The recent surge in drug overdose deaths has prompted media, citizens and politicians to reexamine the problem with illicit drugs. The death rate from “overdose” has exceeded all other causes of involuntary death as revealed in official US government statistics used in this white paper.
We have been through this in our nation at least three times before.
From the eighteenth century to the middle of the nineteenth century the first wave came. It was with distilled alcohol that became cheap. This led to the “inebriate” problem. The abstinence movement coupled with faith from the Oxford movement addressed this public disaster. Prohibition in the early 20th century was the extreme end of this movement’s successes. However, it brought its own problems with gangsterism.
About the middle of the nineteenth century, the second wave began to rise. There was a proliferation of patent medicines. (Our language was enriched with terms like “snake oil” and swamp root” for phony cures to problems.) Many used alcohol as a vehicle to carry drugs like morphine and codeine, which are opiods used to ease chronic pain and discomfort from illness. Others used fruit juice and soda water as a vehicle for cocaine and caffeine, which are from coca leaves and kola nuts used as stimulants to combat fatigue. This problem was addressed by the US congress through the Food and Drug Act. It required honest labeling of ingredients on such products. Later updates in the law restricted volume size and ultimately made them controlled substances available only by doctor’s prescription.
The third wave of substance abuse was rising in the 50’s, the aftermath of World War 2. It brought the rise of black markets in refined drugs from the opium and cocaine plants. To this mix came synthetic drugs and hallucinogens. The liberation wind of the 60’s made drug use acceptable and a symbol of emancipation. In reality it was the bondage of addiction.
The Oxford and abstinence movements of the early twentieth century gave rise to AA that gave rise to encounter groups by the 1950’s. Medical rehabilitation modalities were being developed about the middle of the twentieth century to ease craving. This was recognized as biochemical dependency. The public policy became rehabilitation.
By the end of the twentieth century large appropriations for drug education and treatment were routine in governmental budgets. However, terrorism began to raise its ugly head during the last two decades of the twentieth century. It reached our full consciousness in the 9/11 attacks of 2001. The political focus shifted to radical Islam that had declared war on us. That is where the money and political focus went.
Because of this, the drug problem continued to grow out of sight until the surge in drug deaths from synthetic opiods for the last three years put it back in the headlines.
I believe we need to learn from the past or large sums of money will be spent in panic to only be ignored in the frustration of “no solution”.
This white paper is intended to give a solid foundation to understanding the drug problem by examining and interpreting government statistics. Sample of medical modalities will highlight the difficulty of creating a long-term solution to problem. The next paper will look for “the ultimate solution”.
All schools have or had a substantial drug education program. The cost of the curriculum materials can run over $400/student. A few of these programs are:
MADD Mothers Against Drunk Driving http://www.madd.org/
All Stars http://www.allstarsprevention.com
DARE Drug Abuse Resistance Education http://www.dare.org/
If drug education reduces the number of addicts younger than 18, it will be considered a success. We can examine the results in a report by the National Institute for Drug Abuse (NIDA),
“Monitoring The Future, 2013 Survey Results” https://www.drugabuse.gov/related-topics/trends-statistics/infographics/monitoring-future-2013-survey-results
It shows that use of illicit drugs was 18% in 1993 and is at 25.5 % in 2013 for 12th graders. However, the grand total of users in 8, 10 and 12th grades was unchanged. No overall success with reducing use of illicit drugs! However binge and heavy drinking of alcohol, and smoking declined substantially over the same period. It is uncertain whether the drug education program or societal norm is responsible for the decline in use of alcohol and cigarettes.
Marihuana use is a probable slope for sliding into “hard” drugs. It is considered a “gateway drug” to other drugs. Use is four times higher than all other illicit drugs combined. However, many marijuana users never begin or continue to use hard drugs after sampling them.
In 2014, a total of 2.5 million persons aged 12 years and up used marijuana for the first time. The first use of hard drugs declined slightly. First use has been tracked from 2002 to 2014. It shows a first use increase among persons aged 18 and older but not among those aged 12–17 years. The total in this group was unchanged. The conclusion is that the drug education has no effect either way on use of illicit drugs.
