It has become obvious, especially in recent years, that many people in the United States enjoy drinking alcohol and taking other drugs. The alcohol industry makes billions of dollars in sales annually. Tons of heroin and cocaine flow into the United States. Millions of prescriptions for opioids and benzodiazepines are filled annually, fueling overdose rates that are much higher in the United States than in other countries. Corporations and politicians work overtime to increase legal access to marijuana. The Juul e-cigarette company, which claims to market to adults, creates nicotine pods with the flavor of peaches, grapes, and berries. Substance use is big business.
One impact of all of this drug consumption is that many people develop a substance use disorder. (We tend to use the technical term “substance use disorder” instead of words like “alcoholic” or “addict” that convey a more pejorative meaning.) We hope that this article will be the first in a series of articles discussing substance use disorder and its treatment. This type of community education is an important part of the mission of Chayainu, a new community organization founded by Dr. Aviva Weisbord, Mrs. Esti Ziffer, and Larry Ziffer. Our aim is to help rabbis, schools, parents, and teenagers address the multiple challenges of preventing, identifying, and treating substance use disorder. We have met with the Vaad HaRabbanim, which strongly supports our efforts. We have also met with local schools and hope to work closely with other organizations that have led the way in addressing the impact of substance use disorder inside and outside of our community. There will soon be announcements about a series of parent education and awareness sessions that will feature useful information and strategies for educating our children and promoting wellness in our schools, shuls, and families.
We hope to use these articles to present correct information about substance use disorder. This is not as easy as it sounds. Substance use disorder is a complicated area of study. The National Institute of Health devotes two major centers to understanding alcohol and drug use disorders. Despite decades of research and clinical work, these disorders remain mysterious. Why do only some people develop the disorder? Why would anyone pursue an activity that has so many downsides? Nobody knows for sure.
Presence of the disorder is usually determined through criteria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), a guide used by clinicians to diagnose psychiatric conditions. The DSM-V defines substance use disorder as a “problematic pattern of using alcohol or another substance that results in impairment in daily life or noticeable distress.” Impairment can range across several areas: 1) poor control over use, 2) harming personal relationships and neglecting obligations, 3) disregarding health risks, and/or 4) suffering physiological consequences.
How many adults in this country have a substance use disorder? Two recent studies reported in the Journal of the American Medical Association (JAMA), a widely respected scientific peer-reviewed journal, show that each year 14% of adults in the United States have an alcohol use disorder (over 32 million people!), and 4% have a drug use disorder (more than nine million people). And if we examine prevalence of substance use disorder over the course of a lifetime, rates of these disorders are much higher: almost a third of all adults (29%) meet criteria for an alcohol use disorder at some time in their lives, while 10% would be diagnosed with drug use disorder in their lifetime.
The sheer volume of alcohol and drug use disorders provides good evidence that these conditions are not just reserved for those who are homeless or otherwise down and out. People from all segments of society struggle with substance use disorder. These reports also confirm that people who have a substance use disorder are more likely to have other medical and social problems. They are less happy and healthy. They are more likely to have serious mental health problems like depression or anxiety. None of these data quite accurately depict how the disorder can destroy individuals, marriages, and families. Unfortunately, less than 20% of those with substance use disorder ever seek treatment for it.
We should also mention that these reports show that despite great efforts in our country to eliminate smoking, around 20% of Americans still have a nicotine use disorder, with rates threatening to increase with the proliferation of e-cigarette use among teenagers. In many ways, cigarette smoking is more destructive than alcohol use. The Centers for Disease Control and Prevention (CDC) report that nicotine use is responsible for about 800,000 annual deaths and costs the U.S. economy over $300 billion per year, equally divided between health care costs and lost work productivity. One of the ironies of working with people who have severe alcohol or illicit drug use disorders is that they are more likely to die from cigarette smoking than from any other substance.
While there is less data on rates of substance use disorder among adolescents, the “Monitoring the Future” report from the National Institute of Drug Abuse provides good information on patterns of alcohol and drug use among high school students in public and private schools across the country. About 60% of students report drinking alcohol, with 17% engaged in binge drinking, defined as drinking at least five drinks within a two-hour period (four drinks for females). After alcohol, marijuana is the most frequently used substance, with 40% of students reporting any use and 6% reporting daily use. Smoking cigarettes is also common; 27% of students use nicotine, with 4% reporting daily use. As for other classes of drugs, about 9% use club drugs (e.g., ecstasy), 7% use hallucinogens, and 4% use opioids and cocaine.
Is it reasonable to believe that the national data reflect what is happening in our Orthodox community? It is hard to know for sure. On the one hand, our community enjoys many advantages that offer protection from the harms of alcohol and illicit drugs. Unlike people living in many rural areas, we enjoy excellent access to health care resources. And unlike those who live in some major cities, we do not wake up each day to the sight of bars, liquor stores, and drug dealers. Most of us have little idea what cocaine or heroin even looks like. We have our religion and our leaders, excellent schools, valuable community resources, and wonderful charity organizations.
Yet despite these strengths, there are reasons for concern. Some are anecdotal, and include reports of e-cigarette use in our schools, intoxication in our shuls, and overdoses in our community. Many of us have witnessed excessive drinking at weddings and shalom zachor gatherings. There also seems to be a new kind of boldness. Some teenagers and children drink openly without concern, ingesting shots of whiskey without even making a face!
But perhaps the biggest worry is that many adults and children in our community have the types of vulnerabilities that can, at times, predict development of substance use disorder. For example, we have adults with untreated (or under-treated) psychiatric disorders who are at risk to use alcohol or drugs to relieve distress. We have parents who fail to pursue treatment for their children who have treatable childhood conditions (e.g., attention-deficit disorder, anxiety, depression), leaving them more vulnerable to substance use. We have children who have experienced terrible tragedy and loss, and those who feel quite alienated from the school or community culture, each an important warning sign. And we are not immune to financial, social, health, or other pressures that can often trigger psychiatric conditions and substance use.
What can we do about this? Perhaps the first step is to become more knowledgeable. Over the next few months, we hope to use this space in the Where What When to address common questions about substance use disorder and its treatment. We hope that it will benefit people who have the disorder but are unsure about seeking treatment. We also hope that it will benefit those who suspect that a family member, friend, student, or congregant has the disorder but are not sure what to do about it. There is a general feeling that the status quo is unacceptable and harmful to the wellbeing of our community. Substance use takes a tremendous toll on our children, our families, our friends, our shuls, and our schools. It is a good time to learn more about it.
Dr. Kidorf is Associate Director of Addiction Treatment Services and Associate Professor, Psychiatry and Behavioral Sciences, at Johns Hopkins University School of Medicine.
