share of substance use disorder treatment financing was from state (non-Medicaid) and 

local governments (29 percent).211

Private Insurance 

In 2014, 66.0 percent of individuals in the United States had private health insurance, either obtained 

through employers or individually.212 Approximately 9 percent of insured individuals met criteria 

for a diagnosis of substance use disorder, as defined by the Fourth Edition of the Diagnostic and 

Statistical Manual of Mental Disorders (DSM-IV).214 However, in 2013, only 7 percent of privately insured 

individuals aged 12 and older with a substance use disorder received treatment from specialty treatment 

providers,214 and total spending on treatment for substance use disorders makes up only 0.6 percent of 

overall private insurance spending.

Coverage of substance use disorder services under private insurance has waxed and waned over the past 

30 years. During the 1980s, insurance benefits and specialty addiction providers expanded,215,216 and from 

1986 to 1992, substance use disorder spending grew by 6.7 percent annually, a substantial increase but 

still significantly below the 10.3 percent annual growth rate of all health care spending over the same 

period. This expansion was followed by managed care restrictions on reimbursement for substance use 

disorder treatment in inpatient settings, such as limitations on length of residential rehabilitation stays (a 

common treatment regimen).217,218 As a result, inpatient substance use disorder treatment services declined 

from accounting for 50 percent of total spending for substance use disorder treatment in 1986 to only 19 

percent in 2014 (Figure 6.4). Further, the share of substance use disorder financing from private insurance 

dropped dramatically between 1986 and 2014, from 32 percent in 1986 to 13 percent in 2005; this was 

followed by an increase to 18 percent in 2014, likely due to MHPAEA and qualified health plan coverage 

now being available through the Affordable Care Act.211

Medicaid 

Approximately 20 percent of people in the United States have 

health coverage through Medicaid, a joint federal and state 

health coverage program that provides medical assistance 

for children, families, and individuals with low income 

and limited resources; an estimated 12 percent of adult 

Medicaid beneficiaries have a substance use disorder.212 The federal government finances approximately 

60 percent (national average) of Medicaid and the states finance the balance.220 The federal medical 

assistance percentages (or “match”) vary significantly among states, based on the state’s per capita 

income and other factors. 

See the section on “A Growing Impetus 

for Integration” earlier in this chapter.
HEALTH CARE SYSTEMS

PAGE | 6-24

Figure 6.4: Percentage Distribution of Spending on Substance Misuse Treatment by Setting, 

1986–2014

Source: Substance Abuse and Mental Health Services Administration, (2016).167

The federal government establishes basic requirements that states must follow in designing their Medicaid 

programs, including some mandated services that must be covered and guidance regarding payment 

rate-setting and contractual arrangements, eligibility and quality standards, and provision of optional 

services.221 However, state implementation decisions can have a significant impact on what services are 

covered and for whom. States can choose to cover or not cover specific treatments or to place restrictions 

on covered services. In the past, some states have not included certain critical substance use disorder 

treatment options in their benefit packages (e.g., methadone), or they have restricted the doses or length of 

treatment, or added requirements such as prior authorization processes to obtain some treatments (e.g., 

buprenorphine). In many states, Medicaid also does not cover residential treatment, especially for adults. 

For those who are eligible and have substance use disorders, Medicaid is an extremely important 

program, as it can cover many services that such individuals may need, such as crisis services and many 

preventive services. In addition, while Medicaid does not provide payments for housing (e.g., rental 

subsidies) or other room and board costs in the community, states can supplement Medicaid coverage 

with supportive services to help people maintain housing in collaboration with housing authorities.222

In states that did not expand Medicaid, racial and ethnic minorities are disproportionately affected. In 

addition, in these states, young adult single males—a group with high rates of substance use disorders—

are ineligible for Medicaid benefits.223

An estimated 14 to 15 percent of uninsured individuals nationwide who could be newly eligible for 

Medicaid coverage under the Affordable Care Act have a substance use disorder.35 If they obtain 

substance use disorder treatment, this will lead to an additional 450,000 previously uninsured 

individuals having access to affordable substance use disorder treatment. 
HEALTH CARE SYSTEMS

PAGE | 6-25

Medicare 

Medicare covers almost all individuals aged 65 or over as well as those eligible because of disabilities. 

Approximately 56.2 million, or 17 percent of individuals in the United States, have Medicare.224

Approximately 3 percent of Medicare beneficiaries and 6 percent of those who are eligible for both 

Medicare and Medicaid have a substance use disorder in any given year.226 Of these, 19.3 percent 

received specialty substance use disorder treatment, including individual, group, and/or family 

therapy.225 In general, Medicare Parts A and B (or private Medicare Advantage plans under Part C) cover 

inpatient (but not residential) and outpatient services for substance use disorders, as well as substance 

use disorder screening and brief intervention. Prescription drug treatment is generally covered for 

beneficiaries enrolled in Medicare Part D (or a Medicare Advantage plan that includes drug coverage). 

Medicare does not cover outpatient use of oral methadone for substance use disorders, but Part D can 

include coverage for medications, such as disulfiram, naltrexone, acamprosate, and buprenorphine. 

Other Federal, State, and Local Funding

Although insurance coverage is critical to improving access to and integration of services for individuals 

with substance use disorders, it is unlikely to cover all the services that such individuals may need, such 

as crisis services (e.g., emergency treatment intervention), housing, supported employment, and many 

community prevention programs and services (e.g., school-based prevention programs). These services 

are often supported by federal, state, and local governments and non-profit organizations, financed 

through general revenues and the SAMHSA Substance Abuse Prevention and Treatment Block Grant 

(SABG). 

Uninsured Individuals 

Research has shown that uninsured individuals have higher unmet medical needs than do insured 

individuals, and those without insurance also have higher rates of substance use disorders than do 

individuals with insurance.226 Among uninsured individuals, 12 percent met DSM-IV criteria for a 

substance use disorder.214
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Financing Community Prevention

Federal Funding Streams

Funds from federal block grants to states for substance use disorder treatment services (such as the SABG, 

which is often used for prevention activities) and for maternal, child, and adolescent health services (Title V 

of the Maternal and Child Health Services Block Grant) may be used to fill the gaps in treatment services not 

covered by insurance. These funds also finance treatment for people without insurance and support community 

prevention activities.233 

In addition, federal funding for certain community prevention 

programs encourages public-private partnerships and 

community collaboration to improve health outcomes. Grants 

are used to increase screening, counseling, workplace wellness 

programs, and community prevention. In addition, federal 

funding for community prevention programs is available through 

the Drug Free Communities Support Program, which is funded by the White House Office of National Drug 

Control Policy and administered by SAMHSA.234

Although investments in prevention have repeatedly demonstrated favorable economic returns,235 primary 

prevention for all health conditions still accounts for less than 5 percent of overall health spending in the United 

States. Prevention should be seen as an appropriate health cost to be covered by insurance. Current funding 

options for community prevention, described below, include grants from hospital and health system foundations, 

hospital-based community benefit programs, tax earmarks, and targeted state programs. 

See Chapter 3 - Prevention Programs 

and Policies.

Hospital and Health System Foundation Grants 

Foundations formed from the conversion of tax-exempt non-profit hospitals and health systems into for-profit 

entities are required by federal law to invest in health-related activities within the community area served by 

that hospital.236 These “health conversion foundations” or “new health foundations” now exist in more than 

200 communities in the United States, and they are a potential source of funding for programs relating to the 

prevention and treatment of substance misuse.237

Non-profit Hospital Community Benefits

Beginning in 1994, tax-exempt hospitals have been required to provide benefits to the community in return for 

not paying taxes.238 The Affordable Care Act clarified community benefit expectations for all non-profit hospitals. 

Tax-exempt hospitals must: (1) conduct a community health needs assessment at least once every 3 years; (2) 

involve public health experts and representatives of the community served by the facility in the needs assessment; 

(3) make the results of the assessment available to the public; (4) develop an implementation strategy to address 

each of the community health needs identified through the assessment; and (5) report yearly to the Internal 

Revenue Service.239 The Secretary of the Treasury, in collaboration with the Secretary of Health and Human 

Services, must report annually to Congress on, among other things, hospitals’ levels of charity care, related costs, 

and community benefit activities.

Although hospitals have flexibility in their definition of “community served by the facility,” they are expected to define 

community by the geographic location, not by the demographic or geographic profiles, of patient discharges. Many 

states also have community benefit programs that must be synchronized with the requirements of the Affordable Care 

Act.240 The 1997 IOM report Improving Health in the Community outlined how multiple stakeholders can conduct a 

community health assessment and share accountability for health outcomes of specific populations.241

Local or State Substance Use Tax Earmarks 

In certain jurisdictions, direct funds from a local or state tax can be earmarked for substance misuse prevention 

in the same way as tobacco taxes are currently used for public health and health programming in many states.242

Jackson County, Missouri, is an example of a local jurisdiction with a dedicated funding stream for substance use 

problem prevention.243
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PAGE | 6-27

Financing Community Prevention, continued

Jackson County, Missouri, first introduced a dedicated sales tax in 1989 to tackle drug use and drug-related 

crime. This later became known as COMBAT—Community-Backed Anti-Drug Tax—and enabled Jackson County 

to approach the impact of drugs on individuals and communities as both a legal issue and a public health crisis. 

It was renewed for seven years in 2009, and the one-quarter of one-cent sales tax generates over $20 million per 

year. The funds are used for a variety of prevention, treatment, and anti-drug and drug-related crime prevention 

programs. In addition, Florida and Indiana, among other states, earmark alcohol taxes for child and adolescent 

substance use-related services.244

State Prevention Trust Funds 

The Massachusetts Legislature passed the first state-based prevention fund, called the Prevention and Wellness 

Trust Fund, in 2012 as part of a health cost control bill. Funded through a one-time $57 million assessment, 

the Trust Fund is used to reduce the prevalence of preventable health conditions and lower health care costs. 

Grantees have a strong focus on extending care beyond clinical sites into the community.245

Challenges Facing the Integration of Substance Use 

Services and Health Care 

It is clear that integrating substance use disorder services with mainstream health care is beneficial for 

individuals and communities and that health reform is encouraging this trend. However, several key 

challenges must be addressed if integration is to be fully successful. Specifically:

$ The substance use disorder treatment system is underprepared to support care coordination;

$ The primary care system has been slow to implement MAT as well as prevention, early 

identification, and other evidence-based recommendations;

$ The existing health care workforce is already understaffed and often lacks the necessary 

training and education to address substance use disorders; and

$ The need to protect patient confidentiality creates hurdles for sharing of information.

The Infrastructure of the Substance Use Disorder Treatment 

System Is Underdeveloped

The Congressional Budget Office currently estimates that by 2026, 24 million Americans who would 

otherwise be uninsured will obtain health insurance coverage as a result of the Affordable Care Act.246

For those insured by insurance plans sold to small employers and in the individual market, substance use 

disorder services are considered an essential health benefit. As a result, the Affordable Care Act, coupled 

with MHPAEA is projected to expand access to mental and behavioral health services to more than 60 

million Americans.247

However, the specialty care substance use disorder treatment system faces challenges along with these 

new opportunities.248 That system is changing as health systems respond to new requirements, begin to 

provide services internally, and develop new contracting mechanisms.249 Public substance use disorder 
HEALTH CARE SYSTEMS

PAGE | 6-28

systems are also changing as they are presented with new funding options under Medicaid and other 

funding sources.248

Nationally representative data from the 2014 National Drug Abuse Treatment System Survey underscore 

the importance (but also the difficulty) of integrated care efforts.250 Directors at only 15 percent of 

responding units reported signed contracts to work with a medical home, meaning that less than 50 

percent of patients were receiving treatment in a program that was prepared to integrate general health 

care.250 These data showed particularly dramatic differences between Medicaid expansion and nonexpansion states,250 with Medicaid expansion acting as a key driver of integrated care. Fifty-five percent 

of addiction treatment patients in expansion states are receiving care in organizations that at least have 

contractual linkages to some medical or health home arrangement.251

Substance use disorder treatment organizations currently face significant challenges in engaging in 

care coordination with other types of providers. Because these organizations have traditionally been 

organized and financed separately from general health care systems, the two systems have not routinely 

exchanged clinical information. Efforts to increase HIE are constrained by the relatively low use of 

EHRs. In a 2012 survey of treatment programs to assess their readiness for health reform, 63 percent 

described their organizations’ adoption of EHRs as having not yet begun, or only in the early stages.252

A 2015 study reported that substance use disorder treatment organizations across the nation are poorly 

positioned to work effectively with health homes or other health professionals.253 Not surprisingly, 

organizations with annual budgets less than $5 million were less likely than larger ones to report high 

readiness.254 Some evidence also suggests that publicly funded substance use disorder treatment centers 

are less technically proficient and less responsive to making changes than for-profit treatment facilities. 

For example, private, for-profit treatment facilities were significantly more likely to be early adopters 

of buprenorphine therapies than were their public or private non-profit peers.255 Substantial technical 

assistance and investments in staff and information technology are needed, yet substance use disorder 

treatment providers receive relatively little assistance or resources from federal or state agencies to make 

these changes.253 However, a February 29, 2016 State Medicaid Director Letter outlined that states, subject 

to prior approval by the Centers for Medicare & Medicaid Services (CMS), may use federal matching 

funds to connect Meaningful Use Eligible Medicaid Providers to other providers including substance use 

disorder treatment providers to support HIE and care coordination. This offers promise for increasing 

adoption and use of health IT by behavioral health providers.256

Another challenge for effectively coordinating care relates to the need for specialty substance use 

disorder treatment programs to comply with substance abuse confidentiality regulations (42 CFR Part 

2) and state privacy laws when implementing health IT systems. In addition, substance use disorder 

treatment organizations face the challenge of communicating with non-health care personnel including 

those in social service, criminal justice, and educational facilities and even when EHRs are in place these 

systems lack interoperability (the ability to effectively exchange digital health information from an EHR 

in a common format) with the information systems used by social service organizations, hindering 

communication.

Medical homes are most likely to pursue contractual arrangements with large and technologically 

sophisticated organizations that are best equipped to meet their needs for timely clinical and 

administrative information. The move toward integrated care is therefore likely to accelerate 
HEALTH CARE SYSTEMS

PAGE | 6-29

consolidation of substance use disorder treatment programs, which may hasten the adoption of new 

technologies and processes among sophisticated providers. Particularly in combination with expanded 

insurance coverage, this trend may attract new partnerships, for example between ACOs, which are 

integrated delivery systems, and more sophisticated specialty addiction providers. Yet, the same patterns 

may harm smaller providers, some of whom offer the only culturally competent services for particular 

patient groups, such as services tailored for specific racial and ethnic populations, sexual and gender 

minorities, or women in need of trauma-related residential services.257-259

Slow Implementation of Pharmacotherapies for Use in Treatment

One key challenge for integrating substance use treatment and health care is that implementation 

of pharmacotherapies (i.e., MAT) in primary care has been slow.260 In part, this is due to the fact that 

health insurers individually determine whether they cover substance use medications261 and treatment 

providers may not offer medications to patients with substance use disorders. A study of 2009–2010 

national treatment center data found that only 25 percent of substance use disorder treatment centers 

offered medications for alcohol and/or drugs: 24.5 percent offered buprenorphine, 18.7 percent offered 

acamprosate, 17.3 percent offered tablet naltrexone, 15.9 percent offered disulfiram, 9.1 percent offered 

injectable naltrexone, and 9.0 percent offered methadone.262 Studies have found that only 25 percent 

of private, for-profit treatment centers used buprenorphine, 15.6 percent used acamprosate, and 15.7 

percent used disulfram. Research suggests that whether treatment programs offer MAT is influenced by 

a number of organizational and state-level factors, including differences in organizational size, whether 

the treatment program is in a hospital setting, whether psychiatric medications are prescribed, whether 

the program has access to prescribing staff, and whether state Medicaid policies support the use of 

generic drugs.263-266

Another medication, extended-release injectable naltrexone, approved by the FDA for use in treating 

individuals with opioid use disorders, is underutilized by programs. For example, one study found that 

only three percent of United States treatment programs used it for opioid use disorders.267 In contrast, 

buprenorphine for opioid use disorder is becoming more established, although it too is underused. 

One study found that between 2005 and 2011, its use for detoxification in specialty opioid treatment 

programs (OTPs) increased from 36 percent of programs in the sample to 46 percent; its use for 

maintenance increased from 37 percent of programs in the sample to 53 percent.268 One deterrent to 

rapid expansion of access to buprenorphine has been the limit on the number of patients a certified 

physician can treat with buprenorphine. A recent study found that raising this limit further, rather 

than increasing the number of specialty addiction programs or waivered physicians, may be the most 

effective way to increase buprenorphine use.269 Up until July 2016, qualified practitioners were allowed 

to treat a maximum of 30 patients at a time the first year and up to 100 patients at a time thereafter. 

On July 6, 2016, HHS issued a final rule for “Medication Assisted Treatment for Opioid Use Disorders,” 

which increased access to buprenorphine medications in the office-based setting as authorized under 

the Controlled Substances Act 21 U.S.C. 823(g)(2).270 The rule allows eligible practitioners to request 

approval to treat up to 275 patients under section 303(g)(2) of the Controlled Substances Act.
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PAGE | 6-30

Limited Implementation of Prevention, Early Identification, and 

Other Evidence-based Recommendations

Another key challenge is that primary care settings have not yet routinely implemented recommended 

preventive health and intervention services related to substance misuse. Currently, the Affordable 

Care Act requires that all non-grandfathered health plans must cover, without cost-sharing, certain 

preventive health services recommended by the USPSTF,271 and women’s preventive services and 

preventive services for infants, children, and adolescents in guidelines supported by HRSA. As discussed 

earlier, the USPSTF recommends alcohol screening and counseling for adults. However, none of the 22 

women’s health guidelines, which are being updated at the time of this Report, or 26 children/adolescent 

guidelines supported by HRSA include a screening requirement related to alcohol use.42,43

Studies of SBIRT for alcohol use problems have identified many implementation challenges.272-277 Some 

of the most commonly noted challenges include the intense time constraints experienced in modern 

clinical settings,276 the multiple competing preventive and clinical priorities faced by providers,278

inadequate health care professional training on alcohol SBI techniques,277 and providers’ feelings that 

they are unable to address sensitive health issues adequately.279 Currently, only about one in six adults 

in the United States reports being asked about their drinking,280 and less than 10 percent of health plans 

verify that screening is performed.281 In pediatric health care settings, other issues, especially restrictions 

on disclosure of confidential information to parents (which varies by state), also pose challenges.282

The USPSTF currently considers the evidence to be insufficient to support screening or behavioral 

interventions for substance misuse problems in pediatrics.43,283 However, a number of studies, funded 

by the National Institutes of Health (NIH) and foundations such as The Conrad N. Hilton Foundation, 

are currently underway that could add to the evidence base. Major pediatric medical organizations, 

including the American Academy of Pediatrics, strongly recommend addressing these issues regularly 

at each well-adolescent visit and appropriate urgent care visits.284 Bright Futures, a HRSA-funded 

program, sets Recommendations for Preventive Pediatric Health Care and includes alcohol and drug 

use screening within its recommended schedule for an annual clinical preventive visit for adolescents 

and young adults between the ages of 11 and 21. The Affordable Care Act requires health plans to 

cover, at no out-of-pocket cost to families, the preventive care services outlined in this schedule. Bright 

Futures discusses how to incorporate screening into the preventive services visit for these age groups. In 

addition, SAMHSA recommends universal screening and brief intervention and referral to treatment 

at each well-visit,285 and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends 

universal screening for alcohol misuse.

Screening and brief intervention for substance misuse is also consistent with the prevention activities 

recommended in the 2009 IOM report Preventing Mental, Emotional, and Behavioral Disorders Among Youth: 

Progress and Possibilities.

286 Yet screening is seldom addressed according to guidelines or with appropriate 

evidence-based practices,287,288 and even when screenings are conducted, appropriate follow-up 

is often not provided.289,290 However, SBIRT can be effectively implemented, both for adults and 

adolescents,291,292 and it is likely that many more systems will do so to comply with new requirements by 
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PAGE | 6-31

The Joint Commission and in the Affordable Care Act. The Joint Commission Requirements mandate 

that hospitals offer inpatients brief counseling for alcohol misuse and follow-up, and measure the 

provision of counseling as one of the core measures for hospital accreditation. Primary care teams that 

include non-physician providers (e.g., nurses, health educators) are increasingly used for substance use 

disorder, mental health, and other disease management, and they have proved to be a viable approach 

for implementing alcohol SBIRT.291,293-298

Meeting Challenges in Primary Care

Several large health systems, such as the Veterans Health Administration and Kaiser Permanente, have 

successfully implemented primary care-based alcohol SBI in a sustainable manner.299-302 They have used a variety 

of approaches to accomplish this goal, including:

• Integrating screening, assessment, and clinical decision support tools in the EHR;

• Establishing interdisciplinary (primary care, substance use disorder treatment, and mental health) teams 

to guide integration and collaboration;

• Ensuring health system leadership support; and

• Using training curricula, targeted communications materials, robust performance feedback reporting for 

physicians and other staff, and existing financial incentives.278,291,303-305

These approaches can also be implemented in emergency departments and in obstetrics and gynecology 

departments. 

The Health Care Workforce Is Limited in Key Ways

Workforce Shortages

Data on the substance use workforce are incomplete.306 Although HRSA collects data on mental health 

workforce shortage areas, the agency does not collect similar data on the substance use disorder 

treatment workforce. Nevertheless, it is clear that the workforce is inadequate, as evidenced by its 

uneven geographic distribution (with rural areas underserved), access barriers for adolescents and 

children, and recruitment challenges across the treatment field. Moreover, the workforce is aging. 

For example, 46 percent of psychiatrists are older than age 65.307,308 As of June 2016, more than threequarters of United States counties had severe shortages of psychiatrists and other types of health care 

professionals needed to treat mental health and substance use disorders.309 The scarcity of providers 

who can provide culturally competent services for minority populations and the high turnover rate, 

both noted in SAMHSA’s 2013 Report to Congress307 and other studies, exacerbate the workforce 

shortage.310,311

Recent reforms may strain the current workforce in an already overstretched health care system 

working to address treatment and prevention strategies. A recent study documented staffing models in 

primary care practices and determined that, even among those designated as patient-centered medical 

homes, fewer than 23 percent employed health educators, pharmacists, social workers, nutritionists, 

or community service coordinators, and fewer than half employed care coordinators.312 The opioid 

epidemic has made the shortage of these types of health care professionals an even larger problem.310
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PAGE | 6-32

Thus, it is crucial that health care professionals are given comprehensive training on the prevention and 

treatment of substance use disorders when patients present with comorbid conditions.32

The IOM’s 2006 report Improving the Quality of Health Care for Mental and Substance Use Conditions,32 which 

adapted Crossing the Quality Chasm to address mental and substance use conditions, noted that a critical 

concern in attracting a skilled workforce is the low salary structure of the substance use disorder 

treatment workforce. Much of the public treatment system is funded by Medicaid and SAMHSA’s 

SABG. In practice, the Block Grant is used broadly, and Medicaid less and only with a subset of 

providers. It is not yet clear whether the integration of substance use disorder treatments in general 

health care will help to address salary structure. 

Composition and Education

An integrated health and substance use disorder treatment system requires a diverse workforce that 

includes substance use disorder specialists, physicians, nurses, mental health treatment providers, care 

managers, and recovery specialists. This workforce also includes peer recovery coaches (a reimbursable 

service under some state Medicaid programs), health educators, social workers, and other staff who 

are trained to deliver timely mental health and substance use-related health interventions, such as 

SBI.32 However, Medicare, and in some states Medicaid, restricts “billable” health care professionals 

to physicians (including psychiatrists), nurse practitioners and clinical nurse specialists, physician’s 

assistants, clinical psychologists, clinical social workers, and certain other specified practitioners, and 

does not include as billable the multiple other licensed and certified professionals who are trained to 

provide services for substance use disorders.

As substance use disorder treatment and general health care become more integrated, clinical staff in 

both systems will need to expand their scope of work, operate in an integrated manner with a variety of 

populations, and shift their treatment focus as needed.313-315 Being able to assess substance use disorder 

severity and co-occurring mental health and physical health problems will be important in each setting. 

Health care professionals moving from the specialty workforce into integrated settings will require 

specific training on treatment planning and care coordination and an ability and willingness to work 

under the leadership of medical staff. This transition to a highly collaborative team approach, offering 

individually tailored treatment plans, presents challenges to the traditional substance use disorder 

treatment workforce that is used to administering standard “programs” of services to all patients. 

Working in teams with the broad mandate of improved health is not currently commonplace and 

will require collaboration among professional and certification bodies. Incorporating peer workers, 

who bring specific knowledge of patients’ experiences and needs and can encourage informed patient 

decision making, into teams will also require further adjustment.

Improving the Quality of Health Care for Mental and Substance Use Conditions also discussed the shortage of 

skills both in specialty substance use disorder programs and in the general health care system.32 Of 

special concern was the inadequacy of substance use education as part of medical school training: Only 

8 percent of medical schools had a separate required course on addiction medicine and 36 percent had 

an elective course;32,316 on average, the residency curriculum for psychiatrists included only 8 hours on 

substance use disorders.32,317 Schools of social work and psychology also provided little, and sometimes 

no, mandatory education on substance use-related problems.32 The situation does not appear to have 
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PAGE | 6-33

substantially changed since that report was released, although the recent recognition of addiction 

medicine as a subspecialty by the American Board of Medical Specialties should provide increased focus 

and perhaps attract more physicians to this field.

Workforce Development and Improvement

The Annapolis Coalition on the Behavioral Health Workforce provided a framework for workforce 

development in response to the challenges described above,318 focusing on broadening the definition of 

“workforce” to address needed changes to the health care system. Currently, 66 organizations license 

and credential addiction counselors,319,320 and although a consensus on national core competencies 

for these counselors exists,321 they have not been universally adopted. Credentialing for prevention 

specialists exists through the International Certification & Reciprocity Consortium,322,323 but core 

competencies for prevention professionals have not been developed. Without a comprehensive, 

coordinated, and focused effort, workforce expansion and training will continue to fall short of the 

challenge of meeting the needs of individuals across the continuum of service settings. 

HRSA has taken a number of steps to address these workforce challenges as part of its mission to 

prepare a diverse workforce and improve the workforce distribution to increase access for underserved 

communities. Among its many programs, HRSA awards health professional and graduate medical 

education training grants and operates scholarship and loan repayment programs. Of particular note is 

the National Health Service Corps, where, as of September 2015, roughly 30 percent of its field strength 

of 9,683 was composed of behavioral health providers, meeting service obligations by providing care in 

areas of high need.324 HRSA is also putting increased emphasis on expanding the delivery of medicationassisted treatment, increasing SBI, and coordinating RSS. The development of the workforce qualified 

to deliver these services and services to address co-occurring medical and mental disorders will have 

significant implications for the national workforce’s ability to reach the full potential of integration.

Protecting Confidentiality When Exchanging Sensitive Information 

Effectively integrating substance use disorder treatment and general health care requires the timely 

exchange of patient health care information. In the early 1970s, the federal government enacted 

Confidentiality of Alcohol and Drug Abuse Patient Records (42 U.S.C. § 290dd-2), and released 

regulations (42 CFR Part 2) to protect the confidentiality of substance use disorder treatment data. 

These privacy protections were motivated by the understanding that discrimination attached to a 

substance use disorder might dissuade people from seeking treatment, and were enacted in the context 

of patient methadone records being used in criminal cases. Due to its targeted population, 42 CFR Part 

2 provides more stringent federal protections than most other health privacy laws, including the Health 

Insurance Portability and Accountability Act (HIPAA – 45 CFR Part 160 and 164). HIPAA does not 

require patient authorization to share health information for purposes of treatment, payment, or health 

care operations. With 42 CFR Part 2, patient consent is required to share and use patient identifying 

information and any information that could be used to identify someone as having, or having had, a 

substance use disorder, such as payment data. 

Given the long and continuing history of discrimination against people with substance use disorders, 

safeguards against inappropriate or inadvertent disclosures are important. Disclosures to legal 
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authorities can lead to arrest, loss of child custody, or relinquished parental rights. Disclosures to 

insurers or to employers can render patients unable to obtain disability or life insurance and can cost 

patients their jobs. Currently, persons with substance use disorders involving illicit drugs are not 

protected under anti-discrimination laws, such as the ADA. 

However, exchanging treatment records among health care providers has the potential to improve 

treatment and patient safety. For example, in the case of opioid prescribing, a study in health systems 

of long-term opioid users found those with a prior substance use disorder diagnosis received higher 

dosages and were co-prescribed sedative-hypnotic medications—which can increase the risk for 

overdose—more often. Because of privacy regulations, it is likely that physicians were not aware of their 

patients’ substance use disorders.52 In most states, these challenges are now partially addressed through 

prescription drug monitoring programs (PDMPs), which are also helping to support care coordination. 

PDMPs are state-run databases that collect prescribed and dispensed controlled prescription drug 

information and give prescribers and pharmacists access to a person’s controlled substance prescription 

history. Authorized providers can check the database before prescribing or dispensing. However, 

PDMPs have many limitations. They do not include information about methadone used for opioid use 

disorders, which is exclusively dispensed at OTPs, or from programs covered by 42 CFR Part 2. While 

disclosure of patient-identifying information that is subject to 42 CFR Part 2 is allowable, it would 

require written patient consent, and re-disclosures of this information would not be permitted unless 

the patient consents. However, any information in the PDMP database could be potentially seen by 

anyone who has access to the state PDMP data and therefore may be in violation of Part 2. In addition, 

PDMPs only collect prescription information as allowed by their state laws, in most cases controlled 

substances Scheduled II through IV or V, and thus health care professionals may not be aware of 

other prescriptions their patients are receiving.326 Further, the extent to which the PDMP systems are 

effectively designed and used is not fully known.327

As EHR interoperability and the exchange of health information increases, best practices must be 

developed for handling substance use disorder treatment data, consistent with state and federal privacy 

laws. It will be important that EHR technologies develop the functionality to share health information 

electronically while complying with HIPAA, 42 CFR Part 2, and state privacy statutes. One approach 

to sharing protected data electronically is called Data Segmentation for Privacy (DS4P), an optional 

criterion under the Office of the National Coordinator for Health Information Technology’s (ONC’s) 

2015 Edition Health IT Certification Criteria.325 SAMHSA recently developed an open source tool called 

Consent2Share (C2S), which is based on DS4P and allows patients to electronically create and manage 

consent directives specifying which providers can access their data. 