This increase in illicit drug use is due entirely to the increase in marijuana use. It is the highest component at 19.8 million out of 24.6 million. See the NIDA report
Nationwide Trends (https://www.drugabuse.gov/publications/drugfacts/nationwide-trends)
The first use survey also investigated perceived risk. Fewer persons 12 years old and older perceived a great risk from smoking marijuana once a month, or once a week or twice a week.
Another part of the survey determined the rate of dependency. It decreased for those less than 26, but increased for those 26 and older.
More persons aged 12 years and up report lower perceived legal penalty for the possession of an ounce or less of it. The perception of probation, community service, possible prison sentence, and mandatory prison sentences for possession also decreased.
This may portend more use of the drug unless the lower use in 8th and 10th grades continues to the 12th grade. Since it is appearing in those over 26, it can be said to have the greatest impact on adults, not persons up to young adults.
Among persons aged 12 years and up, the percentage reporting marijuana was fairly easy or very easy to obtain increased. The percentage of persons in the same group reporting the mode of acquisition of marijuana was buying it and growing it increased while getting it for free and sharing it decreased.
This indicates that more are looking at the business or “what’s mine” rather the social aspects of pot smoking.
Since 2002, marijuana addiction and first use in the United States has increased among persons aged 18 years and older, but not among those aged 12–17 years. A decrease in the perception of great risk from smoking marijuana combined with increases in the perception of availability (i.e., fairly easy or very easy to obtain marijuana) and fewer punitive legal penalties (e.g., no penalty) for the possession of marijuana for personal use probably play a role in increased use among adults. For the above discussion of marijuana, see the CDC report,
“National Estimates of Marijuana Use and Related Indicators — National Survey on Drug Use and Health, United States, 2002–2014”
Steep cuts in Funding for Public Health Agencies dealing with mental health happened in 2011. Some of this funding was used for drug education in schools and treatment. (The cuts may be due to large sums of money transferred from other public health programs into “Obama Care”, Affordable Health Care Act, and a soured economy, or, less likely, the realization of high recidivism and failure in addiction treatments.) These had a significant impact on addiction education and treatment. See the reports,
“State Mental Health Cuts” (https/::www2.nami.org:ContentManagement:ContentDisplay.cfm%3FContentFileID=125018)
“An Update on State Budget Cuts
About the same time, school systems began asking the question, “is Drug education a Public Health, Criminal Justice or Academic Concern?” Source of funding depended on the answer. Outside funding was more available in Public Health grants. However this reevaluation primarily arose from the class time that was devoted to this curriculum, not the funding.
It was determined by many schools that it was not of academic concern. If it were so, the school year would need to be substantially extended to continue using this curriculum while recovering sufficient time for the academics. (The national testing of school quality, without doubt, forced the school boards to improve academic performance. This meant recovering or extending academic time.) Drug Education curriculum was largely abandoned except for what could be covered in the traditional health classes that are viewed as an academic requirement.
The cancellation might be viewed as the reason for the apparent failure in drug education to reduce use of illicit drugs. However the NIDA report already mentioned shows a significant steady decline in use of cigarettes and alcohol that has continued after the drug education curriculum was collapsed into the health class.
Another problem in many drug education curriculums is that they are not drug prevention courses. They are nondirective and psychological. They do not teach that drug use is wrong!
Youth have little history and are immature at making good value judgments. They come away from the education program with the feeling, “Try it and see if you like it.” See the Eagle Forum report
“What's Wrong With Current 'Drug Ed'?” (http://www.eagleforum.org/educate/drug_ed/index.shtml)
Total Drug Deaths in 2014 is 47,055, up 6.5 % over 2013. The age-adjusted rate of death involving natural and semisynthetic opioid pain relievers, heroin, and synthetic opioids (e.g., fentanyl), other than methadone increased 9%, 26%, and 80%, respectively. See the CDC reports,
“2014 Drug Overdose State Deaths” (http://www.cdc.gov/drugoverdose/data/statedeaths.html)
“Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014”
For comparison, the number of auto deaths in 2014 is 33,804. See the CDC report,
“Accidents Or Unintentional Injuries” (http://www.cdc.gov/nchs/fastats/accidental-injury.htm)
Following patients for 1 and 5 years after treatment is completed will establish the efficacy of treatment. This would give a short and long-term success/recidivism ratio that would be used to evaluate efficacy and cost effectiveness of a modality. If this is done properly, good treatment decisions can be made.