Promising Innovations That Improve Access to 

Substance Use Disorder Treatment

Clearly, integrating health care and substance use disorder treatment within health care systems, as well as 

integrating the substance use disorder treatment system with the overall health care system, are complex 

undertakings. The good news, however, is that a range of promising health care structures, technologies, 
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and innovations are emerging, or are being refined and strengthened, under health reform. These 

developments are helping to address challenges and facilitate integration. In so doing, they are broadening 

the focus of interventions beyond just the treatment of severe substance use disorders to encompass the 

entire spectrum of prevention, treatment, and recovery. These promising developments include:

$ Medicaid innovations;

$ EHRs and health IT;

$ Disease registries; and

$ Substance misuse and substance use disorder prevention through a public health approach.

Medicaid Innovations

Medicaid is not only an increasing source of financing for substance use disorder treatment services, it 

has become an important incubator for innovative substance use disorder financing and delivery models 

that can help integrate substance use disorder treatment and mainstream health care systems. Within 

the substance use disorder treatment benefit, and in addition to providing the federally required set of 

services, states also may offer a wide range of recovery-oriented services under Medicaid’s rehabilitative 

services option. These services include therapy, counseling, training in communication and independent 

living skills, recovery support and relapse prevention training, skills training to return to employment, 

and relationship skills. Nearly all states offer some rehabilitative mental health services, and most states 

offer the rehabilitation option for substance use disorder services.328

CMS provides various authorities by which states can structure their Medicaid programs, thus 

providing mechanisms for states to expand and improve their substance use disorder treatment delivery 

system: This includes authorities to:328-330

$ Offer coordinating, locating, and monitoring activities broadly and create incentive payments 

for providers who demonstrate improved performance on quality and cost measures (section 

1905(t));

$ Establish Alternative Benefit Plans (ABPs), which require that substance use disorder services 

are included and comply with mental health parity standards (section 1937);

$ Establish voluntary or mandatory managed care plans, which require parity protections for 

enrolled individuals (sections 1915(a) and 1915(b) authorities, and section 1932 State Option to 

Use Managed Care); 

$ Provide home and community-based services and supports (sections 1915(c), 1915(i), 1915(j), 

and 1915(k)); 

$ Develop health homes (section 1945 Health Home State Plan Option); and

$ Conduct demonstrations to test policy innovations (section 1115).

Recently, CMS gave states new opportunities to design service delivery systems for substance use 

disorders through demonstration projects under section 1115. This initiative is designed to support 

states to provide coverage for the full continuum of care; ensure that care is delivered consistent with 

the ASAM Treatment Criteria; design strategies to coordinate and integrate care; and support quality 
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improvement programs. In 2014, CMS launched the Medicaid Innovation Accelerator Program, which 

aims to improve “health and health care for Medicaid beneficiaries by supporting states’ efforts to 

accelerate new payment and service delivery reforms.”331 CMS identified substance use disorders as 

the program’s first area of focus. The agency is providing technical and program support to states to 

introduce policy, program, and payment reforms to identify individuals with substance use disorders, 

expand coverage for effective treatment, expand access to services, and develop data collection, 

measurement, and payment mechanisms that promote better outcomes. Medicaid is also encouraging 

the trend to integration in other ways, including supporting new models for delivering primary 

care, expanding the role of existing community-based care delivery systems, enacting mental health 

and substance use disorder parity for Medicaid and Children’s Health Insurance Program (CHIP) as 

included in the final rule that CMS finalized in March 2016. This rule requires that Medicaid enrollees 

in managed care organizations (MCOs) and in ABPs have access to coverage for mental health and 

substance use services that is in parity to coverage of medical benefits and will benefit the over 23 

million people enrolled in MCOs, Medicaid ABPs, and CHIP. 

Health Homes

Health homes are grounded in the principles of the primary care medical home, which focuses on 

primary care-based coordination of diverse health care services, and patient and provider engagement. 

The Affordable Care Act created an optional Medicaid State Plan benefit allowing states to establish 

health homes to coordinate care for participants who have chronic health conditions. Health homes 

operate under a “whole-person” philosophy that involves integrating and coordinating all primary, 

acute, behavioral health, and long-term care services to address all the individual’s health needs. 

Beneficiaries with chronic conditions are eligible to enroll in health homes if they experience (or are at 

risk for) a second chronic condition, including substance use disorders, or are experiencing serious and 

persistent mental health conditions.332 Such care arrangements are particularly pertinent to individuals 

with substance use disorders who experience severe co-occurring physical and/or mental disorders. 

These arrangements emphasize integration of care, targeting of health home services to high-risk 

populations with substance use and mental health concerns, and integration of social and community 

supports with general health services.

As of January 2016, 19 states and the District of Columbia had established Medicaid health home 

programs – covering nearly one million individuals – and nearly a dozen additional states had plans for 

establishing them. States such as Vermont, Maryland, and Rhode Island have implemented health home 

State Plan Amendments (SPAs) with substance use-related provisions.333 Seven other states specifically 

identify individuals with substance use disorders as a target population.334 Many other SPAs include 

behavioral health care arrangements that encompass substance use disorders.334,335

States that implement Medicaid health homes receive substantial federal subsidies, including 90 percent 

federal matching rates for health home services during the first eight quarters after the effective date 

of health home coverage under the Medicaid state plan, covering comprehensive case management, 

coordinating services and health promotion, comprehensive transitional care from inpatient to other 

settings, individual and family support services, linkage and referrals to community-based services, and 

health IT.336,337
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In some settings, these integrated care models are associated with reduced cost and improved costeffectiveness,338 and research is underway to test new models. Recognizing the important role that 

these kinds of integrated care arrangements can play, the American Academy of Family Physicians and 

SAMHSA have issued reports promoting the inclusion of substance use and mental health services in 

patient-centered medical homes and related efforts.248,339,340 Much remains to be implemented in both 

public and private systems, but health systems are responding in a variety of ways to address substance 

use issues and their efforts will be key in improving treatment quality and outcomes.249,341

Accountable Care Organizations

Another Affordable Care Act provision created opportunities to encourage the integration of primary 

and specialty care, as well as community and public health systems, by establishing integrated delivery 

systems known as ACOs.238 ACOs include health care professionals and hospitals that are responsible, 

together, for the total health of their patient populations. The motivation behind ACOs is that by being 

responsible for the overall health of patients and coordinating the care they provide, the collaborating 

health systems can achieve the “three part aim” of better quality care for individuals, reduced per 

capita costs, and improved population health.342 Because ACOs can include a range of different types 

of providers across a defined region, they interpret “population health” in two broad ways: as a “panel 

population,” referring to all the patients participating in the health delivery system, and as a “geographic 

population,” referring to all who live in the ACO’s defined geographic catchment area.343

An ACO that focuses on the larger community is called an accountable care community (ACC). ACCs 

are an important variation on the ACO model because, by focusing on the larger community, they can 

address the social determinants of health and health disparities that have such a profound impact on 

community members’ health and well-being, including their risks for substance misuse, substance use 

disorders, and related health consequences.344

Initially developed as a model under Medicare, ACOs have now also been encouraged under Medicaid 

for its covered populations.345-348 The CMS State Innovation Models (SIM) Initiative supports the 

development and testing of state-based models for multi-payor payment and health care delivery system 

transformation for improving the performance of health systems. An underlying assumption of the new 

service delivery and payment models funded in the SIM states is that they will be more effective and 

produce better outcomes when implemented as part of a broad-based, statewide initiative that brings 

together multiple payors and stakeholders, and when they use the levers of state government to effect 

change. 

The SIM states are leading the implementation of accountable care systems for Medicaid populations 

that embrace population health (for SIM states, this is defined as health of the community in a 

geographic area as opposed to the population of patients in the health delivery system). Several states 

have adopted ACC models that support integration of medical health care services with public health 

and community-based programs.238 For example, Akron in Summit County, Ohio, set up one of the 

first ACCs to implement community-wide public-private partnerships to improve the health of the 

overall population.349 Maine’s accountable communities, Oregon’s CCOs, and Minnesota’s accountable 

communities are partnering with local public health authorities and other community entities to 

achieve this goal.350
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Oregon’s CCOs are a network of all types of health care professionals (physical health care, addiction 

and mental health care, and dental care providers) who have agreed to work together to serve people 

who receive health care coverage under Oregon’s Medicaid plan, which is called Oregon Health 

Plan. The Oregon Health Authority publishes regular reports on quality, access, and progress toward 

benchmarks in both prevention and treatment.351 Oregon Medicaid CCOs are currently reporting, 

and showing progress on, three quality measures specific to substance use: use of SBIRT, initiation of 

substance use treatment, and engagement in treatment. 

Federally Qualified Health Centers 

Increased insurance coverage and other provisions of the Affordable Care Act have sparked important 

changes that are facilitating comprehensive, high-quality care for people with substance use disorders. 

For example, the Affordable Care Act provided mandatory funding for Federally Qualified Health 

Centers (FQHCs) receiving grants under section 330 of the public health service act, including 

community health centers, migrant health centers, health care for the homeless health centers, and 

public housing primary care centers that is supporting the expansion of their activities and numbers of 

patients served. 

These community health centers emphasize coordinated primary and preventive services that 

promote reductions in health disparities for low-income individuals, racial and ethnic minorities, rural 

communities, and other underserved populations. Two-thirds of health centers have been designated as 

PCMHs.352 PCMHs emphasize care, coordination, and communication to improve health care quality, 

lower health care costs, and enhance both the patient and provider experience. 

Community health centers provide primary and preventive health services to medically underserved 

areas and populations and may offer behavioral and mental health and substance use services as 

appropriate to meet the health needs of the population served by the health center. As such, they are 

well-equipped to address co-occurring physical, mental, and substance use disorders, and provide 

substance misuse prevention, treatment, and RSS to patients. Because they provide services regardless 

of ability to pay and are required to offer services on a sliding scale fee, they are well-positioned to serve 

low-income and economically vulnerable patients. 

An example of the important role FQHCs can play in improving access to treatment for substance use 

disorders is their efforts in providing buprenorphine maintenance treatment for opioid-dependent 

patients within primary care. In 2016, $94 million was awarded by HRSA to 271 health centers in 45 

states, the District of Columbia, and Puerto Rico with a focus on augmenting capacity to treat opioid 

use disorders in vulnerable populations. FQHCs have access to 340B drug pricing, making the purchase 

of substance use disorder medications less costly and thus more accessible than for providers who 

cannot take advantage of this pricing.353 Recent services research indicates that such arrangements can 

achieve comparable outcomes to those achieved within the specialty addiction treatment sector.354

Electronic Health Records and Health Information Technology

EHRs and health IT have the potential to support better coordination of services across primary 

care and specialty substance use disorder treatment, greater safety by reducing harmful drug-drug 

interactions, and improved monitoring of treatment outcomes and relapse risk in general health care. 
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Strong health IT systems improve the organization and usability of clinical data, thereby helping 

patients, health care professionals, and health system leaders coordinate care, promote shared decisionmaking, and engage in quality improvement efforts. These systems have the capacity to easily provide 

information in multiple languages and to put patients in touch with culturally appropriate providers 

through telehealth. 

“Meaningful use” rules from CMS now provide incentives for 

the use of certified health IT to facilitate care coordination. 

Medicare and Medicaid EHR Incentive Programs have thus 

far paid more than $34.5 billion in incentive payments for 

providers who adopt, implement, upgrade, and use certified 

EHR technology.355 These incentives have worked: The 

Meaningful Use. Using certified EHR 

technology to improve quality, safety, 

efficiency, and reduce health disparities; 

engage patients and family; improve 

care coordination and population and 

public health; and maintain privacy and 

security of patient health information.2

National Electronic Health Record Survey found that as of 2014, 

more than 80 percent of primary care physicians had adopted 

an EHR, and more than half were using all basic functions.356

These were the highest rates of any physician type using 

certified EHRs.

Health IT has shown benefits in improving care for patients with chronic conditions,357 and use is 

expected to greatly increase because of the Affordable Care Act and related incentives, such as grants 

supporting health center networks with the implementation and adoption of health IT.358-361 To further 

heighten uptake and implementation, CMS issued new rules to “ease the reporting burden for providers, 

support interoperability, and improve patient outcomes,” including giving states and providers more 

time to comply with regulations and focusing on health information interoperability between providers 

and patients.335,362 Additionally, CMS recently published its proposed rule on the Medicare Access and 

CHIP Reauthorization Act (MACRA) of 2015, providing incentives for using health IT to report quality 

measure results.

Health IT also holds great potential for improving services 

for individuals with substance misuse problems because 

they can provide up-to-date medical histories of patients 

to providers, and they can support care coordination by 

facilitating communications between primary and specialty 

care providers across health systems.363 Clinical decision 

support tools can also help support improvements in care 

and include clinical guidelines, diagnostic support, conditionspecific order sets, computerized alerts and reminders 

to care providers as well as patients, focused patient data reports and summaries, documentation 

templates, and contextually relevant reference information, among others. For example, educational 

and training materials including clinical guidelines for physicians (e.g., Helping Patients Who Drink Too 

Much: A Clinician’s Guide364), can be made available through EHRs. Many health systems have additional 

information on wikis for patients and providers. Most have or will have patient portal websites, which 

can provide patients access to health, mental health, and substance use self-assessments; computerized 

interventions for reducing alcohol or drug use, anger management, dealing with depression, and other 

Clinical Decision Support. A system 

that provides health care professionals, 

staff, patients, or other individuals 

with knowledge and person-specific 

information, intelligently filtered or 

presented at appropriate times, to 

enhance health and health care.
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PAGE | 6-40

problems; referral sources for smoking quit-lines and self-help groups; information on medications for 

substance use disorders; and general health information.

Although research suggests that patients with substance use disorders are not using patient portals 

as much as individuals with other conditions,365 they have great potential for reaching patients.366-368

In particular, because they can be culturally relevant, these innovations may be helpful in providing 

substance use disorder services to individuals who do not have access to, or are hesitant to participate 

in, traditional services, or to augment those services, thereby helping to reduce health disparities. 

To foster systems change, efforts are needed to increase adoption of EHR technology in substance use 

disorder and mental health treatment organizations. These programs currently lag and are likely to 

continue to lag behind the rest of medicine. It will be critical to facilitate the uptake of EHRs within the 

specialty substance use disorder treatment system, to implement common data standards to support 

interoperability across specialty substance use disorder treatment and mainstream health care, and 

to coordinate care across systems. The federal interagency Behavioral Health Coordinating Council 

recently created a quality metrics subcommittee tasked with ensuring that substance use and mental 

health performance and quality measures are consistently and appropriately included across payment 

systems of HHS, including diverse programs within CMS. The National Institute on Drug Abuse 

(NIDA) and NIAAA have developed common data elements for inclusion in EHRs, and SAMHSA 

supports the development of data standards for collecting behavioral health data in EHRs through the 

international standards development organization, Health Level 7, though none of these standards has 

been widely implemented to date.364,369,370

PDMPs are becoming an increasingly important health IT tool for preventing substance misuse and 

identifying patients with substance use disorders. As discussed above, PDMPs are state-run databases 

that collect prescribed and dispensed controlled prescriptions drug information and give providers 

and pharmacists access to information about a person’s controlled substance prescription history. 

They are designed to help identify patients (as well as providers) who are misusing or diverting (i.e., 

channeling drugs into illegal use) these medications who would benefit from early interventions. This 

technology represents a promising state-level intervention for improving opioid prescribing, informing 

clinical practice, and protecting patients at risk in the midst of the ongoing opioid overdose epidemic. A 

number of states have passed legislation requiring prescribers to check their PDMP before prescribing 

controlled substances. Additional research is needed to identify best practices and policies to maximize 

the efficacy of these programs.

Disease Registries 

Databases related to specific diseases or combinations of diseases have long been used by health care 

professionals to manage chronic conditions such as diabetes or HIV/AIDS. Now these disease registries 

are being developed for substance use disorders, such as opioid use disorder.371 Although privacy 

concerns exist, disease registries can alert providers to the health care needs of those at risk because of 

substance misuse, including patients receiving opioids for chronic pain. Even low levels of alcohol and 

drug use are important factors in this population.372
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Prevention of Substance Misuse and Substance Use Disorders 

Through Public Health Approaches

Because substance use disorders often first come to light in the context of school, law enforcement, 

and employment, communities have many opportunities to expand the delivery of prevention and 

treatment services to include schools and school-based health care clinics, jails and prisons, and places 

of employment. Services provided in these settings can range from prevention education to SBIRT to 

treatment for substance use disorders. For example, law enforcement and emergency medical services 

in many communities are already collaborating in the distribution and administration of naloxone to 

prevent opioid overdose deaths. 

These efforts require a public health approach and the development of a comprehensive community 

infrastructure, which in turn requires coordination across federal, state, local, and tribal agencies. 

A number of states are developing promising approaches to address substance use in their 

communities. One recent example is Minnesota’s 2012 State Substance Abuse Strategy, which includes 

a comprehensive strategy focused on strengthening prevention; creating more opportunities for 

intervening before problems become severe; integrating the identification and treatment of substance 

use disorders into health care reform efforts; expanding support for recovery; interrupting the cycle of 

substance use, crime, and incarceration; reducing trafficking, production, and sale of illegal drugs; and 

measuring the impact of various interventions.373

Comprehensive Addiction and Recovery Act (CARA)

On July 22, 2016, President Obama signed the Comprehensive Addiction and Recovery Act (CARA), into law. 

CARA aims to address the national epidemic of opioid addiction by creating and expanding federal grant 

programs to:

• Temporarily expand eligibility to prescribe buprenorphine-based drugs for MAT for substance use 

disorders to qualifying nurse practitioners and physician assistants, through October 1, 2021;

• Expand access to opioid overdose reversal drugs, by supporting the purchase and distribution of such 

medications and training for first responders;

• Increase awareness and educate the public regarding the misuse of prescription opioids;

• Reauthorize the National All Schedules Prescription Electronic Reporting (NASPER) Act, which provides 

grants to states to support and improve interoperability of PDMPs; 

• Authorize Medicare prescription drug plans to develop a safe prescribing and dispensing program for 

beneficiaries that are at risk of misuse or diversion of drugs that are frequently abused or diverted;

• Create a comprehensive program at U.S. Department of Justice to improve efforts by law enforcement 

and the criminal justice system to address substance use disorders; and

• Establish an HHS-led task force to consolidate federal best practices for pain management.   

These measures are important steps for reducing the impact of prescription drug misuse on America’s 

communities by preventing and responding to opioid addiction. However, given the large number of Americans 

with untreated or inadequately treated opioid use disorders and the current scarcity of treatment resources, there 

is concern that the lack of funding for the bill will prevent this new law from having a substantial impact on the 

nation’s ongoing opioid epidemic.
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The opioid guideline published by the Washington State Agency Medical Directors’ Group is another 

useful example. This group is composed of medical directors from seven state agencies, including the 

Department of Labor and Industries, the Health Care Authority, the Board of Health, the Health Officer, 

the Department of Veterans Affairs, the Office of the Insurance Commissioner, and the Department of 

Corrections. In 2007, the group developed its first opioid prescribing guideline in collaboration with 

practicing physicians, with the latest update released in 2015.374 The guideline offers an approach to 

pain management that includes recommendations for appropriate opioid prescribing and management. 

States’ and localities’ efforts to expand naloxone distribution provide another example of building a 

comprehensive, multipronged, community infrastructure. Many communities have recognized the need 

to make this potentially lifesaving medication more widely available. For example, community leaders 

in Wilkes County, North Carolina, implemented Project Lazarus, a model that expands access to naloxone 

for law enforcement, emergency services, education, and health services, and reduced the county 

overdose rate by half within a year. North Carolina also passed a law in 2013 that implemented standing 

orders, allowing naloxone to be dispensed from a pharmacy without a prescription.375

States have also expanded training on naloxone use for opioid users and their families and friends, as 

well as for a wide range of social service agency personnel. Federal partners have been instrumental in 

expanding access to naloxone training. HRSA established the Rural Opioid Overdose Reversal program 

in fiscal year 2015, awarding grants of $100,000 to 18 recipients representing 13 states to increase 

access to naloxone and train health care professionals and other social service personnel to administer 

the drug. In 2016, SAMHSA also provided $11,000,000 in funding to prevent prescription drug/opioid 

overdose-related deaths among individuals aged 18 or older by training first responders and other 

community stakeholders on prevention strategies.

A few states have passed legislation to make naloxone more readily available without a prescription 

if certain procedures are followed.376,377 As of July 2015, 30 states have passed laws to provide legal 

protection to physician prescribers and to bystanders (“Good Samaritans”) who administer naloxone 

when encountering an overdose situation.378 Additionally, 48 states allow pharmacists to enter into 

Collaborative Pharmacy Practice Agreements with prescribers, which allow naloxone to be dispensed 

to those who may be able to use it to save lives.379 For example, the Rhode Island Board of Pharmacy 

approved this type of agreement, which began in 2011 as a pilot program in five pharmacies. This 

program was expanded to all interested pharmacies in 2013 and formalized in regulation in 2014.380,381

States have also expanded naloxone coverage under Medicaid. The CDC reported more than 26,000 

overdose reversals by lay people between 1996 and 2014, all using naloxone.382 Health systems are 

developing protocols to dispense naloxone through primary care providers, pharmacies, and emergency 

departments. The need to engage individuals in services to address their opioid use is a critical next step 

following an overdose reversal. This becomes increasingly challenging as naloxone kits are distributed 

widely, rather than when distribution is limited to health care and substance use disorder treatment 

providers. In 2013, the State of Vermont implemented an innovative treatment system with the goal 

of increasing access to opioid treatment throughout the state. This model, called the “Hub and Spoke” 

approach, met this need by providing physicians throughout the state with training and supports for 

providing evidence-based buprenorphine treatment. 
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The result has been:383,384

$ An increase in the number of physicians providing buprenorphine treatment by over 40 

percent;

$ The transition of several hundred individuals served in traditional OTP programs to certified 

physicians in primary care settings;

$ Better access throughout the state to opioid treatment due to the expansion of entry points, and 

physician/OTP coordination; and

$ An increased integration of primary care and addiction treatment.

Recommendations for Research 

A key finding from this chapter is that the traditional separation of specialty addiction treatment from 

mainstream health care has created obstacles to successful care coordination. Research is needed in 

three main areas: 

$ Models of integration of substance use services within mainstream health care;

$ Models of providing ongoing, chronic care within health care systems; and

$ Models of care coordination between specialty treatment systems and mainstream health care. 

In each of these areas, research is needed on the development of interventions and strategies for 

successfully implementing them. Outcomes for each model should include feasibility, substance use and 

other health outcomes, and cost. 

Although a great deal of research has shown that integrating health care services has potential value 

both in terms of outcomes and cost, only a few models of integration have been empirically tested. 

Mechanisms through the Affordable Care Act make it possible to provide and test innovative structural 

and financing models for integration within mainstream health care. This research should cover the 

continuum of care, from prevention and early intervention to treatment and recovery, and will help 

health systems move forward with integration. This research should explore innovative delivery models 

including telemedicine and other health IT, as well as health or wellness coaching. Studies should focus 

on patient-centered approaches and should address appropriate interventions for individuals across 

race and ethnicity, culture, language, sex, sexual orientation, gender identity, disability, health literacy, 

and for those living in rural areas. So as not to limit health care systems to services for those with mild 

or moderate substance misuse problems and to offer support for individuals with severe problems who 

are not motivated to go to specialty substance use disorder treatment, it is also important to study how 

to implement medication and other evidence-based treatments across diverse health care systems. 

This chapter pointed out that when substance use problems become severe, providing ongoing, 

chronic care is required, as is the case for many other diseases. Little research has studied chronic care 

models for the treatment of substance use disorders. Research is needed to develop and test innovative 

models of care coordination and their implementation. This research should use a more broadly 
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defined workforce in both health care and substance use disorder treatment, develop models to share 

information electronically, and support coordination of care between health systems using health IT. 

Finally, the chapter pointed out the gap in our understanding of how to implement models of care 

coordination between specialty addiction treatment organizations and social service systems, which 

provide important wrap-around services to substance use disorder patients. Many models are in 

existence, but have not been empirically tested. This area of research should involve institutions 

that provide services to individuals with serious co-occurring problems (specialty mental health 

agencies), individuals with legal problems (criminal justice agencies and drug courts), individuals with 

employment or other social issues, as well as the larger community, determining how to most effectively 

link each of these subpopulations with a recovery-oriented systems of care.
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References

1. World Health Organization. (2015). Health systems strengthening glossary, G-H. Health Systems. 

Retrieved from http://www.who.int/healthsystems/hss_glossary/en/index5.html. Accessed on 

August 16, 2016.

2. HealthIT.gov. (2015). Meaningful use definition & objectives. Retrieved from https://www.

healthit.gov/providers-professionals/meaningful-use-definition-objectives. Accessed on July 29, 

2016.

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345. National Academy for State Health Policy (NASHP). (2012). State ‘accountable care’ activity 

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346. Purington, K., Gauthier, A., Patel, S., & Miller, C. (2011). On the road to better value: State roles in 

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350. Institute of Medicine, Roundtable on Population Health Improvement, & Board on Population 

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364. National Institute on Alcohol Abuse and Alcoholism. (2005). Helping patients who drink too 

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369. Ghitza, U. E., Gore-Langton, R. E., Lindblad, R., Shide, D., Subramaniam, G., & Tai, B. (2013). 

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380. Centers for Disease Control Prevention. (2013). Acetyl fentanyl overdose fatalities—Rhode 

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383. Vermont Agency of Human Services. (2012). Integrated treatment continuum for substance use 

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VISION FOR THE FUTURE

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CHAPTER 7.

VISION FOR THE FUTURE: A PUBLIC 

HEALTH APPROACH

Substance misuse and substance use disorders directly affect millions of Americans every year, causing 

motor vehicle crashes, crimes, injuries, reduced quality of life, impaired health, and far too many deaths. 

Throughout this Report, we have summarized the research demonstrating that: 

$ The problems caused by substance misuse are not limited to substance use disorders, but 

include many other possible health and safety problems that can result from substance misuse 

even in the absence of a disorder;

$ Substance use has complex biological and social determinants, and substance use disorders are 

medical conditions involving disruption of key brain circuits; 

$ Prevention programs and policies that are based on sound evidence-based principles have been 

shown to reduce substance misuse and related harms significantly; 

$ Evidence-based behavioral and medication-assisted treatments (MAT) applied using a chronicillness-management approach have been shown to facilitate recovery from substance use 

disorders, prevent relapse, and improve other outcomes, such as reducing criminal behavior and 

the spread of infectious diseases; 

$ A chronic-illness-management approach may be needed to treat the most severe substance use 

disorders; and 

$ Access to recovery support services can help former substance users achieve and sustain longterm wellness. 

Embedding prevention, treatment, and recovery services into the larger health care system will increase 

access to care, improve quality of services, and produce improved outcomes for countless Americans. 
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Time for a Change

It is time to change how we as a society address alcohol and drug misuse and substance use disorders. 

A national opioid overdose epidemic has captured the attention of the public as well as federal, state, 

local, and tribal leaders across the country. Ongoing efforts to reform health care and criminal justice 

systems are creating new opportunities to increase access to prevention and treatment services. 

Health care reform and parity laws are providing significant opportunities and incentives to address 

substance misuse and related disorders more effectively in diverse health care settings. At the same time, 

many states are making changes to drug policies, ranging from mandating use of prescription drug 

monitoring programs (PDMPs) to eliminating mandatory minimum drug sentences. These changes 

represent new opportunities to create policies and practices that are more evidence-informed to address 

health and social problems related to substance misuse. 

The moral obligation to address substance misuse and substance use disorders effectively for all 

Americans also aligns with a strong economic imperative. Substance misuse and substance use disorders 

are estimated to cost society $442 billion each year in health care costs, lost productivity, and criminal 

justice costs.1,2 However, numerous evidence-based prevention and treatment policies and programs 

can be implemented to reduce these costs while improving health and wellness. More than 10 million 

full-time workers in our nation have a substance use disorder—a leading cause of disability3—and 

studies have demonstrated that prevention and treatment programs for employees with substance use 

disorders are cost effective in improving worker productivity.4,5 Prevention and treatment also reduce 

criminal justice-related costs, and they are much less expensive than alternatives such as incarceration. 

Implementation of evidence-based interventions (EBIs) can have a benefit of more than $58 for every 

dollar spent; and studies show that every dollar spent on substance use disorder treatment saves $4 

in health care costs and $7 in criminal justice costs.6 Yet, effective prevention interventions are highly 

underused. For example, only 8 to 10 percent of school administrators report using EBIs to prevent 

substance misuse,7,8 and only about 11 percent of youth (aged 12 to 17) report participating in a 

substance use prevention program outside of school.9 Further, only 10.4 percent of individuals with a 

substance use disorder receive treatment,9 and only about a third of those individuals receives treatment 

that meets minimal standards of care.10

The public health-based approach called for in this Report

aims to address the broad individual, environmental, and 

societal factors that influence substance misuse and its 

consequences, to improve the health, safety, and well-being 

of the entire population. It aims to understand and address 

the wide range of interacting factors that influence substance 

misuse and substance use disorders in different communities 

and coordinates efforts across diverse stakeholders to achieve reductions in both.

The following five general messages described within the Report have important implications for policy 

and practice. These are followed by specific evidence-based suggestions for the roles individuals, 

families, organizations, and communities can play in more effectively addressing this major health issue.

See the side bar on “A Public Health 

Model for Addressing Substance Misuse 

and Related Consequences” in Chapter 

1 - Introduction and Overview.
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1. Both substance misuse and substance use disorders harm 

the health and well-being of individuals and communities. 

Addressing them requires implementation of effective strategies.

Substance misuse is the use of alcohol or illicit or prescription drugs in a manner that may cause 

harm to users or to those around them. Harms can include overdoses, interpersonal violence, motor 

vehicle crashes, as well as injuries, homicides, and suicides—the leading causes of death in adolescents 

and young adults (aged 12 to 25).11 In 2015, 47.7 million Americans used an illicit drug or misused a 

prescription medication in the past year, 66.7 million binge drank in the past month, and 27.9 million 

self-reported driving under the influence (DUI) in the past year.9

Substance use disorders are medical illnesses that develop 

in some individuals who misuse substances—more than 

20 million individuals in 2015.9 These disorders involve 

impaired control over substance use that results from 

disruption of specific brain circuits. Substance use disorders 

occur along a continuum from mild to severe; severe substance use disorders are also called addictions. 

Because substances have particularly powerful effects on the developing adolescent brain, young adults 

who misuse substances are at increased risk of developing a substance use disorder at some point in 

their lives. 

See Chapter 2 - The Neurobiology of 

Substance Use, Misuse, and Addiction.

Implications for Policy and Practice

Expanding access to effective, evidence-based treatments for those with addiction and also less severe 

substance use disorders is critical, but broader prevention programs and policies are also essential 

to reduce substance misuse and the pervasive health and social problems caused by it. Although they 

cannot address the chronic, severe impairments common among individuals with substance use 

disorders, education, regular monitoring, and even modest legal sanctions may significantly reduce 

substance misuse in the wider population. Additionally, these measures are cost-effective. Many policies 

at the federal, state, local, and tribal levels that aim to reduce the harms associated with substance 

use have proven very effective in preventing and reducing alcohol misuse (e.g., binge drinking) and 

its consequences. More than 300,000 deaths have been avoided over the past decade simply from the 

implementation and enforcement of effective policies to reduce underage drinking and DUI.12 Needle/

syringe exchange programs also represent effective and cost-effective prevention strategies that have 

been shown to reduce the transmission of HIV in communities implementing them, without increasing 

rates of injection drug use. These programs also provide the opportunity to engage people who inject 

drugs in treatment. These types of effective prevention policies can and should be adapted and extended 

to reduce the injuries, disabilities, and deaths caused by substance misuse.13
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2. Highly effective community-based prevention programs and 

policies exist and should be widely implemented. 

This Report describes the significant advances in prevention science over the past two decades, including 

the identification of major risk and protective factors and the development of more than four dozen 

research-tested prevention interventions that can be delivered in households, schools, clinical settings, 

and community centers. Three key findings from the Report are especially important in this regard. 

First, science has shown that adolescence and young adulthood are major “at risk” periods for substance 

misuse and related harms. Second, most of the major genetic, social, and environmental risk factors that 

predict substance misuse also predict many other serious adverse outcomes and risks. Third, several 

community-delivered prevention programs and policies have been shown to significantly reduce rates 

of substance-use initiation and misuse-related harms. 

Prevention programs and interventions can have a strong impact and be cost-effective, but only 

if evidence-based components are used and if those components are delivered in a coordinated 

and consistent fashion throughout the at-risk period. Parents, schools, health care systems, faith 

communities, and social service organizations should be involved in delivering comprehensive, 

evidence-based community prevention programs that are sustained over time.

Additionally, research has demonstrated that policies and environmental strategies are highly effective in 

reducing alcohol-related problems by focusing on the social, political, and economic contexts in which 

these problems occur. These evidence-based policies include regulating alcohol outlet density, restricting 

hours and days of sale, and policies to increase the price of alcohol at the federal, state, or local level.

Implications for Policy and Practice

To be effective, prevention programs and policies should be designed to address the common risk and 

protective factors that influence the most common health threats affecting young people. They should 

be tested through research and should be delivered continuously throughout the entire at-risk period by 

those who have been properly trained and supervised to use them. Federal and state funding incentives 

could increase the number of properly organized community coalitions using effective prevention 

practices that adhere to commonly defined standards. The research reviewed in this Report suggests 

that such coordinated efforts could significantly improve the impact of existing prevention funding, 

programs, and policies, enhancing quality of life for American families and communities. 

3. Full integration of the continuum of services for substance 

use disorders with the rest of health care could significantly 

improve the quality, effectiveness, and safety of all health care.

Individuals with substance use disorders at all levels of severity can benefit from treatment, and research 

shows that integrating substance use disorder treatment into mainstream health care can improve the 

quality of treatment services. Historically, however, only individuals with the most severe substance 

use disorders have received treatment, and only in independent “addiction treatment programs” that 

were originally designed in the early 1960s to treat addictions as personality or character disorders. 

Moreover, although 45 percent of patients seeking treatment for substance use disorders have a co-
VISION FOR THE FUTURE

PAGE | 7-5

occurring mental disorder,14 most specialty substance use disorder treatment programs are not part 

of, or even affiliated with, mental or physical health care organizations. Similarly, most general health 

care organizations—even teaching hospitals—do not provide screening, diagnosis, or treatment for 

substance use disorders. 

This separation of substance use disorder treatment from the rest of health care has contributed to the lack 

of understanding of the medical nature of these conditions, lack of awareness among affected individuals 

that they have a significant health problem, and slow adoption of scientifically supported medical 

treatments by addiction treatment providers. Additionally, mainstream health care has been inadequately 

prepared to address the prevalent substance misuse–related problems of patients in many clinical settings. 

This has contributed to incorrect diagnoses, inappropriate treatment plans, poor adherence to treatment 

plans by patients, and high rates of emergency department and hospital admissions. 

The goals of substance use disorder treatment are very similar to the treatment goals for other chronic 

illnesses: to eliminate or reduce the primary symptoms (substance use), improve general health and 

function, and increase the motivation and skills of patients and their families to manage threats of relapse. 

Even serious substance use disorders can be treated effectively, with recurrence rates equivalent to those 

of other chronic illnesses such as diabetes, asthma, or hypertension.15 With comprehensive continuing 

care, recovery is an achievable outcome: More than 25 million individuals with a previous substance use 

disorder are estimated to be in remission.16 Integrated treatment can dramatically improve patient health 

and quality of life, reduce fatalities, address health disparities, and reduce societal costs that result from 

unrecognized, unaddressed substance use disorders among patients in the general health care system. 

However, most existing substance use disorder treatment programs lack the needed training, personnel, 

and infrastructure to provide treatment for co-occurring physical and mental illnesses. Similarly, most 

physicians, nurses, and other health care professionals working in general health care settings have not 

received training in screening, diagnosing, or addressing substance use disorders. 

Implications for Policy and Practice

Policy changes, particularly at the state level, are needed to better integrate care for substance use 

disorders with the rest of health care. States have substantial power to shape the nature of care 

within these programs. State licensing and financing policies should be designed to better incentivize 

programs that offer the full continuum of care (residential, outpatient, continuing care, and recovery 

supports); offer a full range of evidence-based behavioral treatments and medications; and maintain 

working affiliations with general and mental health care professionals to integrate care. Within general 

health care, federal and state grants and development programs should make eligibility contingent on 

integrating care for mental and substance use disorders or provide incentives for organizations that 

support this type of integration. 

But integration of mental health and substance use disorder care into general health care will not 

be possible without a workforce that is competently cross-educated and trained in all these areas. 

Currently, only 8 percent of American medical schools offer a separate, required course on addiction 

medicine and 36 percent have an elective course; minimal or no professional education on substance 

use disorders is available for other health professionals.17-19 Federal and state policies should require 

or incentivize medical, nursing, dental, pharmacy, and other clinical professional schools to provide 
VISION FOR THE FUTURE

PAGE | 7-6

mandatory courses to properly equip young health care professionals to address substance misuse and 

related health consequences. Similarly, associations of clinical professionals should continue to provide 

continuing education and training courses for those already in practice. 

4. Coordination and implementation of recent health reform and 

parity laws will help ensure increased access to services for 

people with substance use disorders. 

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 

(MHPAEA) and the 2010 Affordable Care Act increased access to coverage for mental health and 

substance use disorder treatment services for more than 161 million Americans. Even so, just 10.4 

percent of people with substance use disorders who need treatment are accessing care.9 These pieces 

of legislation, besides promoting equity, make good long-term economic sense: Research reviewed 

in Chapter 6 - Health Care Systems and Substance Use Disorders highlights the extraordinary costs to 

society from unaddressed substance misuse and from untreated or inappropriately treated substance 

use disorders—more than $422 billion annually (including more than $120 billion in health care costs). 

However, there remains great uncertainty on the part of affected individuals and their families, as well 

as among many health care professionals, about the nature and range of health care benefits and covered 

services available for prevention, early intervention, and treatment of substance use disorders. 

Implications for Policy and Practice 

Enhanced federal communication will help increase public understanding about individuals’ rights to 

appropriate care and services for substance use disorders. This communication could help eliminate 

confusion among patients, providers, and insurers. But, more will be needed to extend the reach 

of treatment and thereby reduce the prevalence, severity, and costs associated with substance use 

disorders. Within health care organizations, active screening for substance misuse and substance use 

disorders combined with effective communication around the availability of treatment programs 

could do much to engage untreated individuals in care. Screening and treatment must incorporate 

brief interventions for mildly affected individuals as well as the full range of evidence-based behavioral 

therapies and medications for more severe disorders, and must be provided by a fully trained 

complement of health care professionals.

5. A large body of research has clarified the biological, 

psychological, and social underpinnings of substance misuse and 

related disorders and described effective prevention, treatment, 

and recovery support services. Future research is needed to 

guide the new public health approach to substance misuse and 

substance use disorders.

Five decades ago, basic, pharmacological, epidemiological, clinical, and implementation research played 

important roles in informing a skeptical public about the harms of cigarette smoking and creating new and 

better prevention and treatment options. Similarly, research reviewed in this Report should eliminate many 
VISION FOR THE FUTURE

PAGE | 7-7

of the long-held, but incorrect, stereotypes about substance misuse and substance use disorders, such as that 

alcohol and drug problems are the product of faulty character or willful rejection of social norms. 

Thanks to scientific research over the past two decades, we know far more about alcohol and drugs 

and their effects on health than we knew about the effects of smoking when the first Surgeon General’s 

Report on Smoking and Health was released in 1964. For instance, we now know that repeated substance 

misuse carries the greatest threat of developing into a substance use disorder when substance use begins 

in adolescence. We also know that substance use disorders involve persistent changes in specific brain 

circuits that control the perceived value of a substance as well as reward, stress, and executive functions, 

like decision making and self-control. 

However, although this body of knowledge provides a firm foundation for developing effective prevention, 

early intervention, treatment, and recovery strategies, achieving the vision of this Report will require redoubled 

research efforts. We still do not fully understand how the brain changes involved in substance use disorders 

occur, how individual biological and environmental risk factors contribute to those changes, or the extent to 

which these brain changes reverse after long periods of abstinence from alcohol or drug use. 

Implications for Policy and Practice 

Future research should build upon our existing knowledge base to inform the development of 

prevention and treatment strategies that more directly target brain circuit abnormalities that underlie 

substance use disorders; identify which prevention and treatment interventions are most effective for 

which patients (personalizing medicine); clarify how the brain and body regain function and recover 

after chronic drug exposure; and inform the development of evidence-based strategies for supporting 

recovery. Also critically needed are long-term prospective studies of youth (particularly those deemed 

most at risk) that will concurrently study changes in personal and environmental risks; the nature, 

amount, and frequency of substance use; and changes in brain structure and function. 

To guide the important system-wide changes recommended in this Report, research to optimize 

strategies for broadly and sustainably implementing evidence-based prevention, treatment, and 

recovery interventions across the community is necessary. Within traditional substance use disorder 

treatment programs, research is needed on how to use new insurance benefits and financing models 

to enhance service delivery most effectively, how to form working alliances with general physical and 

mental health providers, and how to integrate new technologies and information systems to enhance 

care without compromising patient confidentiality. 

Specific Suggestions for Key Stakeholders

Current health reform efforts and recent advances in technology are playing a crucial role in moving 

toward an effective public health-based model for addressing substance misuse and its consequences. But 

the health care system cannot address all of the major determinants of health related to substance misuse 

without the help of the wider community. This Report calls on a range of stakeholder groups to do their 

part to change the culture, attitudes, and practices around substance use and to keep the conversation 

going until this goal is met. Prejudice and discrimination have created many of the challenges that plague 
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PAGE | 7-8

the substance use disorder treatment field. These factors can have a profound influence on individuals’ 

willingness to talk to their health care professional about their substance use concerns; to seek or access 

treatment services; and to be open with friends, family, and coworkers about their treatment and recovery 

needs. Changing the culture is an essential piece of lasting reforms, creating a society in which: 

$ People who need help feel comfortable seeking it;

$ There is “no wrong door” for accessing health services;

$ Communities are willing to invest in prevention services, knowing that such investment pays 

off over the long term, with wide-ranging benefits for everyone;

$ Health care professionals treat substance use disorders with the same level of compassion and 

care as they would any other chronic disease, such as diabetes or heart disease;

$ People are celebrated for their efforts to get well and for their steps in recovery; and

$ Everyone knows that their care and support can make a meaningful difference in someone’s 

recovery.

In addition to facilitating such a mindset, community leaders can work together to mobilize the 

capacities of health care organizations, social service organizations, educational systems, communitybased organizations, government health agencies, religious institutions, law enforcement, local 

businesses, researchers, and other public, private, and voluntary entities that impact public health. 

Everyone has a role to play in addressing substance misuse and substance use disorders and in changing the 

conversation around substance use, to improve the health, safety, and well-being of individuals and communities across 

our nation.

Individuals and Families 

Reach out, if you think you have a problem. 

In the past, many individuals and families have kept silent about substance-related issues because of 

shame, guilt, or fear of exposure or recrimination. Breaking the silence and isolation around such issues 

is crucial, so that individuals and families confronting substance misuse and its consequences know that 

they are not alone and can openly seek treatment. As with other chronic illnesses, the earlier treatment 

begins, the better the outcomes are likely to be. 

Be supportive (not judgmental) if a loved one has a problem. 

Recognizing that substance use disorders are medical conditions and not moral failings can help remove 

negative attitudes and promote open and healthy discussion between individuals with substance 

use disorders and their loved ones, as well as with their health care professionals. Overcoming the 

powerful drive to continue substance use can be difficult, and making the lifestyle changes necessary for 

successful treatment—such as changing relationships, jobs, or living environments—can be daunting. 

Providing sensitivity and support can ease this transition. 

This can be challenging for partners, parents, siblings, and other loved ones of people with substance use 

disorders; many of the behaviors associated with substance misuse can be damaging to relationships. Being 
VISION FOR THE FUTURE

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compassionate and caring does not mean that you do not hold the person accountable for their actions. It 

means that you see the person’s behaviors in the light of a medical illness. Love and support can be offered 

while maintaining the boundaries that are important for your health and the health of everyone around you. 

Show support toward people in recovery. 

As a community, we typically show empathy when someone we know is ill, and we celebrate when 

people we know overcome an illness. Extending these kindnesses to people with substance use 

disorders and those in recovery can provide added encouragement to help them realize and maintain 

their recovery. It also will encourage others to seek out treatment when they need it. 

Advocate for the changes needed in your community. 

As discussed throughout this Report, many challenges need to be addressed to support a public healthbased approach to substance misuse and related disorders. Everyone can play an important role in 

advocating for their needs, the needs of their loved ones, and the needs of their community. It is 

important that all voices are heard as we come together to address these challenges. 

Parents, talk to your children about alcohol and drugs. 

Parents have more influence over their children’s behavior, including substance use, than they often 

think. For instance, according to one study, young adults who reported that their parents monitored 

their behavior and showed concern about them were less likely to report misusing substances.20 Talking 

to your children about alcohol and drug use is not always easy, but it is crucial. Become informed, from 

reliable sources, about substances to which your children could be exposed, and about substance use 

disorders, and talk openly with your children about the risks. Some tips to keep in mind:

$ Be a good listener;

$ Set clear expectations about alcohol and drug use, including real consequences for not following 

family rules; 

$ Help your child deal with peer pressure;

$ Get to know your child’s friends and their parents;

$ Talk to your child early and often; and

$ Support your school district’s efforts to implement evidence-based prevention interventions 

and treatment and recovery support.

Educators and Academic Institutions 

Implement evidence-based prevention interventions. 

Schools represent one of the most effective channels for influencing youth substance use. Many highly 

effective evidence-based programs are available that provide a strong return on investment, both in the 

well-being of the children they reach and in reducing long-term societal costs. Prevention programs 

for adolescents should target improving academic as well as social and emotional learning to address 

risk factors for substance misuse, such as early aggression, academic failure, and school dropout. 
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When combined with family-based and community programs that present consistent messages, these 

programs are even more powerful. Interventions that target youth who have already initiated use 

of alcohol or drugs should also be implemented to prevent escalation of use. Colleges, too, should 

implement EBIs to reduce student alcohol misuse.

Provide treatment and recovery supports. 

Many students lack regular access to the health care system. For students with substance use problems, 

schools—ranging from primary school through university—can provide an entry into treatment and 

support for ongoing recovery. School counselors and school health care programs can provide enrolled 

students with screening, brief counseling, and referral to more comprehensive treatment services. 

Schools can also help create a supportive environment that fosters recovery. Many institutions of higher 

learning incorporate collegiate recovery programs that can make a profound difference for young 

people trying to maintain recovery in an environment with high rates of substance misuse.

Teach accurate, up-to-date scientific information about alcohol and drugs and about substance use 

disorders as medical conditions. 

Teachers, professors, and school counselors play an obvious and central role as youth influencers, 

teaching students about the health consequences of substance use and misuse and about substance use 

disorders as medical conditions, as well as facilitating open dialogue. They can also play an active role 

in educating parents and community members on these topics and the role they can play in preventing 

youth substance use. For example, they can educate businesses near schools about the positive impact 

of strong enforcement of underage drinking laws and about the potential harms of synthetic drugs 

(such as K2 and bath salts), to discourage their sale. They can also promote non-shaming language that 

underscores the medical nature of addiction—for instance avoiding terms like “abuser” or “addict” 

when describing people with substance use disorders.21

Enhance training of health care professionals. 

As substance use treatment becomes more integrated with the health care delivery system, there is a 

need for advanced education and training for providers in all health care roles and disciplines, including 

primary care doctors, nurses, specialty treatment providers, and prevention and recovery specialists. 

It is essential that professional schools of social work, psychology, public health, nursing, medicine, 

dentistry, and pharmacy incorporate curricula that reflect the current science of prevention, treatment, 

and recovery. Health care professionals must also be alert for the possibility of adverse drug reactions 

(e.g., co-prescribing of drugs with similar effects, drug overdoses), and co-occurring psychiatric 

conditions and infectious diseases, and should be trained on how to address these issues. These topics 

should also be covered in formal post-graduate training programs (e.g., physician residencies and 

psychology internships) as well as in board certification and continuing education requirements for 

professionals in these fields. Continuing education should include not only subject matter knowledge 

but the professional skills necessary to provide integrated care within cross-disciplinary health care 

teams that address substance-related health issues. 
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Health Care Professionals and Professional Associations

Address substance use-related health issues with the same sensitivity and care as any other chronic 

health condition. 

All health care professionals—including physicians, physician assistants, nurses, nurse practitioners, 

dentists, social workers, therapists, and pharmacists—can play a role in addressing substance misuse 

and substance use disorders, not only by directly providing health care services, but also by promoting 

prevention strategies and supporting the infrastructure changes needed to better integrate care for 

substance use disorders into general health care and other treatment settings. 

Support high-quality care for substance use disorders. 

Professional associations can be instrumental in setting 

workforce guidelines, advocating for curriculum changes 

in professional schools, promoting professional continuing 

education training, and developing evidence-based guidelines 

that outline best practices for prevention, screening and 

assessment, brief interventions, diagnosis, and treatment 

of substance-related health issues. For example, to help address the current prescription opioid crisis 

and overdose epidemic, associations should raise awareness of the most recent guidelines for opioid 

prescribing and commend the use of PDMPs by providers. Associations also should raise awareness 

of the benefits of making naloxone more readily available without a prescription and providing legal 

protection to physician-prescribers and bystanders (“Good Samaritans”) who administer naloxone when 

encountering an overdose situation.

See the section on Enhancing training of 

health care professionals earlier in this 

chapter.

Health Care Systems 

Promote primary prevention. 

Health care systems can help prevent prescription drug misuse and related substance use disorders 

by holding staff accountable for safe prescribing of controlled substances, training staff on alternative 

ways of managing pain and anxiety, and increasing use of PDMPs by pharmacists, physicians, and other 

providers.

Promote use of evidence-based treatments. 

Substance use disorders cannot be effectively addressed without much wider adoption and 

implementation of scientifically tested and proven effective behavioral and pharmacological treatments. 

The full spectrum of evidence-based treatments should be available across all contexts of care, and 

treatment plans should be tailored to meet the specific needs of individual patients. Health care systems 

should take every step to educate health care professionals and the public about the value of MAT for 

alcohol and opioid use disorders, correcting misconceptions that have barred their wider adoption in 

the past.
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Promote effective integration of prevention and treatment services. 

Effective integration of behavioral health and general health care is essential for identifying patients in 

need of treatment, engaging them in the appropriate level of care, and ensuring ongoing monitoring 

of patients with substance use disorders to reduce their risk of relapse. Implementation of systems to 

support this type of integration requires care and foresight and should include educating and training 

the relevant workforces; developing new workflows to support universal screening, appropriate followup, coordination of care across providers, and ongoing recovery management; and linking patients and 

families to available support services. Quality measurement and improvement processes should also 

be incorporated to ensure that the services provided are effectively addressing the needs of the patient 

population and improving outcomes. 

Work with payors to develop and implement comprehensive billing models. 

Consideration of how payors can develop and implement comprehensive billing models is crucial to 

enabling health care systems to sustainably implement integrated services to address substance use 

disorders. Coverage policies will need to be updated to support implementation of prevention measures, 

screening, brief counseling, and recovery support services within the general health care system, and 

to support coordination of care between specialty substance use disorder treatment programs, mental 

health organizations, and the general health care system.

Implement health information technologies to promote efficiency and high-quality care.

Health information technology—ranging from electronic 

health records to patient registries, computer-based 

educational systems, and mobile applications—has the power 

to increase efficiency, improve clinical decision making, 

supplement patient services, extend the reach of the workforce, 

improve quality measurement, and support a “learning health 

care system.” Health care systems should explore how these and other technologies can be used to support 

substance use disorder prevention, treatment, and recovery. 

See the definition of “Learning Health 

Care System” in Chapter 6 - Health Care 

Systems and Substance Use Disorders. 

Communities

Build awareness of substance use as a public health problem. 

Civic and advocacy groups, neighborhood associations, and community-based organizations can all 

play a major role in communication, education, and advocacy efforts that seek to address substance userelated health issues. These organizations provide community leadership and communicate urgent and 

emerging issues to specific audiences and constituencies. Communication vehicles such as newsletters, 

blogs, op-ed articles, and storytelling can be used to raise awareness and underscore the importance 

of placing substance use-related health issues in a public health framework. Community groups and 

organizations can host community forums, town hall meetings, listening sessions, and education 

and awareness days. These events foster public discourse, create venues in which diverse voices can 

be heard, and provide opportunities to educate the community. In addition, they can promote an 

awareness of the medical nature of addiction, to encourage acceptance of opioid treatment programs 
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and other substance use disorder treatment services embedded in the community. Communities also 

can sponsor prevention and recovery campaigns, health fairs, marches, and rallies that emphasize 

wellness activities that bring attention to substance use-related health issues. 

Invest in evidence-based prevention interventions and recovery supports. 

Prevention research has developed effective community-based prevention programs that reduce 

substance use and delinquent behavior among youth. Although the process of getting these programs 

implemented in communities has been slow, resources are available to help individual communities 

identify the risk factors for future substance use among youth that are most prevalent within their 

community and choose evidence-based prevention strategies to address them. Research shows that for 

each dollar invested in research-based prevention programs, up to $10 is saved in treatment for alcohol 

or other substance misuse-related costs.22-25

Implement interventions to reduce harms associated with alcohol and drug misuse.

An essential part of a comprehensive public health approach to addressing substance misuse is wider 

use of strategies to reduce individual and societal harms, such as overdoses, motor vehicle crashes, 

and the spread of infectious diseases. Communities across the country are implementing programs to 

distribute naloxone to first responders, opioid users, and potential bystanders, preventing thousands of 

deaths.26 Others have implemented needle/syringe exchange programs, successfully reducing the spread 

of HIV and Hepatitis C without seeing an increase in injection drug use. These and other evidencebased strategies can have a profound impact on the overall health and well-being of the community. 

Private Sector: Industry and Commerce 

Promote only responsible, safe use of legal substances, by adults. 

Companies that manufacture and sell alcohol and legal drugs, as well as products related to use of 

these substances, can demonstrate social responsibility by taking measures to discourage and prevent 

the misuse of their products. Companies can take steps to ensure that the public is aware of the risks 

associated with substance use, including the use of medications with addictive potential alone and in 

combination with alcohol or other drugs.

Support youth substance use prevention. 

Manufacturers and sellers of alcohol, legal drugs, and related products have a role in reducing and 

preventing youth substance use. They can discourage the sale and promotion of alcohol and other 

substances to minors and support evidence based programs to prevent and reduce youth substance use.

Continue to collaborate with the federal initiative to reduce prescription opioid- and heroin-related 

overdose, death, and dependence.

Pharmaceutical companies and pharmacies can continue to collaborate with the U.S. Department of 

Health and Human Services to identify and implement evidence-informed solutions to the current 

opioid crisis. This collaboration may include examining and revising product labeling, funding 

continuing medical education for providers on the appropriate use of opioid medications, developing 
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abuse-deterrent formulations of opioids, prioritizing development of non-opioid alternatives for pain 

relief, and conducting studies to determine the appropriate dosing of opioids in children and safe 

prescribing practices for both children and adults.27

Federal, State, Local, and Tribal Governments 

Provide leadership, guidance, and vision in supporting a science-based approach to addressing 

substance use-related health issues. 

Coordinated federal, state, local, and tribal efforts are needed to promote a public health approach to 

addressing substance use, misuse, and related disorders. As discussed throughout this Report, widespread 

cultural and systemic issues need to be addressed to reduce the prevalence of substance misuse and 

related public health consequences. Government agencies have a major role to play in:

$ Improving public education and awareness; 

$ Conducting research and evaluations; 

$ Monitoring public health trends; 

$ Providing incentives, funding, and assistance to promote implementation of effective 

prevention, treatment, and recovery practices, policies, and programs; 

$ Addressing legislative and regulatory barriers; 

$ Improving coordination between health care, criminal justice, and social service organizations; and 

$ Fostering collaborative initiatives with the private sector. 

For example, federal and state agencies can implement policies to integrate current best practices—such 

as the Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain29

or mandatory use of PDMPs—among federal and state supported service providers. 

Improve coordination between social service systems and the health care system to address the social 

and environmental factors that contribute to the risk for substance use disorders. 

Social service systems serve individuals, families, and communities in a variety of capacities, often 

in tandem with the health care system. Social workers can play a significant role in helping patients 

with substance use disorders with the wrap-around services that are vital for successful treatment, 

including finding stable housing, obtaining job training or employment opportunities, and accessing 

recovery supports and other resources available in the community. In addition, they can coordinate 

care across providers, offer support for families, and help implement prevention programs. Child and 

family welfare systems also should implement trauma-informed, recovery-oriented, and public health 

approaches for parents who are misusing substances, while maintaining a strong focus on the safety and 

welfare of children.

Implement criminal justice reforms to transition to a less punitive and more health-focused approach. 

The criminal justice and juvenile justice systems can play pivotal roles in addressing substance userelated health issues across the community. These systems are engaged with a population at high-risk 
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for substance use disorders and often at a teachable moment—when individuals are more open to 

prevention messaging or to accepting the need for treatment. Less punitive, health-focused initiatives 

can have a critical impact on long-term outcomes. Sheriff’s offices, police departments, and county 

jails should work closely with citizens’ groups, prevention initiatives, treatment agencies, and recovery 

community organizations to create alternatives to arrest and lockup for nonviolent and substance userelated offenses. For example, drug courts have been a very successful model for diverting people with 

substance use disorders away from incarceration and into treatment.30 It is essential that these programs 

promote the delivery of evidence-based treatment services, including MAT.

Many prisoners have access to regular health care services only when they are incarcerated. Significant 

research supports the value of integrating prevention and treatment into criminal justice settings.31,32 In 

addition, community re-entry is a particularly high-risk time for relapse and overdose. Criminal justice 

systems can reduce these risks and reduce recidivism by coordinating with community health settings to 

ensure that patients with substance use disorders have continuing access to care upon release. 

Facilitate research on Schedule I substances

Some researchers indicate that the process for conducting studies on Schedule I substances, such as 

marijuana, can be burdensome and act as disincentives. It is clear that more research is needed to understand 

how use of these substances affect the brain and body in order to help inform effective treatments for 

overdose, withdrawal management, and addiction, as well as explore potential therapeutic uses. To help ease 

administrative burdens, federal agencies should continue to enhance efforts and partnerships to facilitate 

research. Some of these efforts have already borne positive outcomes. For example, a recent policy change 

will foster research by expanding the number of U.S. Drug Enforcement Administration (DEA) registered 

marijuana growers. Making marijuana available from new sources could both speed the pace of research and 

afford medication developers and researchers more options for formulating marijuana-derived investigational 

products. 

Researchers 

Conduct research that focuses on implementable, sustainable solutions to address high-priority 

substance use issues. 