However the statistics collected by the US government can be used to gain an overall feeling for the efficacy of treatment and prevention provided today.
First get the overall drug use numbers for two sequential years determined by the same method. Then adjust the succeeding year by adding the number of drug related deaths in that year. This will give the total using at some point during the succeeding year. Then subtract the first time users during the succeeding year. The resulting number is the number of users from the previous year that were using before the survey in the succeeding year. This first step in determining efficacy is done below.
In 2013 NIDA determined that 24.6 million Americans over 12 years old used illicit drugs during the reporting month. This is an increase in use and is not due to increase in marijuana use, which is the highest component at 19.8 million out of 24.6 million. See the NIDA report
Nationwide Trends (https://www.drugabuse.gov/publications/drugfacts/nationwide-trends)
In this 2013, an estimated 2.8 million persons aged 12 or older used an illicit drug for the first time within the 12 months. This can be found in, Results from the 2013 National Survey on Drug Use and Health:
Summary of National Findings
The number of drug related deaths in 2013 are 43,982 persons. This can be found in,
Morbidity and Mortality Weekly Report MMWR)
The adjusted statistics for 2013, which is the succeeding year, is
24,600.000 – 2,800.000+ 44,000 = 22,044,000
A total of 23.9 million Americans aged 12 or older used illicit drugs in 2012. This can be found in
Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings
One who stops using before the survey month will not be counted in the survey for the succeeding year. The difference between the previous year and the adjusted succeeding year tells us the number who quit drugs from the previous year. The calculation is
23,900,000 – 22,044,000 = 1,856,000 who stopped using
The three categories of persons in the 1,856,000 are: 1) quit after first using before the survey in the succeeding year, 2) decided to stop on own without treatment and 3) decided to stop because of treatment. The third category is the one that is important for determining the efficacy of treatment. One cannot be sure what that number is without a good study.
We can get the number of Individuals receiving treatment ages 12 and up and compare it to the 1,856,00 who stopped using. This chart, which is Figure 7.7 in the report cited below, can be summed to find the total getting treatment.
This sum is 7,483,000 persons received treatment. Symbols can represent the count in the other two categories. The group that stopped after first use is (x) and those who stopped on own is (y). The fraction of those who received treatment and stopped is (m). The result can be represented this way,
x + y + m*7,483,000 = 1,856,000
As mentioned, a study must be done to get good numbers for two of the three variables. The one that can be obtained most easily is m because treatment records make it possible to follow each patient.
However it is reasonable to assume that x + y is half of the 1,856,00. Then m = 1/8. The sources for the 2012 data are,
Results From The 2012 National Survey On Drug Use And Health: Summary Of National Findings http://archive.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/NationalFindings/NSDUHresults2012.htm#ch7.3
Reports on the efficacy of treatment modalities are few. One is reviewed in this paper under Chemical Imbalance Experiment. However, one can imply failure of treatment and prevention from the year over year increase in addiction plus the number of deaths.
Below is a sample calculation for two years, 2012 and 2013.
Failure Number = 24,600.000-23,900,000+44,000 = 744,000 increase
In other words, 744,000 died from overdose before the survey count or became new addicts. This is about 1/4th of the population increase.
Take a quick look at alcohol use that is legal. Estimates are that nearly 60% of the population of age 12 and higher uses alcohol while approximately 25% are binge or heavy drinkers of alcohol. This can be found in the SAMHSA report,
Results From The 2012 National Survey On Drug Use And Health: Summary Of National Findings (http://archive.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/NationalFindings/NSDUHresults2012.htm#ch3.1)
Interdiction annually removes about 7% of illicit drugs crossing the southern border.
The professionals who treat persons with addiction hold tenaciously to the view that it is only a disease. That is, there is no basis in choice, emotional pain, poor nurture, moral rectitude, beliefs or accident.
The purported cause is chemical imbalance or sensitivity. There is more success at preventing cancer deaths than addiction deaths. The PROBLEM is that an effective disease therapy has not been discovered and probably won’t be because the organizing theory ignores choice, emotional pain, poor nurture, moral rectitude, beliefs and accident.