Scientific research should be informed by ongoing public health needs. This includes research on the 

basic genetic and epigenetic contributors to substance use disorders and the environmental and social 

factors that influence risk; basic neuroscience research on substance use-related effects and brain 

recovery; studies adapting existing prevention programs to different populations and audiences; and 

trials of new and improved treatment approaches. Focused research is also needed to help address the 

significant research-to-practice gap in the implementation of evidence-based prevention and treatment 

interventions. Closing the gap between research discovery and clinical and community practice is 

both a complex challenge and an absolute necessity if we are to ensure that all populations benefit 

from the nation’s investments in scientific discoveries. Research is needed to better understand the 

barriers to successful and sustainable implementation of evidence-based interventions and to develop 

implementation strategies that effectively overcome these barriers. 
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Researchers should collaborate with health care professionals, payors, educators, people in treatment 

and recovery, community coalitions, and others to ensure that real-world barriers, such as workforce 

issues and billing limitations, are taken into consideration. These collaborations should also help 

researchers prioritize efforts to address critical ongoing barriers to effective prevention and treatment 

of substance use disorders. 

Consider how scientific research can inform public policy. 

Effective communication is critical for ensuring that the policies and programs that are implemented 

reflect the state of the science and have the greatest chance for improving outcomes. Scientific findings 

are often misrepresented in public policy debates. Scientific experts have a significant role to play in 

ensuring that the science is accurately represented in policies and program. 

Promote rigorous evaluation of programs and policies. 

Many programs and policies are often implemented without a sufficient evidence base or with 

limited fidelity to the evidence base; this may have unintended consequences when they are broadly 

implemented. Rigorous evaluation is needed to determine whether programs and policies are having 

their intended effect and to guide necessary changes when they are not. 

Conclusion

This Report is a call to all Americans to change the way we address substance misuse and substance 

use disorders in our society. Past approaches to these issues have been rooted in misconceptions and 

prejudice and have resulted in a lack of preventive care; diagnoses that are made too late or never; 

and poor access to treatment and recovery support services, which exacerbated health disparities and 

deprived countless individuals, families, and communities of healthy outcomes and quality of life. Now 

is the time to acknowledge that these disorders must be addressed with compassion and as preventable 

and treatable medical conditions. 

By adopting an evidence-based public health approach, we have the opportunity as a nation to take 

effective steps to prevent and treat substance use-related issues. Such an approach can prevent the 

initiation of substance use or escalation from use to a disorder, and thus it can reduce the number of 

people affected by these conditions; it can shorten the duration of illness for individuals who already 

have a disorder; and it can reduce the number of substance use-related deaths. A public health approach 

will also reduce collateral damage created by substance misuse, such as infectious disease transmission 

and motor vehicle crashes. Thus, promoting much wider adoption of appropriate evidence-based 

prevention, treatment, and recovery strategies needs to be a top public health priority.

Making this change will require a major cultural shift in the way Americans think about, talk about, 

look at, and act toward people with substance use disorders. Negative public attitudes about substance 

misuse and use disorders can be entrenched, but it is possible to change social viewpoints. This has 

been done many times in the past: For example, cancer and HIV used to be surrounded by fear and 

judgment, but they are now regarded by most Americans as medical conditions like many others. This 
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has helped to make people comfortable talking about their concerns with their health care professionals, 

widening access to prevention and treatment. We can similarly change our attitudes toward substance 

use disorders if we come together as a society with the resolve to do so. With the moral case so strongly 

aligned with the economic case, and supported by all the available science, now is the time to make this 

change for the health and well-being of all Americans.
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GLOSSARY

PAGE | 1

GLOSSARY OF TERMS

Term Definition

12-Step Program A group providing mutual support and fellowship for people recovering from addictive 

behaviors. The first 12-step program was Alcoholics Anonymous (AA), founded in 1935; 

an array of 12-step groups following a similar model have since emerged and are the most 

widely used mutual aid groups and steps for maintaining recovery recovery from alcohol 

and drug use disorders. It is not a form of treatment, and it is not to be confused with the 

treatment modality called Twelve-Step Facilitation. 

Abstinence Not using alcohol or drugs.

Addiction The most severe form of substance use disorder, associated with compulsive or 

uncontrolled use of one or more substances. Addiction is a chronic brain disease that has 

the potential for both recurrence (relapse) and recovery.

Agonist A chemical substance that binds to and activates certain receptors on cells, causing a 

biological response. Fentanyl and methadone are examples of opioid receptor agonists.

Antagonist A chemical substance that binds to and blocks the activation of certain receptors on 

cells, preventing a biological response. Naloxone is an example of an opioid receptor 

antagonist.

Binge Drinking For men, drinking 5 or more standard alcoholic drinks, and for women, 4 or more standard 

alcoholic drinks on the same occasion on at least 1 day in the past 30 days.

Case Management A coordinated approach to delivering health care, substance use disorder treatment, 

mental health care, and social services. This approach links clients with appropriate 

services to address specific needs and goals.

Clinical Decision 

Support 

A system that provides health care professionals, staff, patients, or other individuals 

with knowledge and person-specific information, intelligently filtered or presented at 

appropriate times, to enhance health and health care.

Clinical Trial Any research study that prospectively assigns human participants or groups of participants 

to one or more health-related interventions to evaluate the effects on health outcomes.

Compulsivity Repetitive behaviors in the face of adverse consequences, as well as repetitive behaviors 

that are inappropriate to a particular situation. People suffering from compulsions often 

recognize that the behaviors are harmful, but they nonetheless feel emotionally compelled 

to perform them. Doing so reduces tension, stress, or anxiety.
GLOSSARY

PAGE | 2

Term Definition

Continuum of Care An integrated system of care that guides and tracks a person over time through a 

comprehensive array of health services appropriate to the individual’s need. A continuum 

of care may include prevention, early intervention, treatment, continuing care, and 

recovery support.

Cost-Benefit Study A study that determines the economic worth of an intervention by quantifying its costs in 

monetary terms and comparing them with the benefits, also expressed in monetary terms. 

Total benefits divided by total costs is called a cost-benefit ratio. If the ratio is greater than 

1, the benefits outweigh the costs.

Cost-Effectiveness 

Study

A comparative analysis of two or more interventions against their health and economic 

outcomes. These outcomes could be lives saved, illnesses prevented, or years of life gained.

Dependence A state in which an organism only functions normally in the presence of a substance, 

experiencing physical disturbance when the substance is removed. A person can be 

dependent on a substance without being addicted, but dependence sometimes leads to 

addiction

Dissemination The active distribution of evidence-based interventions (EBIs) to specific audiences, with 

the goal of increasing their adoption. 

Drug Diversion A medical and legal concept involving the transfer of any legally prescribed controlled 

substance from the person for whom it was prescribed to another person for any illicit use.

Fidelity The extent to which an intervention is delivered as it was designed and intended to be 

delivered. 

Gender The social, cultural, or community designations of masculinity or femininity.

Health Care System The World Health Organization defines a health care system as (1) all the activities whose 

primary purpose is to promote, restore, and/or maintain health, and (2) the people, 

institutions, and resources, arranged together in accordance with established policies, 

to improve the health of the population they serve. The health care system is made up 

of diverse health care organizations ranging from primary care, specialty substance use 

disorder treatment (including residential and outpatient settings), mental health care, 

infectious disease clinics, school clinics, community health centers, hospitals, emergency 

departments, and others.

Health Disparities Preventable differences in the burden of disease or opportunities to achieve optimal 

health that are experienced by socially disadvantaged populations, defined by factors 

such as race or ethnicity, gender, education or income, disability, geographic location 

(e.g., rural or urban), or sexual orientation.

Heavy Drinking Defined by the Centers for Disease Control and Prevention (CDC) as consuming 8 or 

more drinks per week for women, and 15 or more drinks per week for men, and by the 

Substance Abuse and Mental Health Services Administration (SAMHSA), for research 

purposes, as binge drinking on 5 or more days in the past 30 days.

Implementation A specified set of activities designed to put policies and programs into practice.

Impulsivity Inability to resist urges, deficits in delaying gratification, and unreflective decision-making. 

Impulsivity is a tendency to act without foresight or regard for consequences and to 

prioritize immediate rewards over long-term goals. 

Inpatient Treatment Intensive, 24-hour-a-day services delivered in a hospital setting. 

Integration The systematic coordination of general and behavioral health care. Integrating services for 

primary care, mental health, and substance use use-related problems together produces 

the best outcomes and provides the most effective approach for supporting whole-person 

health and wellness. 
GLOSSARY

PAGE | 3

Term Definition

Intervention A professionally delivered program, service, or policy designed to prevent substance 

misuse (prevention intervention) or treat a substance use disorder (treatment intervention).

Learning Health Care 

System

As described by the IOM, a learning health care system is “designed to generate and 

apply the best evidence for the collaborative healthcare choices of each patient and 

provider; to drive the process of discovery as a natural outgrowth of patient care; and to 

ensure innovation, quality, safety, and value in health care.”

Longitudinal Study A type of study in which data on a particular group of people are gathered repeatedly 

over a period of years or even decades.

Meaningful Use Using certified EHR technology to improve quality, safety, efficiency, and reduce health 

disparities; engage patients and family; improve care coordination and population and 

public health; and maintain privacy and security of patient health information.

Negative 

Reinforcement

The process by which removal of a stimulus such as negative feelings or emotions 

increases the probability of a response like drug taking.

Net Economic Benefit The value of total benefits minus total costs.

Neurobiology The study of the anatomy, function, and diseases of the brain and nervous system.

Opioid Treatment 

Program (OTP)

SAMHSA-certified program, usually comprising a facility, staff, administration, patients, 

and services, that engages in supervised assessment and treatment, using methadone, 

buprenorphine, or naltrexone, of individuals who have opioid use disorders. An OTP can 

exist in a number of settings, including but not limited to intensive outpatient, residential, 

and hospital settings. Services may include medically supervised withdrawal and/or 

maintenance treatment, along with various levels of medical, psychiatric, psychosocial, 

and other types of supportive care.

Pharmacokinetics What the body does to a drug after it has been taken, including how rapidly the drug is 

absorbed, broken down, and processed by the body.

Positive 

Reinforcement

The process by which presentation of a stimulus such as a drug increases the probability 

of a response like drug taking.

Prescription Drug 

Misuse

Use of a drug in any way a doctor did not direct an individual to use it.

Prevalence The proportion of a population who have (or had) a specific characteristic—for example, 

an illness, condition, behavior, or risk factor— in a given time period.

Protective Factors Factors that directly decrease the likelihood of substance use and behavioral health 

problems or reduce the impact of risk factors on behavioral health problems.

Public Health System Defined as “all public, private, and voluntary entities that contribute to the delivery of 

essential public health services within a jurisdiction” and includes state and local public 

health agencies, public safety agencies, health care providers, human service and charity 

organizations, recreation and arts-related organizations, economic and philanthropic 

organizations, education and youth development organizations, and education and youth 

development organizations.

Quality-Adjusted Life 

Year (QALY)

A measure of the burden of disease used in economic evaluations of the value of health 

care interventions that accounts for both the years of life lived and the quality of life 

experienced during those years, relative to quality associated with perfect health.

Randomized 

Controlled Trial (RCT)

A clinical trial of an intervention in which people are randomly assigned either to a group 

receiving the intervention being studied or to a control group receiving a standard 

intervention, a placebo (a medicine with no therapeutic effect), or no intervention. At the 

end of the study, the results from the different groups are compared.
PAGE | 4

Term Definition

Recovery A process of change through which individuals improve their health and wellness, live a 

self-directed life, and strive to reach their full potential. Even individuals with severe and 

chronic substance use disorders can, with help, overcome their substance use disorder 

and regain health and social function. This is called remission. When those positive 

changes and values become part of a voluntarily adopted lifestyle, that is called “being 

in recovery”. Although abstinence from all substance misuse is a cardinal feature of a 

recovery lifestyle, it is not the only healthy, pro-social feature.

Relapse The return to alcohol or drug use after a significant period of abstinence.

Remission A medical term meaning that major disease symptoms are eliminated or diminished below 

a pre-determined, harmful level. 

Residential Treatment Intensive, 24-hour a day services delivered in settings other than a hospital. 

Risk Factors Factors that increase the likelihood of beginning substance use, of regular and harmful 

use, and of other behavioral health problems associated with use.

Sex The biological and physiological characteristics that define human beings as female or male.

Standard Drink Based on the 2015-2020 Dietary Guidelines for Americans, a standard drink is defined 

as 12 fl. oz. of regular beer, 8-9 fl. oz. of malt liquor, 5 fl. oz. of table wine, or 1.5 fl. oz. of 

80-proof distilled spirits. All of these drinks contain 14 grams (0.6 ounces) of pure alcohol.

Substance A psychoactive compound with the potential to cause health and social problems, 

including substance use disorders (and their most severe manifestation, addiction). 

Substance Misuse The use of any substance in a manner, situation, amount or frequency that can cause harm 

to users or to those around them. For some substances or individuals, any use would 

constitute as misuse (e.g., under-age drinking, injection drug use).

Substance Misuse 

Problems or 

Consequences

Any health or social problem that results from substance misuse. Substance misuse problems 

or consequences may affect the substance user or those around them, and they may be acute 

(e.g., an argument or fight, a motor vehicle crash, an overdose) or chronic (e.g., a long-term 

substance-related medical, family, or employment problem, or chronic medical condition, such 

as various cancers, heart disease, and liver disease). These problems may occur at any age and 

are more likely to occur with greater frequency of substance misuse.

Substance Use The use—even one time—of any substance.

Substance Use 

Disorders 

A medical illness caused by repeated misuse of a substance or substances. According to 

the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 

substance use disorders are characterized by clinically significant impairments in health, 

social function, and impaired control over substance use and are diagnosed through 

assessing cognitive, behavioral, and psychological symptoms. Substance use disorders 

range from mild to severe and from temporary to chronic. They typically develop 

gradually over time with repeated misuse, leading to changes in brain circuits governing 

incentive salience (the ability of substance-associated cues to trigger substance seeking), 

reward, stress, and executive functions like decision making and self-control. Note: Severe 

substance use disorders are commonly called addictions. 

Substance Use 

Disorder Treatment

A service or set of services that may include medication, counseling, and other supportive 

services designed to enable an individual to reduce or eliminate alcohol and/or other drug 

use, address associated physical or mental health problems, and restore the patient to 

maximum functional ability.

Telehealth The use of digital technologies such as electronic health records, mobile applications, 

telemedicine, and web-based tools to support the delivery of health care, health-related 

education, or other health-related services and functions.

Telemedicine Two-way, real-time interactive communication between a patient and a physician or other 

health care professional at a distant site. Telemedicine is a subcategory of telehealth.
PAGE | 5

Term Definition

Tolerance Alteration of the body’s responsiveness to alcohol or a drug such that higher doses are 

required to produce the same effect achieved during initial use.

Withdrawal A set of symptoms that are experienced when discontinuing use of a substance to which a 

person has become dependent or addicted, which can include negative emotions such as 

stress, anxiety, or depression, as well as physical effects such as nausea, vomiting, muscle 

aches, and cramping, among others. Withdrawal symptoms often lead a person to use the 

substance again.

Wrap-Around Services Wrap -around services are non-clinical services that facilitate patient engagement and 

retention in treatment as well as their ongoing recovery. This can include services to 

address patient needs related to transportation, employment, childcare, housing, legal 

and financial problems, among others.
ABBREVIATIONS

PAGE | 7

Abbreviation Definition

AA Alcoholics Anonymous

ACC Accountable Care Community

ACO Accountable Care Organization

AIDS Acquired Immune Deficiency Syndrome

ASAM American Society of Addiction Medicine

ASI Addiction Severity Index

AUDIT Alcohol Use Disorders Identification Test

BAC Blood Alcohol Content

BASICS Brief Alcohol Screening and Intervention for College Students

BNST Bed Nucleus of the Stria Terminalis

BRAIN Brain Research through Advancing Innovative Neurotechnologies

CADCA Community Anti-Drug Coalitions of America

CARA Comprehensive Addiction and Recovery Act

CARPS Computerized Alcohol-Related Problems Survey

CBT Cognitive Behavioral Therapy

CCO Coordinated Care Organization

CDC Centers for Disease Control and Prevention

CeA Central Nucleus of the Amygdala

CHIP Children’s Health Insurance Program

CIDI Composite International Diagnostic Interview

CMCA Communities Mobilizing for Change on Alcohol

CMS Centers for Medicare & Medicaid Services

CRF Corticotropin-Releasing Factor

CSA Controlled Substances Act

CTC Communities That Care

DEA Drug Enforcement Administration

LIST OF ABBREVIATIONS
ABBREVIATIONS

PAGE | 8

Abbreviation Definition

DSM-IV Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

DSM-5 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

DUI Driving Under the Influence

DS Dorsal Striatum

EBI Evidence-Based Interventions

EHR Electronic Health Record

FASD Fetal Alcohol Spectrum Disorder

FBT Family Behavior Therapy

FDA Food and Drug Administration

FQHC Federally Qualified Health Center

GABA Gamma-Aminobutyric Acid

HEDIS Healthcare Effectiveness Data and Information Set

HHS U.S. Department of Health and Human Services

HIPAA Health Insurance Portability and Accountability Act

HIV Human Immunodeficiency Virus

HRSA Health Resources and Services Administration

ICCPUD Interagency Coordinating Committee on the Prevention of Underage Drinking

IOM Institute of Medicine, now known as the Health and Medicine Division of the National 

Academies of Science, Engineering, and Medicine

LGBT Lesbian, Gay, Bisexual, and Transgender

LST Life Skills Training

MADD Mothers Against Drunk Driving

MET Motivational Enhancement Therapy

MHPAEA Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008

MLDA Minimum Legal Drinking Age

MRI Magnetic Resonance Imaging

NA Narcotics Anonymous 

NAc Nucleus Accumbens 

NASPER National All Schedules Prescription Electronic Reporting Act

NFP Nurse-Family Partnership Program

NHTSA National Highway Traffic Safety Administration

NIAAA National Institute on National Institute on Alcohol Abuse and Alcoholism 

NIDA National Institute on Drug Abuse

NIH National Institutes of Health

NREPP National Registry of Evidence-based Programs and Practices

NSDUH National Survey on Drug Use and Health

OTP Opioid Treatment Program

PDMP Prescription Drug Monitoring Program

PET Positron Emission Tomography

PFC Prefrontal Cortex

PRISM Psychiatric Research Interview for Substance and Mental Disorders

PROSPER PROmoting School-community-university Partnerships to Enhance Resilience
ABBREVIATIONS

PAGE | 9

Abbreviation Definition

PTSD Post-Traumatic Stress Disorder

QALY Quality-Adjusted Life Year

RHC Raising Healthy Children

RMC Recovery Management Check-up

RSS Recovery Support Services

SAMHSA Substance Abuse and Mental Health Services Administration

SBI Screening and Brief Intervention

SBIRT Screening, Brief Intervention, and Referral to Treatment

SFP Strengthening Families Program

SIM State Innovation Models

SPA State Plan Amendment

THC Δ9

-tetrahydrocannabinol

USPSTF U.S. Preventive Services Task Force

VTA Ventral Tegmental Area
 

LIST OF TABLES AND FIGURES
 

LIST OF TABLES
 

AND FIGURES
 

CHAPTER 1. INTRODUCTION AND OVERVIEW OF THE REPORT 

Figure 1.1 Past Month Rates of Substance Use Among People Aged 12 or Older: 

Percentages, 2002-2014, 2014 National Survey on Drug Use and 

Health (NSDUH) 1-2 

Table 1.1 Categories and Examples of Substances 1-5 

Table 1.2 Past Year Substance Use, Past Year Initiation of Substance Use, and Met 

Diagnostic Criteria for a Substance Use Disorder in the Past Year Among 

Persons Aged 12 Years or Older for Specific Substances: Numbers in Millions 

and Percentages, 2015 National Survey on Drug Use and Health (NSDUH) 1-9 

Figure 1.2 Trends in Binge Drinking and Past 30-Day Use of Illicit Drugs among 

Persons Aged 12 Years or Older, 2014 National Survey on Drug Use 

and Health (NSDUH) 1-10 

Table 1.3 Past Year Alcohol Use, Past Month Binge Alcohol Use, and Met Diagnostic 

Criteria for a Substance Use Disorder in the Past Year Among Persons 

Aged 12 Years or Older: Numbers in Millions and Percentages, 

2015 National Survey on Drug Use and Health (NSDUH) 1-11 

Table 1.4 Past Year Substance Use, Past 30-Day Illicit Drug Use, and Met Diagnostic 

Criteria for a Substance Use Disorder in the Past Year Among Persons 

Aged 12 Years or Older: Numbers in Millions and Percentages, 

2015 National Survey on Drug Use and Health (NSDUH) 1-11 

Table 1.5 Criteria for Diagnosing Substance Use Disorders 1-17 

CHAPTER 2. THE NEUROBIOLOGY OF SUBSTANCE USE, MISUSE, AND ADDICTION 

Figure 2.1 A Neuron and its Parts 2-4 

Figure 2.2 Areas of the Human Brain that Are Especially Important in Addiction 2-5 

Figure 2.3 The Three Stages of the Addiction Cycle and the Brain Regions Associated 

with Them 2-7 

PAGE | 11
 
LIST OF TABLES AND FIGURES
 

Figure 2.4 

Figure 2.5 

Figure 2.6 

Figure 2.7 

Figure 2.8 

The Binge/Intoxication Stage and the Basal Ganglia 

Actions of Addictive Substances on the Brain 

Major Neurotransmitter Systems Implicated in the Neuroadaptations 

Associated with the Binge/Intoxication Stage of Addiction 

The Withdrawal/Negative Affect Stage and the Extended Amygdala 

Time-Related Decrease in Dopamine Released in the Brain of a 

Cocaine User 

2-9 

2-10 

2-11 

2-13 

2-14 

Figure 2.9 

Figure 2.10 

Figure 2.11 

Major Neurotransmitter Systems Implicated in the Neuroadaptations 

Associated with the Withdrawal/Negative Affect Stage of Addiction 

The Preoccupation/Anticipation Stage and the Prefrontal Cortex 

Major Neurotransmitter Systems Implicated in the Neuroadaptations 

Associated with the Preoccupation/Anticipation Stage of Addiction 

2-15 

2-16 

2-17 

CHAPTER 3. PREVENTION PROGRAMS AND POLICIES 

Figure 3.1 

Table 3.1 

Table 3.2 

Table 3.3 

Figure 3.2 

Figure 3.3 

Past-Month Alcohol Use, Binge Alcohol Use, and Marijuana Use, by Age: 

Percentages, 2015 National Survey on Drug and Health (NSDUH) 

Risk Factors for Adolescent and Young Adult Substance Use 

Protective Factors for Adolescent and Young Adult Substance Use 

Cost-Benefit of EBIs Reviewed by the Washington State Institute for 

Public Policy, 2016 

Alcohol- Versus Non-alcohol-related Traffic Deaths, Rate per 100,000, 

All Ages, United States, 1982-2013 

Trends in 2-Week Prevalence of 5 or More Drinks in a Row among 

12th Graders, 1980-2015 

3-3 

3-5 

3-6 

3-14 

3-19 

3-21 

Table 3.4 Status of Selected Evidence-Based Strategies in States for Preventing 

Alcohol Misuse and Related Harms 3-24 

CHAPTER 4. EARLY INTERVENTION, TREATMENT, AND MANAGEMENT 

OF SUBSTANCE USE DISORDERS 

Figure 4.1 

Table 4.1 

Table 4.2 

Table 4.3 

Substance Use Status and Substance Use Care Continuum 

Evidence-Based Screening Tools for Substance Use 

Principles of Effective Treatment for Substance Use Disorders 

Detailed Information on Substance Use Disorder Assessment Tools 

4-4 

4-7 

4-14 

4-16 

Table 4.4 

Table 4.5 

Pharmacotherapies Used to Treat Alcohol and Opioid Use Disorders 

Examples of Technology-Assisted Interventions 

4-19 

4-33 

PAGE | 12
 
LIST OF TABLES AND FIGURES
 

CHAPTER 6. HEALTH CARE SYSTEMS AND SUBSTANCE USE DISORDERS 

Figure 6.1 Substance Use Disorders Services: Past and Future 6-8 

Figure 6.2 A Continuum of Collaboration between Health Care and Specialty 

Services 6-14 

Figure 6.3 Eligibility for Affordable Care Act Coverage Among the Nonelderly 

Uninsured by Race and Ethnicity, as of 2015 6-16 

Figure 6.4 Percentage Distribution of Spending on Substance Misuse Treatment 

by Setting, 1986–2014 6-24 

APPENDIX B. EVIDENCE-BASED PREVENTION PROGRAMS AND POLICIES 

Table B.1 Evidence-Based Interventions for Children Under Age 10 17 

Table B.2 Evidence-Based Interventions for Youth Aged 10 to18 20 

Table B.3 Evidence-Based Interventions for Age 18+ 27 

Table B.4 Evidence-Based Community Implementation Systems/ Coalition 

Models and Environmental Interventions 29 

Table B.5 Community Preventive Services Task Force Recommendations for 

Preventing Alcohol Misuse 32 

PAGE | 13
 
APPENDICES

PAGE | 15

APPENDIx A.

REVIEW PROCESS FOR 

PREVENTION PROGRAMS

Sources and Process 

The review of published research primarily focused on refereed, professional journals, which were 

searched using PubMed and PsycINFO. Government reports, annotated bibliographies, and relevant 

books and book chapters also were reviewed. In addition, programs were searched on SAMHSA’s 

National Registry of Evidence-based Programs and Practices (NREPP) and the Centers for Disease 

Control and Prevention (CDC) Guide to Community Preventive Services. From these collective sources, 

a set of 600 core prevention programs was identified for possible inclusion in this Report. Of those, 42 

met the evaluation criteria listed below and were included. 

Evaluation Criteria

Programs were included only if they met the program criteria of the Blueprints for Healthy Youth 

Development listed below. All of these programs fit within CDC’s well-supported category. 

$ Experimental design: All programs were evaluated using 

a randomized trial design or a quasi-experimental 

design that used an adequate comparison group. The 

prevention effects described compare the group or 

individuals that got the prevention intervention with 

those who did not.

$ Sample specification: The behavioral and social characteristics of the sample for which outcomes 

were measured must have been specified. 

$ Outcome assessments: These assessments must have included pretest, posttest, and follow-up 

findings. The need for follow-up findings was considered essential given the frequently 

observed dissipation of positive posttest results. Follow-up data had to be reported more than 

See Chapter 1 - Introduction and 

Overview.
APPENDICES

PAGE | 16

6 months beyond the time point at which the primary components of the intervention were 

delivered, in order to examine the duration and stability of intervention effects. 

$ Effects: Independent of whether the prevention intervention began prenatally, in the early 

years of life, or in adolescence or adulthood, programs were included only if they produced 

outcomes showing a measurable difference in substance use or substance use-related outcomes 

between intervention and comparison groups based on statistical significance testing. Level of 

significance and the size of the effects are reported in Appendix B - Evidence-Based Prevention 

Programs and Policies. Programs that broadly affected other behavioral health problems but did 

not show reductions in at least one direct measure of substance use were excluded. 

$ Additional quality of evidence criteria: The program provided evidence that seven quality of 

evidence criteria consistent with those of NREPPi were met: (1) reliability of outcome measures, 

(2) validity of outcome measures, (3) pretest equivalence, (4) intervention fidelity, (5) analysis 

of missing data, (6) degree and evaluation of sample attrition, and (7) appropriate statistical 

analyses. 

$ Operations Manual: The program had a written manual that specified the procedures used in the 

intervention to increase likelihood that the prevention intervention would be replicated with 

fidelity.

i Substance Abuse and Mental Health Services Administration. National registry of evidence-based programs 

and practices (NREPP). Retrieved from http://www.samhsa.gov/nrepp. Accessed on March 11, 2016.
APPENDICES

PAGE | 17

Table B.1: Evidence-Based Interventions for Children Under Age 10

Intervention

Type 

(Universal, 

Selective, 

Indicated)

Domain/Level 

(Family, School, 

Community, 

Multicomponent)

Sample

(at pretest)/ 

Ethnicity/ 

Setting Design Summary Results

Citations: Key 

Outcome 

Research/ 

Program 

Information

Source

Nurse-Family 

Partnership 

Program 

(NFP)

Selective Family Study 1: N = 

300 rural, poor 

pregnant White 

women, first 

births

Study 2: N = 

743 urban, 

poor pregnant 

African 

American 

women, first 

births

All studies: 

RCT/NTC

Study 1: At 13-year 

follow-up (age 15), 

parents in the nursevisits intervention 

reported their children 

had fewer behavioral 

problems due to use 

of substances (0.15 

vs. 0.34), and youth 

reported fewer days of 

alcohol consumption 

in past 6 months (1.09 

vs. 2.49). No effects on 

binge drinking or illicit 

drug use at age 19.

Study 2: At 10-year 

follow-up (age 12), 

lower 30-day use of 

cigarettes, alcohol, and 

marijuana (OR = 0.31).

Olds, et al. 

(1998)1

Eckenrode, et al. 

(2010)2

Kitzman, et al. 

(2010)3

APPENDIx B.

EVIDENCE-BASED PREVENTION 

PROGRAMS AND POLICIES
PAGE | 18

Intervention

Type 

(Universal, 

Selective, 

Indicated)

Domain/Level 

(Family, School, 

Community, 

Multicomponent)

Sample

(at pretest)/ 

Ethnicity/ 

Setting Design Summary Results

Citations: Key 

Outcome 

Research/ 

Program 

Information

Source

Raising 

Healthy 

Children 

(RHC) 

(Seattle 

Social 

Development 

Project 

elementary 

only)

Universal Family and School N = 18 urban, 

multiethnic 

schools; 810 

students in 

Grades 1-5

QED/NTC

RCT/NTC

At 6-year follow-up 

(age 18), reductions in 

heavy drinking (15.4% 

vs. 25.0%); high rates 

of attrition (quasi–

experimental).

At ages 21, 24, and 

27, no significant 

effects on any form or 

drug or alcohol use.

At grades 8-10, 

reduced growth of 

frequency of alcohol 

and marijuana use, no 

effects on initiation 

of alcohol, marijuana, 

and cigarettes(d = .40 

for alcohol, d = .57 for 

marijuana).

Hawkins, et 

al. (1992)4

 and 

(1999)5

Hawkins, et 

al. (2005)6 and 

(2008)7

Brown, et al. 

(2005)8

Good 

Behavior 

Game

Universal School N = 864 

large urban, 

multiethnic 

students in 

Grades 1-2

RCT/NTC

At ages 19 to 21, 

intervention males 

with high aggression 

in 1st grade (about 

25% of boys) had 

lower rates of alcohol 

and drug abuse and 

dependence (65.6% 

vs. 28.1%). No effect 

for moderately or low 

aggressive males and 

no effect for females. 

Finding was not 

replicated in second 

cohort of the same 

study.

Kellam, et al. 

(2008)9

 and 

(2014)10

Classroom 

Centered 

Intervention

Universal School N = 9 urban, 

multiethnic 

schools; 576 

students in 

Grades1 and 2 

RCT/NTC

At 6-year follow-up 

(Grade 8), reduced 

risk of starting to use 

other illegal drugs 

(heroin, crack, and 

cocaine powder; 7% 

vs. 2.6%).

No effects on alcohol 

initiation or marijuana 

use.

Ialongo, et al. 

(2001)11

Furr-Holden, et 

al. (2004)12

Liu, et al. 

(2013)13
APPENDICES

PAGE | 19

Intervention

Type 

(Universal, 

Selective, 

Indicated)

Domain/Level 

(Family, School, 

Community, 

Multicomponent)

Sample

(at pretest)/ 

Ethnicity/ 

Setting Design Summary Results

Citations: Key 

Outcome 

Research/ 

Program 

Information

Source

Linking the 

Interests of 

Families and 

Teachers 

(LIFT)

Universal Multicomponent N = 6 schools; 

348 primarily 

White students 

in Grade 5, 

college town

RCT/NTC

At 2- and 3-year 

follow-up, effects on 

patterned alcohol use 

(OR = 1.49) across 

Grades 6-8. 

Lower risk of initiating 

alcohol use (7% 

reduction). Also 

reduced growth 

of illicit drug use, 

particularly for 

females.

Eddy, et al. 

(2003)14

DeGarmo, et al. 

(2009)15

Fast Track Indicated Multicomponent N = 4 urban 

and rural 

multiethnic 

communities; 

891 children 

with behavioral 

problems 

selected in 

kindergarten, 

Grades 1-10

RCT/TAU

No effects on 

substance use in 

Grades 9-12. At 

10-year follow-up 

(age 25), decreased 

probability of DSM 

alcohol abuse (OR 

= 0.69), serious 

substance use (OR 

= 0.58). Lower drug 

crime conviction rate 

(34.7% reduction). 

No effect on binge 

drinking or heavy 

marijuana use.

Dodge, et al. 

(2015)16

Preventive 

Treatment 

Program 

(Montreal)

Selective Multicomponent N = 166 

urban French 

Canadian 

students in 

Grades 1-2 with 

early behavioral 

problems

RCT/TAU

At 7-year follow-up, 

effects on drinking 

to the point of being 

drunk at age 15. 

At 6- to 8- year 

follow-up, reduction 

in alcohol use at 

age 17 (ES = 0.48), 

and the slope of the 

number of drugs used 

between age 14 and 

17 (ES = 0.70).

Tremblay, et al. 

(1996)17

Masse, (1996)18

Abbreviations: RCT - Randomized Controlled Trial, QED - Quasi-Experimental Design, TAU - Control Group Received Treatment 

As Usual, NTC - No Treatment Control, ES - Effect Size, OR - Odds Ratio
PAGE | 20

Table B.2: Evidence-Based Interventions for Youth Aged 10 to18

Intervention

Type 

(Universal, 

Selective, 

Indicated)

Domain/Level 

(Family, School, 

Community, 

Multicomponent)

Sample

(at pretest)/ 

Ethnicity/

Setting/Design Summary Results

Citations: 

Key 

Outcome 

Research/ 

Program 

Information 

Source

Life Skills 

Training (LST)

Universal School Study 1: N = 56 

public schools; 

5,954 White, urban 

students in Grade 7 

(1985-1991)

Study 2: N =29 

schools in New 

York; 3,791 

urban youth in 

Grade 7 (highrisk subsample), 

primarily African 

American and 

Hispanic

Study 2a: N = 758 

high-risk students 

from Study 2 

Study 3: N = 9 rural 

public schools; 732 

White students 

in Grade 6 (1999-

2002)

Study 4: N = 36 

rural schools; 1,650 

primarily White 

students in Grade 7 

(1998-2006)

All Studies: RCT/

NTC

Study 1: 6-year follow-up 

showed significantly lower 

incidence of drunkenness 

(33.5% vs. 40%) but not 

on rate of monthly, or 

weekly alcohol use); no 

effect on marijuana use. 

66% reduction in weekly 

polydrug use (alcohol, 

marijuana, and tobacco).

Study 2: 1- and 2-year 

follow-up showed lower 

rates of alcohol use, binge 

drinking, and inhalant use. 

Study 2a: At 1-year followup, high-risk participants 

(21% of sample) reported 

less drinking (ES = 0.22), 

inhalant use (ES = 0.14), 

and polydrug use (ES = 

0.21).

Study 3: No significant 

findings.

Study 4: At 1.5-year followup, reduction in substance 

use for females, which 

became nonsignificant 

at 2.5-year follow-up. No 

significant effects for males. 

Botvin, et al. 

(1995)19

Botvin, et al. 

(2001)20

Griffin, et al. 

(2003)21

Smith, et al. 

(2004)22

Spoth, et al. 

(2005)23

Spoth, et al. 

(2008)25 and 

(2006)24 
PAGE | 21

Intervention

Type 

(Universal, 

Selective, 

Indicated)

Domain/Level 

(Family, School, 

Community, 

Multicomponent)

Sample

(at pretest)/ 

Ethnicity/

Setting/Design Summary Results

Citations: 

Key 

Outcome 

Research/ 

Program 

Information 

Source

At 5.5-year follow-up, 

lower rate of SU initiation, 

marijuana initiation (23% 

reduction), drunkenness 

(10% reduction), polydrug 

use, and lifetime 

methamphetamine use (2.4% 

vs. 7.6%) when combined 

with the Strengthening 

Families Program: For 

Parents and Youth 10–14.

School 

Health and 

Alcohol Harm 

Reduction 

Project 

(SHAHRP)

Universal School N = 14 public 

secondary schools in 

metropolitan Perth, 

Australia; 2,300 

students aged 12 to 

14 (1997-1999)

QED/NTC

At 17-month followup (after two years of 

intervention), reduced 

weekly drinking (5%) and 

harm from alcohol use.

McBride, et al. 

(2000)26 and 

(2004)27

Preventure/

Adventure

Selective 

(by 

Personality 

Risk)

School Study 1: N = 13 UK 

secondary schools; 

732 youth aged 13 

to 16. Wave 2 youth 

only (N = 364) 

Study 2: N = 21 UK 

secondary schools; 

1,210 high-risk 

students in Grade 

9. Selected as in 

Study 1, lower risk 

sample = 1,433 

students 

Study 1: At 2-year followup, reduced initiation of l 

cocaine (OR = 0.20) and 

other drugs (OR = 0.50). 

No effect on marijuana use. 

Strongest effects on 

impulsive subsample. Effects 

on quantity and binge 

drinking fade after 6 months. 

A 24 months, still an effect on 

problem drinking (ES=0.33; 

Rutgers Scale).

Study 2: At 24-month 

follow-up, high-risk 

students had lowered 

quantity of drinking 

(29% reduction), binge 

drinking (43% reduction), 

and problem drinking 

(29% reduction). Low risk 

students had lower quantity 

of drinking (29% reduction) 

and lower rates of binge 

drinking (35% reduction). 

At 24-month follow-up, 

effects on marijuana use fade 

and are unclear. 24-month 

effects maintained in the 

sensation-seeking subsample 

only (OR = 0.25).

Conrod, et al. 

(2010)28 and

(2011)29

Conrod, et al. 

(2013)30

Mahu, et al. 

(2015)31
PAGE | 22

Intervention

Type 

(Universal, 

Selective, 

Indicated)

Domain/Level 

(Family, School, 

Community, 

Multicomponent)

Sample

(at pretest)/ 

Ethnicity/

Setting/Design Summary Results

Citations: 

Key 

Outcome 

Research/ 

Program 

Information 

Source

Study 3: N = 15 

Schools in The 

Netherlands; 699 

high-risk students 

aged 13 to 15

All Studies: RCT/

NTC

Study 3: At 12-month 

follow-up, effects were 

ambiguous. Regression 

models revealed no 

significant effects on 

alcohol use, binge drinking, 

or problem drinking. Latent 

growth model showed 

effect on binge drinking.

Lammers, et al. 

(2015)32

Unplugged Universal School N = 170 schools in 7 

European countries; 

7,079 students aged 

12 to 14 

At 18-month followup, reductions in any 

drunkenness (3.8% 

reduction), frequent 

drunkenness (2.5% 

reduction), any cannabis 

use (2.9% reduction), and 

frequent cannabis use (2.2% 

reduction). 

Faggiano, et al. 

(2010)33

keepin’ It 

REAL

Universal School Study 1: N = 35 

public schools in 

Phoenix, Arizona; 

4,235 multiethnic/

urban students in 

Grade 7 (1998-2000)

Study 2: N = 30 

public schools in 

Phoenix, Arizona; 

3,038 students in 

Grade 7 (74.3% were 

Mexican-American)

All Studies: RCT/

NTC

Study 1: At 19-month followup, lower increases in pastmonth alcohol and marijuana 

use for the Mexican 

American and multicultural 

version of the program. No 

effects on the Black/White 

version. 

Study 2: At 1-year follow-up, 

no significant difference in 

alcohol or marijuana use. 

Hecht, et al. 

(2003)34 and 

(2006)35

Kulis, et al.

(2007)36

Marsiglia, et al. 

(2012)37

ATLAS 

(Athletes 

Training and 

Learning 

to Avoid 

Steroids)

Universal School N = 31 high school 

football teams from 

Portland, Oregon; 

3,207 athletes (1994-

1996)

RCT/NTC

At 1-year follow-up, reduced 

use of alcohol and illicit 

drug use, and lower rate of 

drinking and driving.

Goldberg, et 

al. (2000)38
PAGE | 23

Intervention

Type 

(Universal, 

Selective, 

Indicated)

Domain/Level 

(Family, School, 

Community, 

Multicomponent)

Sample

(at pretest)/ 

Ethnicity/

Setting/Design Summary Results

Citations: 

Key 

Outcome 

Research/ 

Program 

Information 

Source

Strengthening 

Families 

Program: For 

Parents and 

Youth 10-14

Universal Family and 

School/ 

Multicomponent

Study 1:N = 33 

Midwestern public 

schools; 667 

primarily White, 

rural students in 

Grade 6

Study 2: N = 36

public schools,1,650

primarily White 

students in Grade 

7 from rural Iowa 

(1998-2004)

All Studies: RCT/

NTC

Study 1: At 4-year followup, lower lifetime alcohol 

use (50% vs. 68%), 

drunkenness (26% vs. 

44%), marijuana use (7% vs. 

17%), and lower rates of 

amphetamine use (0% vs. 

3.2%). 

At 6-year follow-up, lower 

rates of substance use 

initiation (OR = 2.34), 

lower drunkenness (41% 

reduction) and lower illicit 

drug use.

At age 21, lower rates of 

substance use initiation 

(27.5% vs. 28.3%), 

drunkenness (19% 

reduction) and illicit drug 

use (31% reduction).

Study 2: At 2.5-year followup, shows significantly less 

alcohol initiation (25.7% 

vs. 36.7%), marijuana 

initiation (4.1% vs. 7.9%), 

and slower growth in 

weekly drunkenness (39% 

reduction) when combined 

with Life Skills Training. 

At 5.5-year followup, lower rate of SU 

initiation, marijuana 

initiation (23% reduction), 

polydrug use, and lifetime 

methamphetamine use 

(2.5% vs. 7.6%) when 

combined with Life Skills 

Training. 

At age 25, lower rates of 

prescription opioid misuse 

(6.0% vs. 8.8%) and lifetime 

prescription drug misuse 

overall (6.3 vs. 9.4) when 

combined with Life Skills 

Training. 

Spoth, et al. 

(2001)39

Spoth, et al.

(2004)40

Spoth, et al.

(2009)41 and 

(2012)42

Spoth, et al.

(2002)43 and 

(2005)23

Spoth, et al. 

(2008)25

Spoth, et al. 

(2013)44
PAGE | 24

Intervention

Type 

(Universal, 

Selective, 

Indicated)

Domain/Level 

(Family, School, 

Community, 

Multicomponent)

Sample

(at pretest)/ 

Ethnicity/

Setting/Design Summary Results

Citations: 

Key 

Outcome 

Research/ 

Program 

Information 

Source

Guiding Good 

Choices

Universal Family N =33 rural, 

Midwestern 

schools; 883 

students in Grade 7

RCT/NTC

Effects on substance 

use initiation through 

high school and alcoholrelated problems and illicit 

drug use through early 

adulthood. No effects on 

drunkenness. 

At age 22, lower rate of 

alcohol misuse for women 

(6% vs. 16%); no effect for 

men.

Spoth, et al. 

(2009)41

Mason, et al 

(2009)45

Strong African 

American 

Families

Universal Family N = 667 Southern 

U.S. rural African 

American students 

in Grade 7

RCT/NTC

At 2-year follow-up, slower 

rate of initiation of alcohol 

(37% vs. 43%). Effect on 

growth trajectory of alcohol 

use through 4.5-year 

follow-up.

Brody, et al. 

(2006)46 and 

(2010)47

SODAS City Universal Family N = 43 community 

agencies in New 

York, New Jersey, 

and Delaware; 514 

urban youth 

(1991-2010)

RCT/NTC

At 3-year follow-up, CDROM alone and CD-ROM 

plus parent intervention 

showed significantly lower 

past-month alcohol use.

At 7-year follow-up, 

lower past-month alcohol 

use, heavy drinking, and 

marijuana use. 

Schinke, et al. 

(2004) 48

Schinke, et al. 

(2010)49

I Hear What 

You’re Saying

Universal 

(MotherDaughter)

Family Study 1: N = 591 

adolescent girls and 

their mothers

Study 2: N = 108 

Asian American 

girls and their 

mothers (2007-

2010) 

All studies: RCT/

NTC

Study 1: At 1-year followup, reductions in use of 

alcohol, marijuana, and 

prescription drugs.

Study 2: At 2-year followup, reductions in use of 

alcohol, marijuana, and 

prescription drugs.

Schinke, et al. 

(2009)50

Fang & Schinke 

(2013)51
PAGE | 25

Intervention

Type 

(Universal, 

Selective, 

Indicated)

Domain/Level 

(Family, School, 

Community, 

Multicomponent)

Sample

(at pretest)/ 

Ethnicity/

Setting/Design Summary Results

Citations: 

Key 

Outcome 

Research/ 

Program 

Information 

Source

Familias 

Unidas

Universal/

Brief 

Version 

Selective

Family Study 1: N = 160 

Hispanic students in 

Grade 8

Study 2: N = 213

Hispanic students 

in Grade 8 with 

behavior problems

All studies: RCT/

TAU

Study 1: At 2-year followup, lower substance use 

initiation (28.6% vs. 65.2%) 

and substance use initiation 

(30.4% vs. 64.0%) among 

girls. 

Study 2: Significantly lower 

past 30-day substance use 

at 18-month (ES = 0.25) and 

30-month follow-ups (25% 

vs. 34%).

Estrada, et al. 

(2015)52

Pantin, et al. 

(2009)53

Bicultural 

Competence 

Skills Program 

(BCSP)

Universal Clinic/School N = 27 public and 

tribal schools; 1,396 

students from an 

American Indian 

Reservation in the 

Midwest (1986-

1999) 

RCT/NTC

At 42-month follow-up, 

weekly alcohol use (22% vs. 

30%) and weekly marijuana 

use (7 % vs. 15%) was lower 

in BCSP-only group. Results 

for a BCSP plus community 

group were not significant.

Schinke, et al. 

(2000)54

Project Chill Universal Primary Care N = 7 urban health 

centers; 714 youth 

with no prior use 

aged 12 to 18

RCT/NTC

At 12-month followup, computer-based 

participants had lower 

rates of marijuana use at 

any point during the year 

(16.8% vs. 24.2%), but 

non-significant effect on 12 

month use. No effects on 

alcohol.

Walton, et al. 

(2014)55

Positive

Family 

Support 

(Family Check 

Up)

Selective Family N = 593 Grade 6-8 

urban youth and 

their parents

RCT/TAU

Lower rates of marijuana 

use through age 23. No 

effect on adult tobacco or 

alcohol use.

For the 42% of families 

who engaged in the 

intervention, CACE analysis 

showed significantly less 

growth in tobacco, alcohol, 

and marijuana use across 

two years

Véronneau, et 

al. (in press)56

Stormshak, et

al. (2011)57

Keep Safe Selective School and Family N = 100 girls in 

foster care entering 

middle school

At 18-month follow-up 

lower rate of substance use 

(ES = 0.47).

Kim et al 

(2011)58
PAGE | 26

Intervention

Type 

(Universal, 

Selective, 

Indicated)

Domain/Level 

(Family, School, 

Community, 

Multicomponent)

Sample

(at pretest)/ 

Ethnicity/

Setting/Design Summary Results

Citations: 

Key 

Outcome 

Research/ 

Program 

Information 

Source

Coping Power Selective School Study 1: N = 245 

high-aggression 

African American 

and White students 

in Grade 5

Study 2: N = 183 

high-aggression 

African American 

and White students 

in Grade 5

Study 3: N = 77 

Dutch youth

All Studies: RCT/

TAU

Study 1: At 1-year follow-up 

(7th grade), lower selfreported past-month use of 

substances (ES = 0.58).

Study 2: At 1-year follow-up 

(7th grade), lower parentreported substance use (ES 

= 0.31).

Study 3: At 4-year followup, lower use of marijuana 

(13% vs. 35%), no 

differences in alcohol use.

Lochman & 

Wells (2003)59

Lochman & 

Wells (2004)60

Zonnevylle, et 

al. (2007)61

Project 

Toward No 

Drug Abuse 

(TND)

Selective 

and 

Indicated

School Study 1: N = 42 

schools in Southern 

California; 2,468 

high school 

students

Study 2: N = 1,186 

alternative high 

school students

All studies: RCT/

TAU

Study 1: At 1-year followup, reduction in levels of 

alcohol use among baseline 

users.

At 5-year follow-up, 

reduced hard drug use.

Study 2: At 1-year 

follow-up, reductions in 

alcohol use (OR = 0.68), 

drunkenness (OR = 0.67), 

and hard drug use (OR = 

0.68).

Sussman, et al. 

(2002)62

Sun, et al.

(2006)62

Sussman, et al. 

(2012)63

Abbreviations: RCT - Randomized Controlled Trial, QED - Quasi-Experimental Design, TAU - Control Group Received Treatment 

As Usual, NTC - No Treatment Control, ES - Effect Size, OR - Odds Ratio
PAGE | 27

Table B.3: Evidence-Based Interventions for Age 18+

Intervention

Type 

(Universal, 

Selective, 

Indicated)

Domain/Level 

(Family, School, 

Workplace, 

Community, 

Multicomponent)

Sample

(at pretest)/ 

Ethnicity/

Setting/Design Summary Results

Citations: 

Key 

Outcome 

Research/

Program 

Information 

Source

BASICS Indicated College Study 1: N = 508 

heavy drinking 

college freshmen

Study 2: N = 

159 Fraternityconnected college 

students (81% 

White)

Study 3: N = 550 

heavy drinking 

college students

All studies: RCT/

TAU

Study 1: At 1- and 2- year 

follow-ups, reductions 

in drinking frequency., 

At 4 year follow-up, 

reduction in drinking 

consequences. 

Study 2: At 1-year followup, reductions in average 

drinks per week (ES = 

0.42) and typical peak 

BAC levels (ES = 0.38).

Study 3: At 1-year followup, lower typical drinking 

(ES = 0.11) and peak 

drinking (ES = 0.42), and 

alcohol problem (ES = 

0.56) for both volunteer 

and mandated students.

Marlatt, et al. 

(1998)64 and 

Baer, et al. 

(2001)65

Larimer, et 

al. (2001)66

Terlecki, et 

al. (2015)67

Parent 

Handbook

Universal College Study 1: N = 882 

college-bound 

students (79% White)

Study 2: N = 1,900 

college-bound 

students (87% White)

Study 3: N = 1,275 

college-bound 

students, high-risk, 

athletes (80% White)

All studies: RCT/NTC

Study 1: At 8-month 

follow-up, females were 

less likely to transition into 

heavy drinking status, but 

males were more likely 

to do so. No effects on 

rate of alcohol-related 

problems.

Study 2: Reduced the 

odds of continuing to be 

a heavy drinker for the 

first two years of college 

for students who came to 

campus with prior highrisk drinking habits (OR = 

0.05).

Study 3: At 10-month 

follow-up, reduced alcohol 

peak consumption (ES = 

0.26) .and alcohol-related 

consequences (ES = 

0.20) for PH and BASICS 

combined. 

At 22 months, reduction 

in the onset of alcohol 

consequences (ES = 0.21). 

No effect for PH alone. 

Ichiyama, et 

al. (2009)68

Turrisi, et al. 

(2013)69

Turrisi, et al. 

(2009)70

Wood, et al. 

(2010)71
PAGE | 28

Intervention

Type 

(Universal, 

Selective, 

Indicated)

Domain/Level 

(Family, School, 

Workplace, 

Community, 

Multicomponent)

Sample

(at pretest)/ 

Ethnicity/

Setting/Design Summary Results

Citations: 

Key 

Outcome 

Research/

Program 

Information 

Source

Yale Work and 

Family Stress 

Project

Universal Workplace N = 4 job sites; 239 

primarily White 

female secretarial 

employees from 

Connecticut-based 

corporations

RTC/NTC

At 22-month follow-up, 

reduced number of drinks 

per month.

Snow, et al. 

(2003)72

Brief

Motivational 

Intervention 

in Emergency 

Department

Universal 

and 

Selective

Community N = 539 injured 

patients treated in 

the ED; mostly males 

from urban, Southern 

New England (72% 

White)

RCT/TAU

At 1-year follow-up, 

patients receiving 

brief intervention (BI) 

with booster reduced 

alcohol-related negative 

consequences and 

alcohol-related injuries; no 

differences were observed 

for heavy drinking days. 

No effects of BI without 

booster.

Longabaugh, 

et al. (2001)73

Team 

Awareness

Universal Workplace N = 235 employees 

in 28 restaurants

RCT/NTC

At 1-year follow-up, the 

odds of recurring heavy 

drinking declined by 50%, 

and the number of workrelated problem areas 

declined by one-third.

Broome 

and Bennett 

(2011)74

Computerized 

AlcoholRelated 

Problems 

Survey 

(CARPS)

Universal Primary Care N = 771 Primary care 

patients aged 65 and 

older

RCT/TAU

At 1-year follow-up, 

participants decreased 

their harmful drinking 

23% and increased their 

nonhazardous drinking 

12%.

Fink, et al. 

(2008)75

Project Share Selective Primary Care N = 1,186 Primary 

care patients aged 

60 or older screened 

for at-risk drinking 

patterns

RCT/TAU

At 1-year follow-up, 

and reductions in at-risk 

drinking (56% vs. 67%), 

lower rates of alcohol 

consumption.

Ettner, et al. 

(2014)76

Abbreviations: RCT - Randomized Controlled Trial, QED - Quasi-Experimental Design, TAU - Control Group Received Treatment 

As Usual, NTC - No Treatment Control, ES - Effect Size, OR - Odds Ratio
PAGE | 29

Table B.4: Evidence-Based Community Implementation Systems/ Coalition Models and 

Environmental Interventions

Intervention

Type 

(Universal, 

Selective, 

Indicated)

Domain/Level 

(Family, School, 

Community, 

Multicomponent)

Sample (at 

pretest)/ 

Ethnicity/

Setting/Design) Summary Results

Citations:

Key 

Outcome 

Research/

Program 

Information 

Source

COMMUNITY COALITION MODELS

Communities 

That Care 

(CTC)

Universal Multi-component N = 24 

communities in 

7 States; 4,407 

students in Grade 

5 (20% Hispanic, 

67% White, 3% 

African American)

RCT/TAU

By Grade 10, students in 

CTC communities were 

less likely to initiate alcohol 

(OR = 0.62). At 10th grade 

there were no differences 

rates of binge drinking 

or in past-month alcohol, 

marijuana, prescription, or 

other illicit drug use. 

By Grade 12, fewer CTC 

students had initiated any 

drug (OR = 0.71), alcohol 

(OR = 0.70), or cigarette 

(OR = 0.80) use. There 

were no differences in 

past-month or past-year 

alcohol, marijuana, or 

other illicit drug use, with 

the exception of higher 

rate of ecstasy use in the 

CTC condition.

Hawkins, et 

al. (2012)77

Hawkins, et 

al. (2014)78

PROmoting 

Schoolcommunityuniversity 

Partnerships 

to Enhance 

Resilience 

(PROSPER)

Universal Multi-component N = 28 rural 

and small town 

communities in 

Pennsylvania 

and Iowa;10,849 

primarily White 

students in Grade 

6 

RCT/TAU

At 3.5-year and 4.5-year 

follow-up (Grades 11 and 

12) youth in PROSPER 

communities showed 

lower past-year marijuana 

(13.5% reduction) and 

methamphetamine use 

(30.9% reduction). At 

Grade 12 only, PROSPER 

youth showed lower pastyear inhalant use (28.3% 

reduction). Six-year growth 

curve effects lower for 

marijuana, amphetamine 

use, and drunkenness. 

By Grade 12, lower lifetime 

rates of prescription opioid 

misuse (22.1% vs. 27.8%) 

and lifetime prescription 

drug misuse overall (23.1% 

vs. 29.0%).

Spoth, et 

al. (2013a)79

and(2013b)44

Spoth, et al. 

(2013a)79
PAGE | 30

Intervention

Type 

(Universal, 

Selective, 

Indicated)

Domain/Level 

(Family, School, 

Community, 

Multicomponent)

Sample (at 

pretest)/ 

Ethnicity/

Setting/Design) Summary Results

Citations:

Key 

Outcome 

Research/

Program 

Information 

Source

Project 

Northland

Universal Multi-component N = 24 multiethnic 

urban, rural, and 

tribal school 

districts in Northern 

Minnesota

RCT/TAU

The Phase 1 intervention 

was conducted when the 

targeted cohort was in 

Grade 6 to Grade 8. At 2.5 

years past baseline, lower 

past-month and past-week 

alcohol use.

The Phase 2 intervention 

was conducted when the 

cohort was in Grade 11 

toGrade 12. At 6.5 years 

past baseline, reductions in 

binge drinking.

Phase 1: Perry, 

et al. (1996)80

and Klepp, et 

al. (1995)81

Phase 2: Perry, 

et al. (2002)82

Project Star 

(Midwestern 

Prevention 

Project)

Universal School and 

Community/ 

Multicomponent

N = 42 urban 

public middle 

and junior high 

schools in Kansas 

City, Missouri 

and Indianapolis, 

Indiana; 3,412 

White and African 

American students

RCT/TAU

At 1-year follow-up, lower 

proportion of students 

reporting past-week and 

past-month use of alcohol. 

Secondary prevention 

effects on baseline users 

were observed up to 1.5 

years past baseline, not 

at 2.5 and 3.5 years past 

baseline. Reductions in 

growth of amphetamine use 

through age 28.

Report 1: 

Pentz, et al. 

(1989)83

Report 2: 

Pentz & 

Valente 

(1993)84

Report 3: 

Pentz, et al. 

(1990)85

Report 4: 

Chou, et al. 

(1998)86

Report 5: 

Riggs, et al. 

(2009)87

ENVIRONMENTAL INTERVENTIONS

Reducing 

Underage 

Drinking 

Through 

State 

Coalitions

Universal Community N = National 

data from the 

Monitoring the 

Future Survey of 

students in Grades 

8, 10, and 12 in ten 

states compared to 

all others

QED

At posttest, significant 

effects in the proportion 

of Grade 8 and Grade 12 

students reporting past 

month drunkenness (ES 

= 1.36; ES = 1.29) and in 

Grade 12 students reporting 

binge drinking (ES = 2.18) 

and past year drinking (ES 

= 0.75).

Wagenaar, et 

al. (2006)88

Safer 

California 

Universities

Universal Community N=14 California 

universities; 19,791 

students (49% 

White)

RCT/TAU

At posttest, significant 

effects in the proportion 

of students reporting 

intoxication (ORs = 0.76 to 

0.81).

Saltz, et al. 

(2010)89
PAGE | 31

Intervention

Type 

(Universal, 

Selective, 

Indicated)

Domain/Level 

(Family, School, 

Community, 

Multicomponent)

Sample (at 

pretest)/ 

Ethnicity/

Setting/Design) Summary Results

Citations:

Key 

Outcome 

Research/

Program 

Information 

Source

Saving Lives Universal Community N = 6 

Massachusetts 

communities 

compared to all 

others in the state; 

15,188 surveys of 

adults and youth 

aged 16 to 19 

(90% White)

QED

At posttest, a 42% 

reduction in fatal alcoholrelated motor vehicle 

crashes and a 40% 

reduction in self-reported 

DUI among 16- to 19-yearolds.

Hingson, et 

al. (1996)90

Communities 

Mobilizing for 

Change on 

Alcohol

Universal Community Report 1: N = 

15 Minnesota 

& Wisconsin 

communities

Report 2: N = 

1,721-3,095 

surveys of 18-20 

year-olds (96% 

White) 

RCT/TAU

Report 1: At posttest, 

a 17% reduction in the 

proportion reporting that 

they provided alcohol to 

minors.