If addiction is also about the above needs not being met, then these must be addressed along with the disease, (physical aspects) for a cure to last. Otherwise these unmet needs will amplify the cravings for a substance. These will keep one in habitual use and dependency.
Imagine what could happen if one really believed in his value, quality and purpose while learning life skills to deal with the vicissitudes of life. Would not this individual have a much better chance to avoid first use and addiction?
The most important medical treatment for opiod dependency is replacement therapy. It uses methadone, suboxone, buprenorphine, naloxone or similar opiod-like substances to replace opiods
This is promoted as the answer for dependence on opiods. What follows is from a Canadian study that raises doubt on the effectiveness of replacement therapy. A summary follows. However, it is recommended that the original paper be read.
Suboxone versus Methadone for the Treatment of Opioid Dependence: A Review of the Clinical and Cost-effectiveness
A literature search by the Canadian Agency for Drug and Technologies in Health (CADTH) for of use of Suboxone compared with methadone. These are used in the treatment of patients with opioid dependence. The period for the search was between 2003 and 15 October 2013. It gathered 121 citations identified from electronic literature search and screened based on titles and abstracts there. When various quality and relevance criteria were applied the collection was reduced to 28 potential articles. The articles were read in their entirety and evaluated on certain relevance and quality standards. From this, 9 were included in the CADTH study.
Criteria for inclusion and Assessment
• Patients of any age with opioid dependence
• Clinical efficacy
o Retention in treatment
o Harms reduction
o Health-related quality of life
o Safety in use
• Cost-effectiveness in controlling use of heroin, other opioids and
other drugs of abuse
• Health technology assessment (HTA) methods,
o Systematic review (SR) and meta-analysis (MA)
o Randomized controlled trial (RCT)
o Non-randomized study
o Economic evaluation
An assessment tool appropriate for the particular study design was used. The Downs and Black checklist12 was used for RCTs and non-randomized studies. The economic evaluations were assessed using the 35-item Drummond’s checklist.
The official pertinent CADTH conclusions are,
• Opioid dependence is a chronic, relapsing illness and patients usually need long-term maintenance treatment.
• Generalizability (of this study) was limited as it was uncertain as to whether the study patients were representative of all patients.
• Inconsistent results of clinical effectiveness and safety limit generalizability
• The results should be interpreted with caution, due to the small sample sizes, relatively short study durations (3 to 6 months therapy), and high discontinuation rates.
• The limited evidence suggested that Suboxone may be an alternative to methadone in the study population
• Low doses of replacement drugs encountered higher use of opiods. High doses had less use of opiods.
• There is no evidence available on other clinically relevant outcomes, such as health-related quality of life, mortality and so forth.
• There is a lack of evidence to evaluate the benefits/risks of Suboxone in special populations (children, pregnant women, or others).
My general conclusion follows. This is the best recent report on replacement therapy for opiod use. Even so, all 9 citations but one were compromised by high dropout rates. This reduced the sample size to the point of questionable usefulness by the end of each study. Even so, the following additional conclusions are still justified.
• On average only 1 out of three patients remained in the study. This probably means 2 out of 3 rejected this treatment and probably any replacement treatment.
• Most of the remaining patients more or less regularly continued using opiods during the study. This shows that replacement therapy is of limited value. In addition, there is a black market for these substances because they moderate the opiod high in ways that are desirable for some users.
• The experimental period was too small, at 3 to 6 months, to draw a reliable conclusion on long term effectiveness
• There was no follow up after the treatment period to determine opiod sobriety. The study statements, “chronic relapsing illness” and “long-term maintenance treatment” imply that all patients returned to opiod dependence.
• NO successful cure within the “disease modality” of replacement therapy has been found that ends habitual use of opiods. This is also implied in the conclusion that opiod dependence “must have long-term maintenance treatment.” The scope of maintenance treatment is not specified in this report beyond replacement drugs that are only moderately effective.
A report published in 2011 by National Alliance on Mental Illness alerts the mental health professionals to a crisis in funding. See,
State Mental Health Cuts: A National Crisis https://www2.nami.org/ContentManagement/ContentDisplay.cfm?ContentFileID=125018
This occurred after Addiction to drugs was removed from the list of disabilities for SSD. Along with this, states reduced funding for the 28-day program and prioritized it for first time patients. Repeaters were accepted on the basis of available funds for beds.