Report 2: At posttest, a 

reduction in the number of 

arrests for DUI.

Wagenaar, et 

al. (2000)91

Wagenaar, et 

al. (2000)92

Study to 

Prevent 

Alcohol 

Related 

Consequences 

(SPARC)

Universal Community N = 10 colleges/ 

universities in 

North Carolina; 

3,811 students 

(80% White)

RCT/TAU

At posttest, signification 

reductions in student 

reports of alcohol-related 

personal harms and 

causing injuries to others.

Wolfson, et 

al. (2012)93

Sacramento 

Neighborhood 

Alcohol 

Prevention 

Project 

(SNAPP)

Selective Community N = 2 low-income 

communities 

compared to all 

others in the city 

(35% Hispanic, 

18% African 

American)

QED

At posttest, fewer arrests 

for assaults (ES = 0.48), 

Emergency Medical 

Services (EMS) calls for 

assaults (ES = 0.57), and 

car accidents (ES = 0.55). 

Treno, et al. 

(2007)94

Abbreviations: RCT - Randomized Controlled Trial, QED - Quasi-Experimental Design, TAU - Control Group Received Treatment 

As Usual, NTC - No Treatment Control, ES - Effect Size, OR - Odds Ratio
PAGE | 32

Table B.5: Community Preventive Services Task Force Recommendations for Preventing 

Alcohol Misuse

Policy Interventions

Increase Alcohol Taxes

Regulate Alcohol Outlet Density

Dram Shop (Commercial Host ) Liability

Avoid Further Privatization of Alcohol Sales

Maintain Limits on Days of Sale

Maintain Limits on Hours of Sale

Enhanced Enforcement of Laws Prohibiting Sales to Minors

Electronic Screening and Brief Intervention (e-SBI)

Source: Community Preventive Services Task Force, (2016).95
PAGE | 33

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APPENDICES

PAGE | 41

APPENDIx C.

RESOURCE GUIDE

U.S. Department of Health and Human Services Resources and 

Publications: 2013-2016

Topic Title Description Target Audience

ADHD and 

Substance Use 

Disorders

SAMHSA Advisory: 

Adults With Attention 

Deficit Hyperactivity 

Disorder and Substance 

Use Disorders

This Advisory defines ADHD in 

adults. It discusses the interaction 

and relationship between ADHD and 

substance use disorders and provides 

information on screening for ADHD 

in adults, treatment of co-occurring 

ADHD and substance use disorders, 

and prevention of stimulant abuse in 

clients with ADHD.

Primary Care Doctors, 

Nurses, Drug and Alcohol 

Counselors, Mental 

Health Clinicians

Complementary 

Health Approaches

SAMHSA Advisory: 

Complementary Health 

Approaches: Advising 

Clients About Evidence 

and Risks

This Advisory provides behavioral 

health practitioners a brief 

overview of complementary health 

approaches, gives examples of the 

types of practices and products 

considered complementary, and 

discusses how practitioners can offer 

guidance to clients regarding the 

benefits and risks of adopting such 

approaches.

Prevention Professionals, 

Public Health 

Professionals, People 

with Substance Use or 

Misuse Problems, People 

with Alcohol Use or 

Misuse Problems, People 

with Mental Health 

Problems, Patients
PAGE | 42

Topic Title Description Target Audience

Cultural Competence TIP 59: Improving Cultural 

Competence

This Treatment Improvement 

Protocol (TIP) uses a multidimensional 

model for developing cultural 

competence. Adapted to address 

cultural competence across 

behavioral health settings, this model 

serves as a framework for targeting 

three organizational levels of 

treatment: individual counselor and 

staff, clinical and programmatic, and 

organizational and administrative. 

The chapters target specific racial, 

ethnic, and cultural considerations 

along with the core elements of 

cultural competence highlighted 

in the model. These core elements 

include cultural awareness, general 

cultural knowledge, cultural 

knowledge of behavioral health, and 

cultural skill development.

Professional Care 

Providers, Program 

Planners, Administrators, 

Project Managers

Disaster Planning TAP 34: Disaster Planning 

Handbook for Behavioral 

Health Treatment 

Programs

This Technical Assistance Publication 

(TAP) offers guidance in creating 

a disaster preparedness and 

recovery plan for programs that 

provide treatment for mental illness 

and substance use disorders. It 

also covers the planning process, 

preparing for disaster, roles and 

responsibilities, training, and testing.

Professional Care 

Providers, Disaster 

Response Workers, 

Program Planners, 

Administrators, Project 

Managers

Gambling SAMHSA Advisory: 

Gambling Problems: An 

Introduction for Behavioral 

Health Services Providers

This Advisory provides an 

introduction to pathological 

gambling, gambling disorder, 

and problem gambling; it also 

explores their links with substance 

use disorders. It describes tools 

available for screening and diagnosis 

of gambling disorder as well as 

strategies for treating people with 

gambling problems.

Drug and Alcohol 

Counselors, Mental 

Health Clinicians, Peer 

Counselors

Homelessness TIP 55: Behavioral Health 

Services for People Who 

Are Homeless

This TIP is for behavioral health 

service providers and program 

administrators who want to work 

more effectively with people who are 

homeless or at risk of homelessness 

and who need, or are currently in, 

substance use disorder or mental 

health treatment. The TIP addresses 

treatment and prevention issues. The 

approach advocated by the TIP is 

integrated and is aimed at providing 

services to the whole person to 

improve quality of life in all relevant 

domains.

Public Officials, Public 

Health Professionals, 

Program Planners, 

Administrators, Project 

Managers, Professional 

Care Providers, 

Non-Profits & FaithBased Organizations, 

Community Coalitions
PAGE | 43

Topic Title Description Target Audience

Medication-Assisted 

Treatment

CMCS Informational 

Bulletin: Medication 

Assisted Treatment for 

Substance Use Disorders

This Bulletin highlights the use 

of FDA-approved medications in 

combination with evidence-based 

behavioral therapies, commonly 

referred to as “Medication Assisted 

Treatment” (MAT), to help persons 

with substance use disorders (SUD) 

recover in a safe and cost-effective 

manner. Specifically, the Bulletin 

provides background information 

about MAT, examples of state-based 

initiatives, and useful resources to 

help ensure proper delivery of these 

services.

People with Substance 

Use or Misuse Problems, 

People in Recovery, 

People in Treatment

Medication-Assisted 

Treatment

DrugFacts: Treatment 

Approaches for Drug 

Addiction

This website describes research 

findings on effective medication and 

behavioral treatment approaches for 

drug addiction and discusses special 

considerations for the criminal justice 

setting.

General public

Medication-Assisted 

Treatment

In Brief: Adult Drug Courts 

and Medication-Assisted 

Treatment for Opioid 

Dependence

This In Brief highlights the use of 

MAT for opioid dependence in 

drug courts. It reviews effective 

medications, including methadone, 

buprenorphine, and naltrexone and 

provides strategies to increase the 

use of MAT in drug court programs.

Public Health 

Professionals, Program 

Planners, Administrators, 

Project Managers, 

Policymakers, Public 

Officials

Medication-Assisted 

Treatment

MATx Mobile App This mobile app supports the 

practice of health care practitioners 

who provide MAT. MATx features 

include resources to support ongoing 

MAT practices, guidance on attaining 

a Drug Addiction Treatment Act of 

2000 (DATA) waiver for treatment 

with buprenorphine, and tips 

for conducting effective patient 

assessments. 

Physicians

Medication-Assisted 

Treatment

Medication-Assisted 

Treatment of Opioid Use 

Disorder Pocket Guide

This pocket guide offers guidelines 

for physicians using MAT for 

patients with opioid use disorder. It 

includes a checklist for prescribing 

medication, approved medications in 

the treatment of opioid use disorder, 

screening and assessment tools, and 

best practices for patient care.

Physicians

Medication-Assisted 

Treatment

Medication for the 

Treatment of Alcohol Use 

Disorder: A Brief Guide

This guide provides evidence on the 

effectiveness of available medications 

for the treatment of alcohol use 

disorder and guidance for the use of 

medications in clinical practice.

Physicians
PAGE | 44

Topic Title Description Target Audience

Opioid Prevention CMCS Informational 

Bulletin: Best Practices for 

Addressing Prescription 

Opioid Overdoses, Misuse 

and Addiction

This Bulletin highlights emerging 

Medicaid strategies for preventing 

opioid-related harms and provides 

background information on overdose 

deaths involving prescription opioids, 

describes several Medicaid pharmacy 

benefit management strategies for 

mitigating prescription drug abuse 

and discusses strategies to increase 

the provision of naloxone to reverse 

opioid overdose, thereby reducing 

opioid-related overdose deaths. 

Wherever possible, the Bulletin

provides examples of methods states 

can use to target the prescribing of 

methadone for pain relief, given the 

disproportionate share of opioidrelated overdose deaths associated 

with methadone when used as a pain 

reliever.

People with Substance 

Use or Misuse Problems, 

People in Recovery, 

People in Treatment

Opioid Prevention Opioid Overdose 

Prevention Toolkit 

(updated 2016)

This toolkit provides guidance to 

develop practices and policies 

to help prevent opioid-related 

overdoses and deaths.

Health Care 

Professionals, 

First Responders, 

Treatment Providers, 

Local Governments, 

Communities, Those 

Recovering from Opioid 

Overdose

Opioid Prevention Opioid and Pain 

Management CMEs/

CEs: Safe Prescribing for 

Pain and Managing Pain 

Patients Who Abuse Rx 

Drugs

These CME courses developed by 

NIDA and Medscape Education, 

with funding from the White House 

Office of National Drug Control 

Policy provide practical guidance 

for physicians and other clinicians 

in screening pain patients for 

substance use disorder risk factors 

before prescribing, and in identifying 

when patients are abusing their 

medications. 

Health Care Professionals

Recovery Motivation for Change: 

John’s Story—

Consequences of His 

Heavy Drinking and His 

Recovery

This comic book/fotonovela uses 

photographs with captions to help 

the reader recognize the dangers 

people face when they have a 

substance use disorder. It tells the 

troubles of a family as the son, John, 

faces his substance use problem, 

enters treatment, and moves into 

recovery.

People with Alcohol Use 

or Misuse Problems, 

People With Substance 

Use or Misuse Problems
PAGE | 45

Topic Title Description Target Audience

Recovery You Can Manage Your 

Chronic Pain To Live a 

Good Life: A Guide for 

People in Recovery from 

Mental Illness or Addiction

This consumer brochure equips 

people who have chronic pain and 

mental illness or addiction with tips 

for working with their health care 

professional to decrease their pain 

without jeopardizing their recovery. 

It also explores counseling, exercise, 

and alternative therapy, as well as 

medications.

People in Recovery, 

People in Treatment

Screening and Brief 

Intervention

Alcohol Screening and 

Brief Intervention for 

Youth: A Practitioner’s 

Guide

This Guide helps health care 

professionals who manage the 

health and well-being of children and 

adolescents conduct fast, effective 

alcohol screens and interventions 

with patients ages 9-18.

Health Care Professionals

Screening and 

Referral to Treatment

SAMHSA Advisory: 

Hepatitis C Screening in 

the Behavioral Healthcare 

Setting

This Advisory explains why 

behavioral health services programs 

should consider screening clients for 

Hepatitis C if clients have known risk 

factors for Hepatitis C viral infection 

or if they have signs and symptoms 

of liver disease. The Advisory 

explains how onsite screening, 

or referral to screening, can be 

incorporated into existing intake and 

monitoring procedures. It also offers 

guidance on providing clients with 

viral hepatitis prevention education, 

counseling, and referral to follow-up 

evaluation and medical treatment as 

needed.

Public Health 

Professionals, Program 

Planners, Administrators, 

Project Managers, Health 

Care Professionals

Screening and 

Referral to Treatment

NIDA Drug Use Screening 

Tool

This tool features a one-question 

Quick Screen as well as the full NIDAModified Alcohol, Smoking and 

Substance Involvement Screening 

Test.

Health Care Professionals

Screening, Brief 

Intervention, and 

Referral to Treatment

TAP 33: SystemsLevel Implementation 

of Screening, Brief 

Intervention, and Referral 

to Treatment (SBIRT)

This TAP describes core elements of 

SBIRT programs for people with or 

at risk for substance use disorders 

and also describes SBIRT services 

implementation, covering challenges, 

barriers, cost, and sustainability.

Public Health 

Professionals, Program 

Planners, Administrators, 

Project Managers, 

Professional Care 

Providers, Grant Seekers 

and Grantees, Public 

Officials

Substance Misuse and 

Mental Health

In Brief: An Introduction to 

Co-Occurring Borderline 

Personality Disorder and 

Substance Use Disorders

This In Brief Introduces professional 

care providers to borderline 

personality disorder. It covers signs 

and symptoms, with or without cooccurring substance use disorder; 

monitoring clients for self-harm and 

suicide; and referrals to treatment.

Professional Care 

Providers, Public Health 

Professionals
PAGE | 46

Topic Title Description Target Audience

Substance Misuse and 

Mental Health

National Prevention Week National Prevention Week is an 

annual health observance dedicated 

to increasing public awareness of, 

and action around, substance use 

and mental health issues. 

Businesses, Communities, 

Educators, Health Care 

Professionals, Law 

Enforcement, Parents and 

Caregivers, Prevention 

Specialists, Youth

Substance Misuse and 

Mental Health

No Longer Alone (A Story 

About Alcohol, Drugs, 

Depression, and Trauma): 

Addressing the Specific 

Needs of Women

This comic book tells the stories 

of three women with substance 

misuse and mental health problems 

who have received treatment 

and improved their quality of life. 

Featuring flashbacks, the fotonovela 

is culturally relevant and dispels 

myths around behavioral health 

disorders.

Adolescents, Young 

Adults, Mature Adults

Substance Misuse 

Prevention

Alcohol Overdose: The 

Dangers of Drinking Too 

Much

This fact sheet provides information 

about the signs and symptoms of 

alcohol overdose. 

Individuals

Substance Misuse 

Prevention

Center for the Application 

of Prevention Technologies 

(CAPT)

SAMHSA’s CAPT is a national training 

and technical assistance (T/TA) 

system committed to strengthening 

prevention systems and building the 

nation’s behavioral health workforce.

SAMHSA Substance Use 

Prevention Grantees and 

Prevention Professionals

Substance Misuse 

Prevention

CMCS Informational 

Bulletin: Prevention 

and Early Identification 

of Mental Health and 

Substance Use Conditions

This Bulletin helps inform states 

about resources available to help 

them meet the needs of children 

under Early and Periodic Screening, 

Diagnostic, and Treatment (EPSDT), 

specifically with respect to mental 

health and substance use disorder 

services.

Public Officials

Substance Misuse 

Prevention

Harmful Interactions This resource provides information 

about medications that can cause 

harm when taken with alcohol and 

describes the effects that can result.

Adolescents, Young 

Adults, Mature Adults, 

Health Care Professionals

Substance Misuse 

Prevention

Health Education 

Curriculum Analysis Tool 

(HECAT) and HECAT 

Module AOD

This tool can help school districts, 

schools, and others conduct a clear, 

complete, and consistent analysis 

of health education curricula based 

on the National Health Education 

Standards and CDC’s Characteristics 

of an Effective Health Education 

Curriculum. Results of the HECAT 

can help schools select or develop 

appropriate and effective health 

education curricula and improve the 

delivery of health education. The 

HECAT can be customized to meet 

local community needs and conform 

to the curriculum requirements of the 

state or school district.

Educators
PAGE | 47

Topic Title Description Target Audience

Substance Misuse 

Prevention

Marijuana Facts for Teens

and Marijuana Facts 

Parents Need to Know

The teen booklet is presented in 

question-and-answer format and 

provides facts about marijuana and its 

potential harmful effects. The parent 

booklet provides important facts 

about marijuana and offers tips for 

talking with children about the drug 

and its potential harmful effects.

Teens, parents, 

caregivers, general public

Substance Misuse 

Prevention

National Drug & Alcohol 

Facts Week

This online guide gives organizers 

everything they need to plan, 

promote, and host their own 

National Drug & Alcohol Facts 

Week (NDAFW) event. NDAFW is 

a national health observance for 

teens to promote local events that 

use NIDA science to SHATTER THE 

MYTHS about drugs.

Teens, parents, 

educators, general public

Substance Misuse 

Prevention

Principles of Substance 

Abuse Prevention for Early 

Childhood

This guide begins with a list of 7 

principles addressing the specific 

ways in which early interventions can 

have positive effects on development; 

these principles reflect findings on 

the influence of intervening early 

with vulnerable populations, on the 

course of child development, and on 

common elements of early childhood 

programs.

Parents, health 

care providers, and 

policymakers

Substance Misuse 

Prevention

Rethinking Drinking This website is a tool for individuals 

who want to assess and/or change 

their drinking habits.

Individuals, Family 

Members

Substance Use 

Disorder Services

CMCS Informational 

Bulletin: Coverage of 

Behavioral Health Services 

for Youth with Substance 

Use Disorders

This Bulletin, based on evidence from 

scientific research and the results 

of a Substance Abuse and Mental 

Health Services Administration 

(SAMHSA)-supported technical 

expert panel consensus process, is 

intended to assist states to design a 

benefit that will meet the needs of 

youth with substance use disorders 

(SUD) and their families and help 

states comply with their obligations 

under Medicaid’s Early and Periodic 

Screening, Diagnostic, and Treatment 

(EPSDT) requirements. The services 

described in this document are 

designed to enable youth to address 

their substance use disorders, to 

receive treatment and continuing 

care and to participate in recovery 

services and supports. This Bulletin

also identifies resources that are 

available to states to facilitate their 

work in designing and implementing 

a benefit package for these youth and 

their families.

Public Officials
PAGE | 48

Topic Title Description Target Audience

Substance Use 

Disorder Services

New Service Delivery 

Opportunities for 

Individuals with a 

Substance Use Disorder

This State Medicaid Director Letter 

informs states of opportunities to 

design service delivery systems 

for individuals with substance use 

disorder (SUD), including a new 

opportunity for demonstration 

projects approved under section 

1115 of the Social Security Act (Act) 

to ensure that a continuum of care is 

available to individuals with SUD.

Public Officials

Substance Use 

Disorder Treatment

In Brief: Treating Sleep 

Problems of People in 

Recovery From Substance 

Use Disorders

This In Brief discusses the 

relationship between sleep 

disturbances and substance use 

disorders and provides guidance on 

how to assess for and treat sleep 

problems for people in recovery. It 

also reviews nonpharmacological 

as well as over-the-counter and 

prescription medications.

Professional Care 

Providers

Substance Use 

Disorder Treatment

Principles of Adolescent 

Substance Use Disorder 

Treatment: A ResearchBased Guide

This guide presents research-based 

principles of adolescent substance 

use disorder treatment; covers 

treatment for a variety of drugs 

including, illicit and prescription 

drugs, alcohol, and tobacco; 

presents settings and evidencebased approaches unique to treating 

adolescents.

Professional Care 

Providers, Administrators, 

Public Health 

Professionals, individuals 

and families

Substance Use 

Disorder Treatment

Principles of Drug Abuse 

Treatment for Criminal 

Justice Populations - A 

Research-Based Guide

This guide presents research-based 

principles of addiction treatment that 

can inform drug treatment programs 

and services in the criminal justice 

setting.

Professional Care 

Providers, Administrators, 

Public Health 

Professionals, individuals 

and families

Substance Use 

Disorder Treatment

SAMHSA Advisory: 

Diabetes Care for Clients 

in Behavioral Health 

Treatment

This Advisory reviews diabetes and 

its link with mental illness, stress, 

and substance use disorders, and it 

discusses ways to integrate diabetes 

care into behavioral health treatment, 

such as screening and intake, staff 

education, integrated care, and 

counseling support.

Professional Care 

Providers, Program 

Planners, Administrators, 

Project Managers, Public 

Health Professionals

Substance Use 

Disorder Treatment

SAMHSA Advisory: Spice, 

Bath Salts, and Behavioral 

Health

This Advisory equips professional 

health providers with an introduction 

to spice and bath salts in the context 

of treating people with substance 

use disorders and mental illness. It 

discusses adverse effects of use, 

patient assessment, and abstinence 

monitoring, among other issues.

Prevention Professionals, 

Professional Care 

Providers, Public Health 

Professionals, Public 

Officials
PAGE | 49

Topic Title Description Target Audience

Substance Use 

Disorder Treatment

SAMHSA Advisory: 

Sublingual and 

Transmucosal 

Buprenorphine for Opioid 

Use Disorder: Review and 

Update

This Advisory provides an overview 

of data on the use of sublingual 

(medicine that dissolves under the 

tongues) and transmucosal (medicine 

that dissolves between the cheeks 

and gums) buprenorphine to treat 

opioid use disorder and discusses 

the implications of using MAT as a 

recovery support.

Primary Care Doctors and 

Nurses, Drug and Alcohol 

Counselors

Substance Use 

Disorder Treatment

Seeking Drug Abuse 

Treatment: Know What 

To Ask

This guide offers guidance in seeking 

drug abuse treatment and lists five 

questions to ask when searching for 

a treatment program.

General Public

Substance Use 

Disorder Treatment

TIP 56: Addressing the 

Specific Behavioral Health 

Needs of Men

This TIP is a companion to TIP 

51, Substance Abuse Treatment: 

Addressing the Specific Needs of 

Women. It examines how genderspecific treatment strategies can 

improve outcomes for men. It also 

covers differences between men and 

women in the effects of substance 

use and misuse and the implications 

these differences have in behavioral 

health services. It provides practical 

information based on available 

evidence and clinical experience that 

can help counselors more effectively 

treat men with substance use 

disorders.

Public Health 

Professionals, Program 

Planners, Administrators, 

Project Managers, 

Professional Care 

Providers, Prevention 

Professionals, 

Researchers

Substance Use 

Disorder Treatment

TIP 51: Substance Abuse 

Treatment: Addressing the 

Specific Needs of Women

This TIP assists treatment providers 

in offering treatment to adult women 

with substance use disorders. It 

reviews gender-specific research 

and best practices, such as common 

patterns of initiation of substance 

use among women and specific 

treatment issues and strategies.

Public Health 

Professionals, Program 

Planners, Administrators, 

Project Managers, 

Professional Care 

Providers, Prevention 

Professionals, 

Researchers

Substance Use 

Disorder Treatment

Treatment for Alcohol 

Problems: Finding and 

Getting Help

This guide is written for individuals, 

and their family and friends who are 

looking for options to address to 

address alcohol problems. 

Individuals, Families, 

Friends

Suicide Prevention In Brief: Substance Use 

and Suicide: A Nexus 

Requiring a Public Health 

Approach

This In Brief summarizes the 

relationship between substance 

use and suicide and provides state 

and tribal prevention professionals 

with information on the scope of 

the problem, an understanding of 

traditional barriers to collaboration 

and current programming, and ways 

to work together on substance use 

and suicide prevention strategies.

State and Tribal 

Prevention Professionals 

working in the fields 

of substance use and 

suicide prevention
PAGE | 50

Topic Title Description Target Audience

Suicide Prevention Suicide Prevention 

Resource Center (SPRC)

SAMHSA’s SPRC provides technical 

assistance, training, and materials 

to increase the knowledge and 

expertise of suicide prevention 

practitioners and other professionals 

serving people at risk for suicide. 

While multiple factors influence 

suicidal behaviors, substance use—

especially alcohol use—is a significant 

factor that is linked to a substantial 

number of suicides and suicide 

attempts.

Professionals in a variety 

of settings (e.g., tribal 

communities, schools, 

colleges and universities, 

primary care, emergency 

departments, behavioral 

health care, workplace, 

and faith communities) 

Technology-Assisted 

Care

TIP 60: Using TechnologyBased Therapeutic Tools in 

Behavioral Health Services

This TIP provides an overview 

of current technology-based 

behavioral health assessments and 

interventions, and it summarizes 

the evidence base supporting the 

effectiveness of such interventions. 

It also examines opportunities for 

technology-assisted care (TAC) 

in the behavioral health arena. It 

emphasizes use of TAC with clients 

who might not otherwise receive 

treatment or whose treatment might 

be impeded by physical disabilities, 

rural or remote geographic locations, 

lack of transportation, employment 

constraints, or symptoms of mental 

illness. The TIP covers programmatic, 

technological, budgeting, vendor 

selection, data management, privacy 

and confidentiality, and regulatory 

considerations likely to arise during 

adoption of technology-based 

interventions.

Program Planners, 

Administrators, 

Project Managers, 

Prevention Professionals, 

Professional Care 

Providers

Trauma-Informed 

Care

TIP 57: Trauma-Informed 

Care in Behavioral Health 

Services

This TIP presents fundamental 

concepts that behavioral health 

service providers and program 

administrators can use to initiate 

trauma-related screening and 

assessment, implement collaborative 

strengths-based interventions, 

learn the core principles and 

practices that reflect traumainformed care, decrease inadvertent 

retraumatization, and evaluate and 

build a trauma-informed organization 

and workforce.

Professional Care 

Providers, Program 

Planners, Administrators, 

Project Managers

Underage Drinking College Alcohol 

Intervention Matrix 

(CollegeAIM)

This matrix is a resource to help 

colleges and universities address 

harmful and underage student 

drinking. Developed with leading 

college alcohol researchers and 

staff, it is an easy-to-use and 

comprehensive tool to identify 

effective alcohol interventions.

Higher Education 

Officials, particularly 

alcohol and other drug 

program and student life 

staff
PAGE | 51

Topic Title Description Target Audience

Underage Drinking Stop Underage Drinking 

website

This interagency Web portal provides 

key federal resources targeting the 

prevention of underage alcohol use.

Businesses, Communities, 

Educators, Health Care 

Professionals, Law 

Enforcement, Parents and 

Caregivers, Prevention 

Specialists, Youth

Underage Drinking Talk. They Hear You. 

- Underage Drinking 

Prevention

This underage drinking prevention 

campaign sponsored by SAMHSA 

provides parents and caregivers 

with information and resources 

they need to start addressing 

the dangers of alcohol with their 

children, 9 to 15 years old.

Parents and Other 

Caregivers of Youth 9 to 

15 years old
APPENDICES

PAGE | 53

Appendix D outlines important facts about the following substances:

$ Alcohol

$ Cocaine

$ GHB (gamma-hydroxybutyric acid)

$ Heroin

$ Inhalants

$ Ketamine

$ LSD (lysergic acid diethylamide)

$ Marijuana (Cannabis)

$ MDMA (Ecstasy)

$ Mescaline (Peyote)

$ Methamphetamine

$ Over-the-counter Cough/Cold Medicines (Dextromethorphan or DXM)

$ PCP (Phencyclidine)

$ Prescription Opioids

$ Prescription Sedatives (Tranquilizers, Depressants)

$ Prescription Stimulants

$ Psilocybin

$ Rohypnol® (Flunitrazepam)

$ Salvia

$ Steroids (Anabolic)

$ Synthetic Cannabinoids (“K2”/”Spice”)

$ Synthetic Cathinones (“Bath Salts”)

APPENDIx D.

IMPORTANT FACTS ABOUT

ALCOHOL AND DRUGS
PAGE | 54

Sources cited in this Appendix are: 

$ Drug Enforcement Administration’s Drug Facts Sheets1

$ Inhalant Addiction Treatment’s Dangers of Mixing Inhalants with Alcohol and Other Drugs2

$ National Institute on Alcohol Abuse and Alcoholism’s (NIAAA’s) Alcohol’s Effects on the Body3

$ National Institute on Drug Abuse’s (NIDA’s) Commonly Abused Drugs4

$ NIDA’s Treatment for Alcohol Problems: Finding and Getting Help5

$ National Institutes of Health (NIH) National Library of Medicine’s Alcohol Withdrawal6

$ Rohypnol® Abuse Treatment FAQs7

$ Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Keeping Youth Drug 

Free8

$ SAMHSA’s Center for Behavioral Health Statistics and Quality’s (CBHSQ’s) Results from the 2015 

National Survey on Drug Use and Health: Detailed Tables9

The substances that are considered controlled substances under the Controlled Substances Act (CSA) 

are divided into five schedules. An updated and complete list of the schedules is published annually 

in Title 21 Code of Federal Regulations (C.F.R.) §§ 1308.11 through 1308.15.10 Substances are placed in 

their respective schedules based on whether they have a currently accepted medical use in treatment in 

the United States, their relative abuse potential, and likelihood of causing dependence when abused. A 

description of each schedule is listed below.

$ Schedule I (1): Substances in this schedule have no currently accepted medical use in the United 

States, a lack of accepted safety for use under medical supervision, and a high potential for 

abuse.

$ Schedule II/IIN (2/2N): Substances in this schedule have a high potential for abuse which may 

lead to severe psychological or physical dependence.

$ Schedule III/IIIN (3/3N): Substances in this schedule have a potential for abuse less than 

substances in Schedules I or II and abuse may lead to moderate or low physical dependence or 

high psychological dependence.

$ Schedule IV (4): Substances in this schedule have a low potential for abuse relative to substances 

in Schedule III.

$ Schedule V (5): Substances in this schedule have a low potential for abuse relative to substances 

listed in Schedule IV and consist primarily of preparations containing limited quantities of 

certain narcotics.
APPENDICES

PAGE | 55

Alcohol

Ethyl alcohol, or ethanol, is an intoxicating ingredient found in beer, wine, and liquor. Alcohol is produced by the 

fermentation of yeast, sugars, and starches.i

Common 

Commercial Names Street Names Common Forms Common Ways Taken

DEA Schedule / 

Legal Status

Various Booze, Juice, 

Sauce, Brew

Beer, Wine, Liquor/

Spirits/Malt 

Beverages

Ingested by 

drinking

Not scheduled / 

Illegal for purchase 

or use by those 

under age 21ii

Uses & Possible Health Effectsiii

Short-term Symptoms 

of Use

Injuries and risky behavior, memory and concentration problems, coma, breathing 

problems, slurred speech, confusion, impaired judgment and motor skills, drowsiness, 

nausea and vomiting, emotional volatility, loss of coordination, visual distortions, impaired 

memory, changes in mood and behavior, and depression. Impaired judgment can result in 

inappropriate sexual behavior, sexually transmitted infections, and reduced inhibitions. 

Long-term 

Consequences of Use 

and Health Effects

Some studies have found benefits associated with moderate alcohol consumption,iv,v

while other studies do not support a role for moderate alcohol consumption in providing 

health benefits.vi,vii Studies have shown alcohol misuse use can lead to: an inability to 

control drinking; a high tolerance level; changes in mood and behavior; difficulty thinking 

clearly; impaired coordination; cardiovascular problems including heart muscle injury, 

irregular heartbeat, stroke, and high blood pressure; liver problems including steatosis 

(fatty liver), alcoholic hepatitis, fibrosis, and cirrhosis; pancreatitis; increased risk of 

various cancers (including of the mouth, esophagus, larynx, pharynx, liver, colon, and 

rectum); weakened immune system; depression; interference with personal relationships; 

coma, and death due to alcohol overdose. For breast cancer, even moderate drinking 

may increase the risk.

Other Health-related 

Issues

Pregnancy-related: sudden infant death syndrome (SIDS), fetal alcohol spectrum 

disorders (FASD).

In Combination with 

Alcohol N/A

Withdrawal 

Symptoms

Alcohol withdrawal symptoms usually occur within 8 hours after the last drink, but can 

occur days later. Symptoms usually peak by 24 to 72 hours, but may go on for weeks. 

Common symptoms include: anxiety or nervousness, depression, fatigue, irritability, 

jumpiness or shakiness, mood swings, nightmares, and not thinking clearly. Other 

symptoms may include: clammy skin, enlarged (dilated) pupils, headache, insomnia, 

loss of appetite, nausea and vomiting, pallor, rapid heart rate, sweating, and tremor 

of the hands or other body parts. A severe form of alcohol withdrawal called delirium 

tremens can cause: agitation, fever, hallucinations, seizures, and severe confusion. 

i. Source: NIDA, (2016).

ii. Most states prohibit possession and consumption of alcoholic beverages by those under age 21, though some 

make exceptions for possession or consumption in the presence, or with the consent, of family or on private 

property.

iii. Sources: NIDA, (2016) & NIAAA, (n.d.). The uses and possible health effects that are listed are illustrative 

examples and not exhaustive. 

iv. Source: Gepner, et al. (2015).12

v. Source: Howard, et al. (2004).13

vi. Source: Stockwell, et al. (2016).14

vii. Source: Fillmore, et al. (2006).15
APPENDICES

PAGE | 56

Alcohol

Treatment Optionsviii

Medications

The U.S. Food and Drug Administration (FDA) has approved three medications for 

treating alcohol dependence, and others are being tested to determine if they are 

effective.

• Naltrexone can help people reduce heavy drinking.

• Acamprosate makes it easier to maintain abstinence.

• Disulfiram blocks the breakdown (metabolism) of alcohol by the body, causing 

unpleasant symptoms such as nausea and flushing of the skin. Those unpleasant 

effects can help some people avoid drinking while taking disulfiram.

Behavioral Therapies

Also known as alcohol counseling, behavioral treatments involve working with a health 

professional to identify and help change the behaviors that lead to heavy drinking. 

Behavioral treatments share certain features, which can include:

• Developing the skills needed to stop or reduce drinking

• Helping to build a strong social support system

• Working to set reachable goals

• Coping with or avoiding the triggers that might cause relapse

Statistics as of 2015ix

Prevalence

Lifetime: 217 million persons (81.0%) aged 12 or older have used alcohol in their 

lifetime. 

Past Year: 176 million persons (65.7%) aged 12 or older have used alcohol in the past 

year. 

Average Age of 

Initiationx 17.6

viii. Source: NIDA, (2016).

ix. Source: CBHSQ, (2016). 

x. Average age of initiation (for all substances) is based on respondents aged 12 to 49 years old. 
PAGE | 57

Cocaine

A powerfully addictive stimulant drug made from the leaves of the coca plant native to South America.i

Common Commercial 

Names Street Names Common Forms Common Ways Taken

DEA Schedule / 

Legal Status

Cocaine hydrochloride 

topical solution 

(anesthetic rarely used 

in medical procedures)

Cocaine: Blow, Bump, 

C, Candy, Charlie, 

Coke, Crack, Flake, 

Rock, Snow, Toot, Dust

Crack cocaine: Crack, 

Rock, Base, Sugar 

Block, Rox/Roxanne

White powder, 

whitish rock crystal

Snorted, smoked, 

injected, orally, 

topically

Schedule II / 

Illegal, except 

for use in 

hospital settings 

(however it’s 

rarely used)

Uses & Possible Health Effectsii

Short-term Symptoms 

of Use

Narrowed blood vessels; enlarged pupils; increased body temperature, heart rate, 

and blood pressure; headache; abdominal pain and nausea; euphoria; increased 

energy, alertness; insomnia; restlessness, irritability, anxiety; erratic and violent 

behavior, panic attacks, paranoia, psychosis; heart rhythm problems, heart attack; 

stroke, seizure, coma; and death from cardiac arrest, respiratory arrest, or suicide.

Long-term 

Consequences of Use 

and Health Effects

Loss of sense of smell, nosebleeds, nasal damage and trouble swallowing from 

snorting; infection and death of bowel tissue from decreased blood flow; poor 

nutrition and weight loss from decreased appetite; and severe depression.

Other Health-related 

Issues

Risk of HIV, hepatitis, and other infectious diseases from shared needles.

Pregnancy-related: premature delivery, low birth weight, neonatal abstinence syndrome.iii

In Combination with 

Alcohol Greater risk of overdose and sudden death than from alcohol or cocaine alone.

Withdrawal Symptoms Depression, tiredness, increased appetite, insomnia, vivid unpleasant dreams, slowed 

thinking and movement, restlessness.

Medical Use

Cocaine hydrochloride topical solution is indicated for the introduction of local 

(topical) anesthesia of accessible mucous membranes of the oral, laryngeal and nasal 

cavities.

Treatment Optionsiv

Medications There are no FDA-approved medications to treat cocaine addiction.

Behavioral Therapies

• Cognitive-behavioral therapy (CBT)

• Community reinforcement approach plus vouchers

• Contingency management, or motivational incentives

• The Matrix Model

• 12-Step facilitation therapy

i. Source: NIDA, (2016). 

ii. Sources: NIDA, (2016) and DEA, (2015). 

iii. Neonatal abstinence syndrome is a group of problems that occur in a newborn who was exposed to addictive 

opioid drugs while in the mother’s womb. At birth, the baby is still dependent on the drug. Because the baby is 

no longer getting the drug after birth, symptoms of withdrawal may occur.11

iv. Source: NIDA, (2016). 
PAGE | 58

Cocaine

Statistics as of 2015v

Prevalence

Lifetime: 

• Cocaine: 38.7 million persons (14.5%) aged 12 or older have used cocaine in their 

lifetime. 

• Crack: 9.0 million persons (3.4%) aged 12 or older have used crack cocaine in 

their lifetime. 

Past Year:

• Cocaine: 4.8 million persons (1.8%) aged 12 or older have used cocaine in the past 

year. 

• Crack: 833,000 persons (0.3%) aged 12 or older have used crack cocaine in the 

past year. 

Average Age of 

Initiation

Cocaine: 21.5

Crack: 21.3

v. Source: CBHSQ, (2016).
PAGE | 59

GHB (gamma-hydroxybutyric acid)

A depressant approved for use in the treatment of narcolepsy, a disorder that causes daytime “sleep attacks”.i

Common 

Commercial Names Street Names Common Forms Common Ways Taken

DEA Schedule 

/ Legal Status

Gammahydroxybutyrate 

or sodium oxybate 

(Xyrem®)

G, Georgia Home 

Boy, Goop, Grievous 

Bodily Harm, Liquid 

Ecstasy, Liquid X, 

Soap, Scoop 

Colorless liquid, white 

powder

Ingested (often 

combined with alcohol 

or other beverages)

Schedule I / 

Illegal; GHB 

products such 

as Xyrem®, 

are Schedule III 

substances

Uses & Possible Health Effectsii

Short-term 

Symptoms of Use

Euphoria, drowsiness, decreased anxiety, confusion, memory loss, hallucinations, excited 

and aggressive behavior, nausea, vomiting, unconsciousness, seizures, slowed heart rate 

and breathing, lower body temperature, coma, and death.

Long-term 

Consequences of 

Use and Health 

Effects

Unknown.

Other Health-related 

Issues Sometimes used as a date rape drug.

In Combination with 

Alcohol Nausea, problems with breathing, greatly increased depressant effects.

Withdrawal 

Symptoms

Insomnia, anxiety, tremors, sweating, increased heart rate and blood pressure, and 

psychosis.

Medical Use Sodium Osybate (Xyrem®) is approved for use in the treatment of narcolepsy, a disorder 

that causes daytime “sleep attacks.”

Treatment Optionsiii

Medications Benzodiazepines

Behavioral Therapies More research is needed to determine if behavioral therapies can be used to treat GHB 

addiction.

Statistics as of 2015iv

Prevalence

Lifetime: 1.2 million persons (0.4%) aged 12 or older have used GHB in their lifetime.

Past Year: 136,000 persons (0.1%) aged 12 or older have used GHB in the past year.

Average Age of 

Initiation Sedatives in general: 28.3

i. Source: NIDA, (2016).

ii. Sources: NIDA, (2016) & DEA, (2015).

iii. Sources: NIDA, (2016). 

iv. Source: CBHSQ, (2016). 
PAGE | 60

Heroin

An opioid drug made from morphine, a natural substance extracted from the seed pod of the Asian opium 

poppy plant.i

Common 

Commercial Names Street Names Common Forms Common Ways Taken

DEA Schedule / 

Legal Status

No commercial uses Brown sugar, China 

White, Dope, H, Horse, 

Junk, Skag, Skunk, 

Smack, White Horse

With OTC cold 

medicine and 

antihistamine: Cheese

White or brownish 

powder, or black 

sticky substance 

known as “black tar 

heroin”

Injected, smoked, 

snorted

Schedule I / Illegal

Uses & Possible Health Effectsii

Short-term Symptoms 

of Use

Euphoria; warm flushing of skin; dry mouth; heavy feeling in the hands and feet; 

clouded thinking, impaired coordination; alternate wakeful and drowsy states; itching; 

nausea; vomiting; slowed breathing and heart rate; and fatal overdose.

Long-term 

Consequences of Use 

and Health Effects

Collapsed veins; abscesses (swollen tissue with pus); infection of the lining and valves in 

the heart (endocarditis); constipation and stomach cramps; liver or kidney disease; and 

pneumonia.

Other Health-related 

Issues

Pregnancy-related: miscarriage, low birth weight, neonatal abstinence syndrome. 

Risk of HIV, hepatitis, and other infectious diseases from shared needles.

In Combination with 

Alcohol Dangerous slowdown of heart rate and breathing, coma, and death.

Withdrawal 

Symptoms

Restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, and cold flashes with 

goose bumps.

Treatment Optionsiii

Medications Methadone, Buprenorphine, and Naltrexone. 

Behavioral Therapies Contingency management, or motivational incentives

12-Step facilitation therapy

Statistics as of 201523

Prevalence

Lifetime: 5.1 million persons (1.9%) aged 12 or older have used heroin in their lifetime. 

• Heroin needle use: 2.2 million persons (0.8%)

• Smoked heroin: 2.0 million persons (0.7%)

• Sniffed or snorted heroin: 3.3 million persons (1.2%)

Past Year: 828,000 persons (0.3%) aged 12 or older have used heroin in the past year. 

Average Age of 

Initiation 25.4

i. Source: NIDA, (2016).

ii. Sources: NIDA, (2016) & DEA, (2015).

iii. Sources: NIDA, (2016). 
PAGE | 61

Inhalants

Solvents, aerosols, and gases found in household products such as spray paints, markers, glues, and cleaning 

fluids; also nitrites (e.g., amyl nitrite), which are prescription medications for chest pain. Precise categorization 

of inhalants is difficult, however one classification system lists four general categories of inhalants — volatile 

solvents, aerosols, gases, and nitrites — based on the forms in which they are often found in household, 

industrial, and medical products.i

Common 

Commercial Names

Street 

Names Common Forms Common Ways Taken

DEA Schedule / 

Legal Status

Solvents (paint 

thinners, gasoline, 

glues, organic 

solvents, nail polish 

remover); gases 

(butane, propane, 

aerosol propellants), 

nitrous oxide, hair 

spray; and nitrites 

(isoamyl, isobutyl, and 

cyclohexyl)

Poppers, 

snappers, 

whippets, 

laughing gas

Paint thinners or removers, 

degreasers, dry-cleaning 

fluids, gasoline, lighter fluids, 

correction fluids, permanent 

markers, electronics cleaners 

and freeze sprays, glue, spray 

paint, hair or deodorant 

sprays, fabric protector sprays, 

aerosol computer cleaning 

products, vegetable oil sprays, 

butane lighters, propane 

tanks, whipped cream aerosol 

containers, refrigerant gases, 

ether, chloroform, halothane, 

nitrous oxide

Inhaled through 

the nose or mouth

N/A

Uses & Possible Health Effectsii

Short-term Symptoms 

of Use

While symptoms vary by chemical, potential symptoms include: confusion; nausea or 

vomiting; slurred speech; loss of coordination; euphoria; dizziness; drowsiness; loss of 

inhibition, lightheadedness, hallucinations/delusions; headaches; sudden sniffing death 

due to heart failure (from butane, propane, and other chemicals in aerosols); death 

from asphyxiation, suffocation, convulsions or seizures, coma, or choking.

Nitrites: Enlarged blood vessels, enhanced sexual pleasure, increased heart rate, brief 

sensation of heat and excitement, dizziness, and headache.

Long-term 

Consequences of Use 

and Health Effects

Liver and kidney damage; damage to cardiovascular and nervous systems; bone 

marrow damage; nerve damage; and brain damage from lack of oxygen that can cause 

problems with thinking, movement, vision, and hearing.

Nitrites: Increased risk of pneumonia. 

Other Health-related 

Issues

Pregnancy-related: low birth weight, bone problems, delayed behavioral development 

due to brain problems, altered metabolism and body composition.

In Combination with 

Alcoholiii

Intensifies the toxic effects of inhalants; serious mental impairment can result, leading 

the user to engage in deadly behavior; and may lead to coma or death. 

Nitrites: dangerously low blood pressure.

Withdrawal Symptoms Nausea, loss of appetite, sweating, tics, problems sleeping, and mood changes.

Medical Useiv Nitrous oxide only, for anesthesia: amyl nitrate indicated for rapid relief of angina 

pectoris.

Treatment Optionsv

Medications There are no FDA-approved medications to treat inhalant addiction.

i. Source: NIDA, (2016).

ii. Sources: NIDA, (2016). 

iii. Source: Inhalant Addiction Treatment, (n.d.).

iv. Source: SAMHSA, (2004). 

v. Source: NIDA, (2016).
PAGE | 62

Inhalants

Behavioral Therapies More research is needed to determine if behavioral therapies can be used to treat 

inhalant addiction.

Statistics as of 2015vi

Prevalence

Lifetime: 25.8 million persons (9.6%) aged 12 or older have used inhalants in their 

lifetime.

• Amyl Nitrite, Poppers, Locker Room Odorizers, or Rush: 7.4 million persons (2.8%)

• Computer Cleaner/Air Duster: 3.0 million persons (1.1 %)

• Correction Fluid, Degreaser, or Cleaning Fluid: 1.6 million persons (0.6%)

• Felt-Tip Pens, Felt-Tip Markers, or Magic Markers: 6.8 million persons (2.5 %)

• Gasoline or Lighter Fluid: 3.2 million persons (1.2%)

• Glue, Shoe Polish, or Toluene: 3.2 million persons (1.2%)

• Halothane, Ether, or Other Anesthetics: 809,000 persons (0.3%)

• Lacquer Thinner or Other Paint Solvents: 1.5 million persons (0.6%)

• Lighter Gases (Butane, Propane): 767,000 persons (0.3%)

• Nitrous Oxide or Whippits: 12.4 million persons (4.6%)

• Spray Paints: 1.9 million persons (0.7%)

• Other Aerosol Sprays: 1.5 million persons (0.6%)

Past Year: 1.8 million persons (0.7%) aged 12 or older have used inhalants in the past 

year.

Average Age of 

Initiation 17.4

vi. Source: CBHSQ, (2016).
PAGE | 63

Ketamine

A dissociative drug, hallucinogen, which causes the user to feel detached from reality.i

Common 

Commercial Names Street Names Common Forms Common Ways Taken

DEA Schedule / 

Legal Status

Ketalar Cat Valium, K, 

Special K, 

Vitamin K

Liquid, white powder Injected , snorted, 

smoked (powder 

added to tobacco or 

marijuana cigarettes), 

ingested

Schedule III / Legal 

by prescription only

Uses & Possible Health Effectsii

Short-term 

Symptoms of Use

Problems with attention, learning, and memory; dreamlike states, hallucinations; 

sedation; confusion and problems speaking; memory loss; stiffening of the muscles and 

numbness; problems moving, to the point of being immobile; increased blood pressure; 

nausea; unconsciousness; slowed breathing (respiratory depression) that can lead to 

death.

Long-term 

Consequences of 

Use and Health 

Effects

Ulcers and pain in the bladder; kidney problems; stomach pain; depression; flashbacks; 

and poor memory.

Other Health-related 

Issues

Sometimes used as a date rape drug.

Risk of HIV, hepatitis, and other infectious diseases from shared needles.

In Combination with 

Alcohol Increased risk of adverse effects.

Withdrawal 

Symptoms Unknown.

Medical Use Used as an anesthetic agent.

Treatment Optionsiii

Medications There are no FDA-approved medications to treat addiction to ketamine or other 

dissociative drugs.

Behavioral Therapies More research is needed to determine if behavioral therapies can be used to treat 

addiction to dissociative drugs.

Statistics as of 2015iv

Prevalence

Lifetime: 3.0 million persons (1.1%) aged 12 or older have used ketamine in their lifetime.

Past Year: Data not collected.

Average Age of 

Initiation Hallucinogens in general: 19.6

i. Source: NIDA, (2016).

ii. Sources: NIDA, (2016) & DEA, (2015). 

iii. Source: NIDA, (2016).

iv. Source: CBHSQ, (2016).
PAGE | 64

LSD (lysergic acid diethylamide)

A hallucinogen manufactured from lysergic acid, which is found in ergot, a fungus that grows on rye and other 

grains. LSD is an abbreviation of the scientific name lysergic acid diethylamide.i

Common 

Commercial Names Street Names Common Forms Common Ways Taken

DEA Schedule / 

Legal Status

No commercial uses Acid, Blotter, 

Blue Heaven, 

Cubes, Microdot, 

Yellow Sunshine, 

A, Windowpane

Tablet; capsule; 

clear liquid; small, 

decorated squares 

of absorbent paper 

that liquid has been 

added to

Ingested, absorbed 

through mouth 

tissues (paper 

squares)

Schedule I / Illegal

Uses & Possible Health Effectsii

Short-term Symptoms 

of Use

Rapid mood swings; distortion of a person’s ability to recognize reality, think rationally, 

or communicate with others; raised blood pressure, heart rate, body temperature; 

dizziness and insomnia; loss of appetite; dry mouth; sweating; numbness; weakness; 

tremors; enlarged pupils; and impulsive behavior.

Long-term 

Consequences of Use 

and Health Effects

Frightening flashbacks (called Hallucinogen Persisting Perception Disorder [HPPD]); 

ongoing visual disturbances, disorganized thinking, paranoia, mood swings; and 

prolonged depression.

Other Health-related 

Issues Unknown.

In Combination with 

Alcohol May decrease the perceived effects of alcohol.

Withdrawal Symptoms Unknown.

Treatment Optionsiii

Medications There are no FDA-approved medications to treat addiction to LSD or other 

hallucinogens.

Behavioral Therapies More research is needed to determine if behavioral therapies can be used to treat 

addiction to hallucinogens.

Statistics as of 2015iv

Prevalence

Lifetime: 25.3 million persons (9.5%) aged 12 or older have used LSD in their lifetime.

Past Year: 1.5 million persons (0.6%) aged 12 or older have used LSD in the past year.

Average Age of 

Initiation 19.6

i. Source: NIDA, (2016).

ii. Sources: NIDA, (2016) & DEA, (2015). 

iii. Source: NIDA, (2016).

iv. Source: CBHSQ, (2016).
PAGE | 65

Marijuana (Cannabis)

Marijuana is Cannabis sativa, a plant with psychoactive properties. The main psychoactive (mind-altering) 

chemical in marijuana is delta-9-tetrahydrocannabinol, or THC.i

Common 

Commercial Names Street Names Common Forms Common Ways Taken

DEA Schedule / Legal 

Status

Various brand names in 

states where the sale of 

marijuana is legal

Marijuana: Blunt, 

Bud, Dope, Ganja, 

Grass, Green, 

Herb, Joint, Mary 

Jane, Pot, Reefer, 

Sinsemilla, Skunk, 

Smoke, Trees, Weed

Hashish: Boom, 

Gangster, Hash, 

Hemp, THC 

Greenish-gray 

mixture of dried, 

shredded leaves, 

stems, seeds, and/

or flowers; resin 

(hashish) or sticky, 

black liquid (hash 

oil)

Smoked, ingested 

(mixed in food or 

brewed as tea)

Schedule I/ Illegalii for 

both marijuana and THC, 

the active ingredient in 

marijuana, which is listed 

separately from marijuana.

Marinol®, containing THC 

as synthetically-derived 

dronabinol, is an FDAapproved drug product, 

controlled in Schedule III / 

Legal by prescription only

Uses & Possible Health Effectsiii

Short-term Symptoms 

of Use

Enhanced sensory perception and euphoria followed by drowsiness/relaxation; 

disinhibition, increased sociability; dry mouth; slowed reaction time; time distortion; 

impaired balance and coordination; increased heart rate and appetite; decreased blood 

pressure; problems with learning and memory; heightened imagination, hallucinations 

and delusions; anxiety; panic attacks; and psychosis.

Long-term 

Consequences of Use 

and Health Effects

Mental health problems, chronic cough, frequent respiratory infections, increased risk 

for cancer, and suppression of the immune system.

Other Health-related 

Issues

Breathing problems and increased risk of cancer of the head, neck, lungs, and 

respiratory tract.

Youth: Possible loss of IQ points when repeated use begins in adolescence. 

Pregnancy-related: Babies born with problems with attention, memory, and problem solving.

In Combination with 

Alcohol Increased heart rate, blood pressure; further slowing of mental processing and reaction time.

Withdrawal Symptoms Irritability, trouble sleeping, decreased appetite, anxiety.

Medical Uses

Marino® is indicated for the treatment of:

• Anorexia associated with weight loss in patients with AIDS; and

• Nausea and vomiting associated with cancer chemotherapy in patients who have 

failed to respond adequately to conventional antiemetic treatments.

Treatment Optionsiv

Medications There are no FDA-approved medications to treat marijuana addiction.

Behavioral Therapies

• Behavioral treatments tested with adolescents 

• Cognitive-behavioral therapy (CBT)

• Contingency management, or motivational incentives

• Motivational Enhancement Therapy (MET) 
PAGE | 66

Marijuana (Cannabis)

Statistics as of 2015v

Prevalence

Lifetime: 117.9 million persons (44.0%) aged 12 or older have used marijuana in their lifetime.

Past Year: 36.0 million persons (13.5%) aged 12 or older have used marijuana in the past year.

Average Age of 

Initiation 19.0

i. Source: NIDA, (2016).

ii. As of this writing, 25 states and the District of Columbia have legalized medical marijuana use, four states have 

legalized retail marijuana sales, and the District of Columbia has legalized personal use and home cultivation 

(both medical and recreational). See Chapter 3 - Prevention Programs and Policies for more detail on this issue.

iii. Sources: NIDA, (2016) & DEA, (2015). 

iv. Source: NIDA, (2016).

v. Source: CBHSQ, (2016).
PAGE | 67

MDMA (Ecstasy)

A synthetic, psychoactive drug that has similarities to both the stimulant amphetamine and the hallucinogen 

mescaline. MDMA is an abbreviation of the scientific name 3,4-methylenedioxy-methamphetamine.i

Common Commercial 

Names Street Names Common Forms Common Ways Taken

DEA Schedule / 

Legal Status

No commercial uses Adam, Clarity, Eve, 

Lover’s Speed, 

Peace, Uppers, E, X, 

XTC, Molly 

Colorful tablets with 

imprinted logos, 

capsules, powder, 

liquid

Ingested, snorted Schedule I / Illegal

Uses & Possible Health Effectsii

Short-term Symptoms 

of Use

Lowered inhibition and coordination; sleep disturbances; enhanced sensory 

perception; confusion; depression; sleep problems; anxiety; increased heart rate and 

blood pressure; muscle tension; teeth clenching; increased motor activity, alertness; 

nausea; blurred vision; faintness; chills or sweating; sharp rise in body temperature 

leading to liver, kidney, or heart failure and death. 

Long-term 

Consequences of Use 

and Health Effects

Long-lasting confusion; depression; damage to the serotonin system; problems with 

attention, memory, and sleep; increased anxiety, impulsiveness, and aggression; loss of 

appetite; and less interest in sex.

Other Health-related 

Issues Unknown.

In Combination with 

Alcohol May increase the risk of cell and organ damage.

Withdrawal Symptoms Fatigue, loss of appetite, depression, and trouble concentrating.

Treatment Optionsiii

Medications There is conflicting evidence about whether MDMA is addictive. There are no FDAapproved medications to treat MDMA addiction.

Behavioral Therapies More research is needed to determine if behavioral therapies can be used to treat 

potential MDMA addiction.

Statistics as of 2015iv

Prevalence

Lifetime: 18.3 million persons (6.8%) aged 12 or older have used ecstasy in their lifetime.

Past Year: 2.6 million persons (1.0%) aged 12 or older have used ecstasy in the past year.

Average Age of 

Initiation 20.7

i. Source: NIDA, (2016).

ii. Sources: NIDA, (2016) & DEA, (2015). 

iii. Source: NIDA, (2016).

iv. Source: CBHSQ, (2016).
PAGE | 68

Mescaline (Peyote)

A hallucinogen found in disk-shaped “buttons” in the crown of several cacti, including peyote, and can also be 

created synthetically.

i

Common Commercial 

Names Street Names Common Forms Common Ways Taken

DEA Schedule / 

Legal Status

No commercial uses Buttons, Cactus, 

Mesc, Peyote

Fresh or dried 

buttons, capsule

Ingested (chewed or 

soaked in water and 

drunk) or smoked

Schedule I / Illegal

Uses & Possible Health Effectsii

Short-term Symptoms 

of Use

Enhanced perception and feeling; hallucinations; euphoria; anxiety; increased body 

temperature, heart rate, blood pressure; sweating; headaches; and impaired motor 

coordination.

Long-term 

Consequences of Use 

and Health Effects

Unknown. 

Other Health-related 

Issues Unknown.

In Combination with 

Alcohol Unknown.

Withdrawal Symptoms Unknown.

Treatment Optionsiii

Medications There are no FDA-approved medications to treat addiction to mescaline or other 

hallucinogens.

Behavioral Therapies More research is needed to determine if behavioral therapies can be used to treat 

addiction to hallucinogens.

Statistics as of 2015iv

Prevalence

Lifetime:

• Mescaline: 8.0 million persons (3.0%) aged 12 or older have used mescaline in 

their lifetime.

• Peyote: 5.5 million persons (2.0%) aged 12 or older have used peyote in their 

lifetime.

Past Year: 4.7 million persons (1.8%) aged 12 or older have used hallucinogens in the 

past year. 

Average Age of 

Initiation Hallucinogens in general: 19.6

i. Source: NIDA, (2016).

ii. Sources: NIDA, (2016) & DEA, (2015). 

iii. Source: NIDA, (2016).

iv. Source: CBHSQ, (2016).
PAGE | 69

Methamphetamine

An extremely addictive stimulant amphetamine drug.i

Common Commercial 

Names Street Names Common Forms Common Ways Taken

DEA Schedule / 

Legal Status

Desoxyn® Crank, Chalk, 

Crystal, Fire, 

Glass, Go Fast, 

Ice, Meth, Speed 

White powder or pill; 

crystal meth looks 

like pieces of glass 

or shiny blue-white 

“rocks” of different 

sizes

Ingested, 

snorted, 

smoked, injected

Schedule II / Illegal 

(except for Desoxyn®

by prescription only)

Uses & Possible Health Effectsii

Short-term Symptoms 

of Use

Increased wakefulness and physical activity; decreased appetite; hyperthermia; 

increased breathing, heart rate, blood pressure, temperature; irregular heartbeat; and 

death from cardiac arrest, stroke, or suicide.

Long-term 

Consequences of Use 

and Health Effects

Anxiety, confusion, insomnia, mood problems, violent behavior, paranoia, 

hallucinations, delusions, weight loss, severe dental problems (“meth mouth”), 

memory loss, intense itching leading to skin sores from scratching and high-risk for 

addiction.

Other Health-related 

Issues

Sharing needles increases the risk of contracting infectious diseases like HIV and 

Hepatitis B and C.

Pregnancy-related: premature delivery; separation of the placenta from the uterus; 

low birth weight; lethargy; heart and brain problems.

In Combination with 

Alcohol

Masks the depressant effect of alcohol, increasing risk of alcohol overdose; may 

increase blood pressure and jitters.

Withdrawal Symptoms Depression, anxiety, tiredness.

Medical Uses

Desoxyn® is indicated for the treatment of:

• Attention Deficit Disorder with Hyperactivity

• Exogenous Obesity

Treatment Optionsiii

Medications There are no FDA-approved medications to treat methamphetamine addiction.