The recidivism/cure ratio for one year after treatment in the 28-day hospitalization has been anecdotally described as 30:1. The cost is 40-50,000 dollars for 28 days. This raises the cost to as much as 1.5 million dollars for the first success.
The 180-day therapeutic community is not in existence in most states today. However there are 6-month halfway homes that are semi independent. These can cost $130,000 for six months. The success is about 13%. The cost per success is about a million dollars.
When the number of successful treatments divides the state expenditure for drug treatment, the result is always over one million dollars.
This is true for all programs whether one looks at just the 28-day hospitalization or the 180-day halfway house. This is so even with a very broad definition of success. It is,
“Not using the drug of choice for one year.”
Therapeutic communities, which held so much hope for success, have disappeared from nearly all of the state programs. The 28-day hospitalization program has been replaced by detox only. A few beds are available for longer stays. The limited number of state funded hospital beds available has caused prioritization of admission. The addict seeking admission for the first time has the highest priority.
The cry is for more treatment facilities, and NOW! Should we imperatively drop billions of state money into establishing more of the same treatment programs?
We must consider the history of treatment.
What are the most successful methods?
What do they cost?
What is the recidivism rate?
What is our clearly defined measurable program outcome?
Otherwise we will repeat history. Is this not being a fool?
Please consider another financial hole.
The Great Society imperative over 50 years ago took trillions from taxpayer’s pockets. The result is that poverty increased to over 40% of the population.
Perhaps the societal destruction is the worst part of the great society. Perhaps it crated fertile ground for the drug problem to grow.
Abuse of tobacco, alcohol, and illicit drugs is costly to our Nation. Abuse took more than $700 billion in 2003 from the economy. This was from crime, lost work, reduced productivity, death, and increased health care. This an be seen in the report,
Costs of Substance Abuse
The practices associated with drug and behavior dependencies increase the opportunity for disease, accident and death. For example, the drug death rate for ages 21-30 during the 4 years following institutional treatment is about 5%. See the report on this study at
“Addict Death Rates During A Four-Year Posttreatment Follow-Up - George W. Joe, Ed, Wayne Lehman, MS, And D. Dwayne Simpson, Ph.D.”
The equivalent overall death rate for non-addicts in this group is about 1/3rd %. See the CDC report,
CDC Mortality Rates 2007
Thus the mortality for this group is about fifteen times higher than the population that is without drug dependencies.
Another terrible example is that over 47,000 persons died in 2014 in the US due to overdose.
FACING THE GORILLA IN THE LIVING ROOM
There is societal breakdown of norms for goodness, helpfulness and love. Each seems to do what feels right. This has led to depression and anxiety that exceed plague levels. My conclusion is that narcissism is at the core of,
And more ……
The most productive years are spent in delusions, unconsciousness, and imaginations. One indulges in chemicals or behaviors just to feel somewhat normal. Life is preoccupied with the next fix. The self-preservation instinct is corrupted resulting in disease, disablement and death.
So, love for another is inverted to narcissism. Faithful friends become resources to support the habit. Thirst for significance draws one to take greater chances with drugs and behavior. Anxiety over finding the next high never leaves.
The chase for the high is elusive!
This scene is as terrifying to the addict’s friends and loved ones as a gorilla in their living room.
Dependency blinds eyes to the gorilla!
This conclusion should sober our nation; the rate of increase in illicit drug use is growing faster than the rate of population growth. “We are headed for disaster!” At what count of drug use will we tip into societal chaos?
In this seemingly hopeless situation, faith has an answer.
One must give up his own solution to the to hear the answer. This is sometimes called “hitting your bottom”. Learning form another’s experience will turn one around before hitting bottom.
The advice to the friends and family members: Some can respond to kindness and love. However, enablement is not love and seals the addicts descent to the bottom and more probable death.
Remember Faith and then embrace HOPE, which brings the joy of tomorrow’s success into today’s hardship:
The seasons of winter to summer speak Father’s message of hope.
As long as one has breath “yes” can be voiced at the Father’s call.
Fulfilling Father’s purpose for me brings the greatest joy.
Father allows all things for His children’s good.
Father corrects those whom He loves.
Father will have His children become complete and perfect