Behavioral Therapies

• Cognitive-behavioral therapy (CBT)

• Contingency management or motivational incentives

• The Matrix Model

• 12-Step facilitation therapy

Statistics as of 2015iv

Prevalence

Lifetime: 14.5 million persons (5.4%) aged 12 or older have used methamphetamine in 

their lifetime.

Methamphetamine needle use: 1.9 million persons (0.7%) 

Past Year: 1.7 million persons (0.6%) aged 12 or older have used methamphetamine in 

the past year.

Average Age of 

Initiation  25.8

i. Source: NIDA, (2016).

ii. Sources: NIDA, (2016) & DEA, (2015). 

iii. Source: NIDA, (2016).

iv. Source: CBHSQ, (2016).
PAGE | 70

Over-the-counter Cough/Cold Medicines (Dextromethorphan or DXM)

Psychoactive when taken in higher-than-recommended amounts.i

Common Commercial 

Names Street Names Common Forms Common Ways Taken

DEA Schedule / 

Legal Status

Various (many brand 

names include “DM”)

Robotripping, 

Robo, Triple C

Suspension, 

capsule

Ingested Cough medicines 

with codeine are 

Schedule V. DXM is 

not Scheduled and is 

an over-the-counter 

medication

Uses & Possible Health Effectsii

Short-term Symptoms 

of Use

Euphoria; slurred speech; increased heart rate, blood pressure, and body 

temperature; numbness; dizziness; nausea; vomiting; confusion; hallucinations; 

paranoia; agitation; altered visual perceptions; loss of coordination, problems with 

movement; buildup of excess acid in body fluids; liver damage; seizures; and coma.

Long-term 

Consequences of Use 

and Health Effects

Unknown. 

Other Health-related 

Issues

Breathing problems, seizures, and increased heart rate may occur from other 

ingredients in cough/cold medicines.

In Combination with 

Alcohol Increased risk of adverse effects.

Withdrawal Symptoms Unknown.

Medical Useiii Used for cough suppression.

Treatment Optionsiv

Medications There are no FDA-approved medications to treat addiction to over-the-counter 

cough/cold medicines.

Behavioral Therapies More research is needed to determine if behavioral therapies can be used to treat 

addiction to over-the-counter cough/cold medicines.

Statistics as of 2015v

Prevalence

Lifetime: Data not collected. 

Past Year: Data not collected.

Average Age of 

Initiation Stimulants in general: 22.3

i. Source: NIDA, (2016).

ii. Sources: NIDA, (2016) & DEA, (2015). 

iii. Source: SAMHSA, (2004).

iv. Source: NIDA, (2016).

v. Source: CBHSQ, (2016).
PAGE | 71

PCP (Phencyclidine)

A dissociative drug developed as an intravenous anesthetic that has been discontinued due to serious adverse 

effects. Dissociative drugs are hallucinogens that cause the user to feel detached from reality.i

Common 

Commercial Names Street Names Common Forms Common Ways Taken

DEA Schedule / 

Legal Status

No commercial uses Angel Dust, Boat, 

Hog, Love Boat, 

Peace Pill, Angel 

Mist

White or colored 

powder, tablet, or 

capsule; clear liquid

Injected, snorted, 

ingested, smoked 

(powder added to 

mint, parsley, oregano, 

or marijuana)

Schedule I, II / 

Illegal

Uses & Possible Health Effectsii

Short-term Symptoms 

of Use

Delusions, hallucinations, paranoia, problems thinking, a sense of distance from one’s 

environment, anxiety.

Low doses: slight increase in pulse and breathing rate; increased blood pressure and 

heart rate; shallow breathing; face redness and sweating; numbness of the hands or 

feet; and loss of coordination. 

High doses: lowered blood pressure, heart rate, and breathing; nausea; vomiting; 

blurred vision; flicking up and down of the eyes; drooling; loss of balance; dizziness; 

violence; suicidal thoughts; seizures, coma, and death.

Long-term 

Consequences of Use 

and Health Effects

Memory loss, problems with speech and thinking, depression, psychosis, weight loss, 

anxiety.

Other Health-related 

Issues

PCP has been linked to self-injury. 

Risk of HIV, hepatitis, and other infectious diseases from shared needles.

In Combination with 

Alcohol Increased risk of coma.

Withdrawal Symptoms Headaches and sweating.

Treatment Optionsiii

Medications There are no FDA-approved medications to treat addiction to PCP or other dissociative 

drugs.

Behavioral Therapies More research is needed to determine if behavioral therapies can be used to treat 

addiction to dissociative drugs.

Statistics as of 2015iv

Prevalence

Lifetime: 6.3 million persons (2.4%) aged 12 or older have used PCP in their lifetime. 

Past Year: 120,000 persons (<0.1%) aged 12 or older have used PCP in the past year.

Average Age of 

Initiation 15.3

i. Source: NIDA, (2016).

ii. Source: NIDA, (2016). 

iii. Source: NIDA, (2016).

iv. Source: CBHSQ, (2016).
PAGE | 72

Prescription Opioids

Pain relievers with an origin similar to that of heroin. Opioids can cause euphoria and are sometimes used 

nonmedically, leading to overdose deaths.i

Common 

Commercial Names Street Names Common Forms

Common Ways 

Taken

DEA Schedule / 

Legal Status

Codeine (various brand

names)

Captain Cody, Cody, 

Lean, Schoolboy, 

Sizzurp, Purple Drank

With glutethimide:

Doors & Fours, Loads, 

Pancakes and Syrup

Tablet, capsule, 

liquid 

Injected, 

ingested

(often mixed

with soda and 

flavorings)

Schedule II, III, V / 

Legal by prescription 

only

Fentanyl (Actiq®, 

Duragesic®, 

Sublimaze®)

Apache, China Girl, 

China White, Dance 

Fever, Friend,

Goodfella, Jackpot,

Murder 8, Tango and 

Cash, TNT

Lozenge, 

sublingual tablet, 

film, buccal tablet

Injected, 

smoked,

snorted

Schedule II / Legal by

prescription only

Hydrocodone or

dihydrocodeinone

(Vicodin®, Lortab®,

Lorcet®, and others)

Vike, Watson-387 Capsule, liquid, 

tablet

Ingested, 

snorted,

injected

Schedule II / Legal by

prescription only

Hydromorphone 

(Dilaudid®)

D, Dillies, Footballs, 

Juice, Smack

Liquid, 

suppository

Injected, rectally 

inserted

Schedule II / Legal by 

prescription only

Meperidine (Demerol®) Demmies, Pain Killer Tablet, liquid Ingested, 

snorted,

injected

Schedule II / Legal by

prescription only

Methadone 

(Dolophine®)

Amidone, Fizzies

With MDMA: Chocolate

Chip Cookies

Tablet Ingested, 

injected 

Schedule II / Legal by 

prescription only for 

pain indication

Morphine, various 

brand names

M, Miss Emma, 

Monkey, White Stuff 

Tablet, liquid, 

capsule, 

suppository 

Ingested, 

injected, 

smoked

Schedule II, III / Legal

by prescription only

Oxycodone 

(OxyContin®,

Percodan®, Percocet®,

and others)

O.C., Oxycet,

Oxycotton, Oxy,

Hillbilly Heroin, Percs

Capsule, liquid, 

tablet

Ingested, 

snorted,

injected

Schedule II / Legal by

prescription only

Oxymorphone 

(Opana®)

Biscuits, Blue Heaven, 

Blues, Mrs. O, O Bomb, 

Octagons, Stop Signs

Tablet Ingested, 

snorted,

injected

Schedule II / Legal by

prescription only

i. Sources: NIDA, (2016) & DEA, (2015). 
PAGE | 73

Prescription Opioids

Uses & Possible Health Effectsii

Short-term Symptoms 

of Use

Pain relief, drowsiness, nausea, constipation, altered judgment and decision making, 

sedation, euphoria, confusion, clammy skin, muscle weakness, slowed breathing, 

lowered heart rate and blood pressure, coma, heart failure, and death.

For oxycodone specifically: Pain relief, sedation, respiratory depression, constipation, 

papillary constriction, and cough suppression. 

For fentanyl specifically: Fentanyl is about 100 times more potent than morphine as an 

analgesic and results in frequent overdoses.

Long-term 

Consequences of Use 

and Health Effects

Heart or respiratory problems. Extended or chronic use of oxycodone containing 

acetaminophen may cause severe liver damage. Abuse of opioid medications can lead 

to psychological dependence.

Other Health-related 

Issues

Pregnancy-related: Miscarriage, low birth weight, neonatal abstinence syndrome.

Older adults: higher risk of accidental misuse or abuse because many older adults have 

multiple prescriptions, increasing the risk of drug-drug interactions, and breakdown of 

drugs slows with age; also, many older adults are treated with prescription medications 

for pain.

Risk of HIV, hepatitis, and other infectious diseases from shared needles.

In Combination with 

Alcohol Dangerous slowing of heart rate and breathing leading to coma or death.

Withdrawal 

Symptoms

Restlessness, anxiety, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes 

with goose bumps, and muscle tremors.

Medical Useiii Used for pain relief. Methadone is also used to treat opioid use disorders. 

Treatment Optionsiv

Medications

• Methadone

• Buprenorphine

• Naltrexone (oral and extended-release injectable)

Behavioral Therapies Behavioral therapies that have helped treat addiction to heroin may be useful in 

treating prescription opioid addiction.

Statistics as of 2015v

Prevalence

Lifetime: 36 million persons (13.6%) aged 12 or older have misused pain relievers in 

their lifetime.

Past Year: 12.5 million persons (4.7 %) aged 12 or older have misused pain relievers in 

the past year.

• OxyContin®: 1.7 million persons (0.7%) aged 12 or older have used OxyContin®

non-medically in the past year.

Average Age of 

Initiation Prescription Opioids: 25.8

ii. Sources: NIDA, (2016) & DEA, (2015). 

iii. Source: SAMHSA, (2004).

iv. Source: NIDA, (2016).

v. Source: CBHSQ, (2016).
PAGE | 74

Prescription Sedatives (Tranquilizers, Depressants)

Medications that slow brain activity, which makes them useful for treating anxiety and sleep problems.i

Common Commercial 

Names Street Names Common Forms Common Ways Taken

DEA Schedule / 

Legal Status

Barbiturates: pentobarbital 

(Nembutal®), phenobarbital 

(Luminal®)

Barbs, Phennies, Red 

Birds, Reds, Tooies, 

Yellow Jackets, Yellows

Pill, capsule, 

liquid

Ingested, 

injected

Schedule II, III, 

IV / Legal by 

prescription only

Benzodiazepines: alprazolam 

(Xanax®), chlorodiazepoxide 

(Limbitrol®), diazepam 

(Valium®), lorazepam 

(Ativan®), triazolam (Halicon®)

Candy, Downers, 

Sleeping Pills, Tranks 

Pill, capsule, 

liquid

Ingested, 

snorted

Schedule IV 

/ Legal by 

prescription only

Sleep Medications: 

eszopiclone (Lunesta®), 

zaleplon (Sonata®), zolpidem 

(Ambien®)

Forget-me Pill, Mexican 

Valium, R2, Roche, 

Roofies, Roofinol, Rope, 

Rophies 

Pill, capsule, 

liquid

Ingested, 

snorted

Schedule IV 

/ Legal by 

prescription only

Uses & Possible Health Effectsii

Short-term Symptoms of 

Use

Drowsiness, sedation; slurred speech; poor concentration, confusion, dizziness; 

clammy skin; impaired judgment, coordination and memory; reduced anxiety; lowered 

blood pressure; slowed breathing and central nervous system; coma, and death. 

Long-term Consequences 

of Use and Health Effects Increased risk of respiratory distress. 

Other Health-related 

Issues

Sleep medications are sometimes used as date rape drugs.

Risk of HIV, hepatitis, and other infectious diseases from shared needles.

In Combination with 

Alcohol Dangerous slowdown of heart rate and breathing, coma, and death.

Withdrawal Symptoms Must be discussed with a health care professional; barbiturate withdrawal can 

cause a serious abstinence syndrome that may even include seizures.

Medical Useiii For tranquilization, sedation, and sleep.

Treatment Optionsiv

Medications

There are no FDA-approved medications to treat addiction to prescription 

sedatives; lowering the dose over time must be done with the help of a health 

care professional.

Behavioral Therapies More research is needed to determine if behavioral therapies can be used to treat 

addiction to prescription sedatives.

Statistics as of 2015v

Prevalence

Lifetime: Data not collected. 

Past Year:

• 1.5 million persons (0.6%) aged 12 or older have misused sedatives in the past year. 

• 6.1 million persons (2.3%) aged 12 or older have misused tranquilizers in the past 

year.

Average Age of Initiation

Sedatives: 28.3

Tranquilizers: 25.9

i. Source: NIDA, (2016).

ii. Sources: NIDA, (2016) & DEA, (2015). 

iii. Source: SAMHSA, (2004).

iv. Source: NIDA, (2016).

v. Source: CBHSQ, (2016).
PAGE | 75

Prescription Stimulants

Medications that increase alertness, attention, energy, blood pressure, heart rate, and breathing rate.i

Common Commercial 

Names Street Names Common Forms Common Ways Taken

DEA Schedule / 

Legal Status

Amphetamine 

(Adderall®, 

Benzedrine®)

Bennies, Black 

Beauties, Crosses, 

Hearts, LA 

Turnaround, Speed, 

Truck Drivers, 

Uppers 

Tablet, capsule Ingested, snorted, 

smoked, injected

Schedule II / Legal 

by prescription only

Methylphenidate 

(Concerta®, Ritalin®)

JIF, MPH, R-ball, 

Skippy, The Smart 

Drug, Vitamin R

Liquid, tablet, 

chewable tablet, 

capsule

Ingested, snorted, 

smoked, injected, 

chewed

Schedule II / Legal 

by prescription only

Uses & Possible Health Effectsii

Short-term Symptoms 

of Use

Increased alertness, attention, energy; euphoria; insomnia, wakefulness; increased 

blood pressure and body temperature, metabolism, and heart rate; narrowed blood 

vessels; increased blood sugar; agitation; opened-up breathing passages; and violent 

and erratic behavior.

High doses: dangerously high body temperature and irregular heartbeat; seizures; and 

death from heart failure or suicide.

For amphetamines specifically: Paranoia, picking at the skin, preoccupation with one’s 

own thoughts, and auditory and visual hallucinations. 

Long-term 

Consequences of Use 

and Health Effects

Heart problems, psychosis, anger, paranoia, addiction, and chronic sleep problems.

Other Health-related 

Issues Risk of HIV, hepatitis, and other infectious diseases from shared needles.

In Combination with 

Alcohol

Masks the depressant action of alcohol, increasing risk of alcohol overdose; may 

increase blood pressure and jitters.

Withdrawal Symptoms Depression, tiredness, and sleep problems.

Medical Useiii For narcolepsy, obesity, and hyperkinesis.

Treatment Optionsiv

Medications There are no FDA-approved medications to treat stimulant addiction.

Behavioral Therapies Behavioral therapies that have helped treat addiction to cocaine or methamphetamine 

may be useful in treating prescription stimulant addiction.

Statistics as of 2015v

Prevalence

Lifetime: Data not collected.

Past Year: 5.3 million (2.0%) aged 12 or older have misused stimulants in the past year.  

Average Age of 

Initiation Stimulants in general: 22.3

i. Source: NIDA, (2016).

ii. Sources: NIDA, (2016) & DEA, (2015). 

iii. Source: SAMHSA, (2004).

iv. Source: NIDA, (2016).

v. Source: CBHSQ, (2016).
PAGE | 76

Psilocybin

A hallucinogen in certain types of mushrooms that grow in parts of South America, Mexico, and the United States.i

Common Commercial 

Names Street Names Common Forms Common Ways Taken

DEA Schedule / 

Legal Status

No commercial uses Little Smoke, 

Magic 

Mushrooms, 

Purple Passion, 

Shrooms 

Fresh or dried 

mushrooms with 

long, slender stems 

topped by caps with 

dark gills

Ingested (eaten, 

brewed as tea, or 

added to other 

foods)

Schedule I / Illegal

Uses & Possible Health Effectsii

Short-term Symptoms 

of Use

Hallucinations, altered perception of time, inability to tell fantasy from reality, panic, 

muscle relaxation or weakness, loss of coordination, enlarged pupils, nausea, vomiting, 

and drowsiness.

Long-term 

Consequences of Use 

and Health Effects

Risk of flashbacks, psychosis, and memory problems.

Other Health-related 

Issues Risk of poisoning if a poisonous mushroom is accidentally used.

In Combination with 

Alcohol May decrease the perceived effects of alcohol.

Withdrawal Symptoms Unknown.

Treatment Optionsiii

Medications It is not known whether psilocybin is addictive. There are no FDA-approved 

medications to treat addiction to psilocybin or other hallucinogens.

Behavioral Therapies More research is needed to determine if psilocybin is addictive and whether 

behavioral therapies can be used to treat addiction to this or other hallucinogens.

Statistics as of 2014iv

Prevalence

Lifetime: 22.8 million persons (8.5%) aged 12 or older have used psilocybin in their 

lifetime.  

Past Year: Data not collected. 

Average Age of 

Initiation Hallucinogens in general: 19.6

i. Source: NIDA, (2016).

ii. Sources: NIDA, (2016) & DEA, (2015). 

iii. Source: NIDA, (2016).

iv. Source: CBHSQ, (2016).
PAGE | 77

Rohypnol® (Flunitrazepam)

A benzodiazepine chemically similar to prescription sedatives such as Valium® and Xanax®. Teens and young 

adults tend to abuse this drug at bars, nightclubs, concerts, and parties. It has been used to commit sexual 

assaults due to its ability to sedate and incapacitate unsuspecting victims.1

Common Commercial 

Names Street Names Common Forms Common Ways Taken

DEA Schedule 

/ Legal Status

Flunitrazepam, 

Rohypnol®

Circles, Date Rape Drug, 

Forget Pill, Forget-Me 

Pill, La Rocha, Lunch 

Money, Mexican Valium, 

Mind Eraser, Pingus, R2, 

Reynolds, Rib, Roach, 

Roach 2, Roaches, 

Roachies, Roapies, Rochas 

Dos, Roofies, Rope, 

Rophies, Row-Shay, Ruffies, 

Trip-and-Fall, Wolfies

Tablet Ingested (as a pill 

or as dissolved in 

a drink), snorted

Schedule IV / 

Rohypnol® is 

not approved 

for medical use 

in the United 

States; it is 

available as a 

prescription 

sleep aid in 

other countries

Uses & Possible Health Effectsii

Short-term Symptoms 

of Use

Drowsiness, sedation, sleep; amnesia, blackout; decreased anxiety; muscle relaxation, 

impaired reaction time and motor coordination; impaired mental functioning and 

judgment; confusion; aggression; excitability; slurred speech; headache; slowed 

breathing and heart rate.

Long-term 

Consequences of Use 

and Health Effectsiii

Physical and psychological dependence; cardiovascular collapse; and death

Other Health-related 

Issues Sometimes used as a date rape drug. 

In Combination with 

Alcohol

Exaggerated intoxication, severe sedation, unconsciousness, and slowed heart rate 

and breathing, which can lead to death.

Withdrawal Symptoms

Headache; muscle pain; extreme anxiety, tension, restlessness, confusion, irritability; 

numbness and tingling of hands or feet; hallucinations, delirium, convulsions, seizures, 

or shock.

Treatment Optionsiv

Medications There are no FDA-approved medications to treat addiction to Rohypnol® or other 

prescription sedatives.

Behavioral Therapies More research is needed to determine if behavioral therapies can be used to treat 

addiction to Rohypnol® or other prescription sedatives.

Statistics as of 2015v

Prevalence

Lifetime: Data not collected. 

Past Year: Data not collected. 

Average Age of 

Initiation Sedatives in general: 23.4

i. Source: NIDA, (2016).

ii. Sources: NIDA, (2016) & DEA, (2015). 

iii. Source: Rohypnol Abuse Treatment, (n.d.).

iv. Source: NIDA, (2016).

v. Source: CBHSQ, (2016).
PAGE | 78

Salvia

A dissociative drug (Salvia divinorum) that is an herb in the mint family native to southern Mexico. Dissociative 

drugs are hallucinogens that cause the user to feel detached from reality.i

Common Commercial 

Names Street Names Common Forms Common Ways Taken

DEA Schedule / 

Legal Status

Sold legally in most 

states as Salvia 

divinorum

Magic mint, Maria 

Pastora, Sally-D, 

Shepherdess’s Herb, 

Diviner’s Sage

Fresh or dried 

leaves

Smoked, chewed, 

or brewed as tea

Not scheduled; 

labeled drug of 

concern by DEA / 

Illegal in some states

Uses & Possible Health Effectsii

Short-term Symptoms 

of Use

Short-lived but intense hallucinations; loss of coordination, dizziness, slurred 

speech; altered visual perception, mood, body sensations; mood swings, feelings of 

detachment from one’s body; sweating; uncontrollable laughter; and paranoia.

Long-term 

Consequences of Use 

and Health Effects

Unknown. 

Other Health-related 

Issues Unknown.

In Combination with 

Alcohol Unknown.

Withdrawal Symptoms Unknown.

Treatment Optionsiii

Medications It is not known whether salvia is addictive. There are no FDA-approved medications to 

treat addiction to salvia or other dissociative drugs.

Behavioral Therapies More research is needed to determine if salvia is addictive, but behavioral therapies 

can be used to treat addiction to dissociative drugs.

Statistics as of 2015iv

Prevalence

Lifetime: 5.1 million persons (1.9%) aged 12 or older have used salvia in their lifetime.  

Past Year: Data not collected.

Average Age of 

Initiation Hallucinogens in general: 19.6

i. Source: NIDA, (2016).

ii. Sources: NIDA, (2016) & DEA, (2015). 

iii. Source: NIDA, (2016).

iv. Source: CBHSQ, (2016).
PAGE | 79

Steroids (Anabolic)

Man-made substances used to treat conditions caused by low levels of steroid hormones in the body and 

abused to enhance athletic and sexual performance and physical appearance.i

Common Commercial 

Names Street Names Common Forms Common Ways Taken

DEA Schedule / 

Legal Status

Nandrolone (Oxandrin®), 

oxandrolone (Anadrol®), 

oxymetholone (Winstrol®), 

stanozolol (Durabolin®), 

testosterone cypionate 

(Depo-testosterone®)

Juice, Gym Candy, 

Pumpers, Roids

Tablet, capsule, 

liquid drops, gel, 

cream, patch, 

injectable solution

Injected, ingested, 

applied to skin

Schedule III / Legal 

by prescription only

Uses & Possible Health Effectsii

Short-term Symptoms 

of Use

Headache, acne, fluid retention (especially in the hands and feet), oily skin, yellowing 

of the skin and whites of the eyes, and infection at the injection site.

Long-term 

Consequences of Use 

and Health Effects

Kidney damage or failure; liver damage; high blood pressure, enlarged heart, or 

changes in cholesterol leading to increased risk of stroke or heart attack, even in 

young people; hostility and aggression; extreme mood swings; anger (“roid rage”); 

paranoid jealousy; extreme irritability; delusions; impaired judgment.

Other Health-related 

Issues

Risk of HIV, hepatitis, and other infectious diseases from shared needles.

Males: shrunken testicles, lowered sperm count, infertility, baldness, development of 

breasts, increased risk for prostate cancer.

Females: facial hair, male-pattern baldness, menstrual cycle changes, enlargement of 

the clitoris, deepened voice.

Adolescents: stunted growth.

In Combination with 

Alcohol Increased risk of violent behavior.

Withdrawal Symptoms Mood swings; tiredness; restlessness; loss of appetite; insomnia; lowered sex drive; 

depression, sometimes leading to suicide attempts.

Medical Use Used to treat conditions caused by low levels of steroid hormones in the body.

Treatment Optionsiii

Medications Hormone therapy

Behavioral Therapies More research is needed to determine if behavioral therapies can be used to treat 

steroid addiction.

Statistics as of 2015iv

Prevalence Data not collected.

Average Age of 

Initiation Data not collected.

i. Source: NIDA, (2016).

ii. Sources: NIDA, (2016) & DEA, (2015). 

iii. Source: NIDA, (2016).

iv. Source: CBHSQ, (2016).
PAGE | 80

Synthetic Cannabinoids (“K2”/”Spice”)

A wide variety of herbal mixtures containing man-made cannabinoid chemicals related to THC in marijuana but 

often much stronger and more dangerous. Sometimes misleadingly called “synthetic marijuana” and marketed 

as a “natural,” “safe,” legal alternative to marijuana.1

Common Commercial 

Names Street Names Common Forms Common Ways Taken

DEA Schedule / 

Legal Status

No commercial uses K2, Spice, Black 

Mamba, Bliss, 

Bombay Blue, Fake 

Weed, Fire, Genie, 

Moon Rocks, Skunk, 

Smacked, Yucatan, 

Zohai 

Dried, shredded 

plant material that 

looks like potpourri 

and is sometimes 

sold as “incense”

Smoked, ingested 

(brewed as tea)

Schedule I 

Uses & Possible Health Effectsii

Short-term Symptoms 

of Use

Increased heart rate and blood pressure; vomiting; agitation; confusion; hallucinations, 

anxiety, paranoia; euphoria, relaxation; headache; numbness and tingling; reduced 

blood supply to the heart; heart attack; and seizures.

Long-term 

Consequences of Use 

and Health Effects

Kidney damage and psychosis. 

Other Health-related 

Issues

Use of synthetic cannabinoids has led to an increase in emergency department visits in 

certain areas. 

In Combination with 

Alcohol Unknown.

Withdrawal Symptoms Headaches, anxiety, depression, irritability.

Treatment Optionsiii

Medications There are no FDA-approved medications to treat K2/Spice addiction.

Behavioral Therapies More research is needed to determine if behavioral therapies can be used to treat 

synthetic cannabinoid addiction.

Statistics as of 2015iv

Prevalence Data not collected.

Average Age of 

Initiation Data not collected. 

i. Source: NIDA, (2016).

ii. Sources: NIDA, (2016) & DEA, (2015). 

iii. Source: NIDA, (2016).

iv. Source: CBHSQ, (2016).
PAGE | 81

Synthetic Cathinones (“Bath Salts”)

An emerging family of drugs containing one or more synthetic chemicals related to cathinone, a stimulant 

found naturally in the khat plant. Examples of such chemicals include mephedrone, methylone, and 3,4- 

methylenedioxypyrovalerone (MDPV).

i

Common Commercial 

Names Street Names Common Forms Common Ways Taken

DEA Schedule 

/ Legal Status

No commercial names for 

“bath salts”

Bloom, Cloud Nine, Cosmic 

Blast, Ivory Wave, Lunar 

Wave, Scarface, Vanilla Sky, 

White Lightning MDPV 

and mephedrone: Meow 

meow, MCAT, drone, plant 

feeder, bubbles, bliss, blue 

silk, cloud nine, energy-1, 

ivory wave, lunar wave, 

ocean burst, pure ivory, 

purple wave, red dove, snow 

leopard, stardust, vanilla sky, 

white dove, white night, and 

white lightning

White or brown 

crystalline powder 

sold in small 

plastic or foil 

packages labeled 

“not for human 

consumption” and 

sometimes sold 

as jewelry cleaner; 

tablet, capsule, 

liquid

Ingested, snorted, 

injected, ingested, 

smoked

Schedule I

Uses & Possible Health Effectsii

Short-term Symptoms 

of Use

Increased heart rate and blood pressure; euphoria; increased sociability and sex 

drive; paranoia, agitation, and hallucinations; psychotic and violent behavior; 

nosebleeds; sweating; headaches; teeth grinding; nausea, vomiting; insomnia; 

irritability; dizziness; depression; suicidal thoughts; panic attacks; reduced motor 

control; and cloudy thinking.

Long-term 

Consequences of Use 

and Health Effects

Breakdown of skeletal muscle tissue, kidney failure, psychosis, and death.

Other Health-related 

Issues

Risk of HIV, hepatitis, and other infectious diseases from injecting with shared 

needles.

In Combination with 

Alcohol Unknown.

Withdrawal Symptoms Depression, anxiety, problems sleeping, tremors, paranoia.

Treatment Optionsiii

Medications There are no FDA-approved medications to treat addiction to bath salts.

Behavioral Therapies

• Behavioral treatments geared to teens

• Cognitive-behavioral therapy (CBT)

• Contingency management, or motivational incentives

• Motivational Enhancement Therapy (MET) 

Statistics as of 2015iv

Prevalence Data not collected.

Average Age of 

Initiation Data not collected.

i. Source: NIDA, (2016).

ii. Sources: NIDA, (2016) & DEA, (2015). 

iii. Source: NIDA, (2016).

iv. Source: CBHSQ, (2016).
PAGE | 82

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Washington, DC: Drug Enforcement Administration.

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3. National Institute on Alcohol Abuse and Alcoholism. (n.d.). Alcohol’s effects on the body. 

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12, 2016.

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Accessed on June 10, 2016.

8. Substance Abuse and Mental Health Services Administration. (2004). Keeping youth drug free. 

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10. U.S. Department of Justice. (n.d.). Title 21 code of federal regulations: Part 1308 — Schedules of 

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htm. Accessed on June 27, 2016.

11. U.S. National Library of Medicine. (2015). Neonatal abstinence syndrome. Retrieved from 

https://www.nlm.nih.gov/medlineplus/ency/article/007313.htm. Accessed on July 5, 2016.

12. Gepner, Y., Golan, R., Harman-Boehm, I., Henkin, Y., Schwarzfuchs, D., Shelef, I., ... Shai, I. 

(2015). Effects of initiating moderate alcohol intake on cardiometabolic risk in adults with type 

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diabetes mellitus: a systematic review. Annals of Internal Medicine, 140(3), 211-219.

14. Stockwell, T., Zhao, J., Panwar, S., Roemer, A., Naimi, T., & Chikritzhs, T. (2016). Do “moderate” 

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U.S. Department of Health & Human Services

HHS Publication No. (SMA) 16-4991