Substance Abuse as a Cross-Cutting Issue

By: Matthew Gever

November 30, 2006

Introduction

Substance abuse and addiction are significant yet often overlooked factors in many of society’s ills. Drug abuse costs to society are estimated to be as high as $358 billion, and it accounts for more than 550,000 deaths annually.¹ Child welfare, criminal justice and public health caseloads and budgets are swelled by individuals with chemical dependence problems and the resulting negative consequences. As these sectors account for a growing share of states’ budgets, examining the role of substance abuse and addiction become crucial for states to save lives and save money and increase public safety.

Substance Abuse and Child Welfare

The overwhelming majority of parents who come into contact with the child welfare system have problems with substance abuse. Problems with addiction can significantly affect a parent’s ability to raise a child and can threaten a child’s safety. Specifically, addiction can have the following effects on a parent’s abilities:²

• Interfere with a parent’s judgment, inhibitions and overall mental functioning.
• Reduce a parent’s sensitivity. This can interfere with the bonding of a parent and child.
• Cause parents to ignore the needs of the child, spending time and money in pursuit of alcohol and other drugs rather than on basic needs for the house and child.
• Increase aggression and the threat of physical violence towards a child.

Approximately 28.6 million children live in a household with at least one parent who is an alcoholic,³ and roughly 11 percent of all children in the United States live in a household with a parent who is in need of treatment for alcoholism or other substance abuse problems.⁴ When examined within the child welfare system specifically, these numbers become far worse. For example, of parents with children in the child welfare system, 67 percent require treatment for use of alcohol and other drugs.⁵ In a study examining the 1 million children who are substantiated victims of child abuse and neglect, 50 percent had caregivers with chemical dependency. In addition, more than three-fourths of states report that substance abuse is one of the top two conditions leading to child maltreatment in their state.⁶

The worst of the child welfare cases end up in the foster care system. Although only a small number of cases end up in foster care, the system is growing. In 2003, approximately 520,000 children were in foster care in the US.⁷ This is a 50 percent increase over 1998, when there were 340,000 foster care cases.⁸ Chemical dependency plays a role in many of these cases. The Government Accountability Office found that, of children in foster care in Illinois, 74 percent had one or both parents in need of treatment for substance abuse problems. In California, the same problem applied to 65 percent of foster care cases.⁹ Overall, children from homes with substance abuse issues were far more likely to be served in the foster care system than in their own homes. Recent child welfare numbers show that 54 percent of cases involving substance abuse were served by foster care, compared to only 23 percent of cases for households without such problems. In addition, children in substance abusing households spend twice as long in foster care as do other children. These children also are younger, averaging age 5 at time of placement compared to age 7 for others.

These problems affect the state budget. Approximately $7.6 billion is spent at the state level for the child welfare system. Of this money, $5.3 billion – 70 percent – is spent on problems caused or exacerbated by substance abuse and addiction.¹⁰

Substance Abuse and Criminal Justice

The criminal justice system often is the largest and the fastest growing element of a state’s budget. Currently, more than 2 million people are behind bars in this country; the number has increased by an average of 3.4 percent per year during the past 10 years. Roughly 20 percent of these inmates are incarcerated on a drug-related offense, such as selling or possession.¹¹ This fact does not tell the full story of addiction’s true effect on the criminal justice system, however.

For the vast majority of inmates – as well as for former inmates and parolees – substance   

abuse and addiction play a significant role in their lives and in the crimes they committed. In addition to buying and selling illegal substances, many offenders have committed crimes while under the influence, stolen money or goods to buy drugs, driven drunk or under the influence, or have acted violently because of their addiction. Overall, drugs and alcohol are implicated in the crimes of 81 percent of state prison inmates.¹²

Alcohol is the substance most closely linked with criminal behavior. The No. 1 crime in America most directly linked to substance abuse is drunk driving. In 2004, 1.4 million people were arrested for driving under the influence. That same year, nearly 17,000 people were killed in alcohol-related accidents.¹³ Alcohol also leads to a number of other crimes. Among state prison inmates convicted of a violent crime, 21 percent reported that they were under the influence of alcohol at the time of their crime, with no other substances involved. This trend continues while they are behind bars; 26 percent of inmates convicted of a violent offense have committed another violent crime in prison while under the influence of alcohol alone.¹⁴ Of all adults arrested, 14 percent have had an alcohol addiction at some point in their lives, and 10 percent were addicted at the time of their arrest.¹⁵

Illegal drugs also play a significant role in initiating criminal behavior. Roughly half (49 percent) of state inmates convicted of a violent offense committed the crime while under the influence of one or more drugs. The problem is even more pronounced for property crime, used by a number of those with drug problems to generate money to purchase drugs. Two-thirds of adults arrested for property crime test positive for at least one drug. Many demonstrate dependence on at least one substance, most commonly alcohol, cocaine, crack or heroin. In fact, 17 percent of all inmates claim to have committed their crime for the sole purpose of obtaining money to buy drugs.¹⁶ Addiction appears at both ends of the criminal justice spectrum and is a leading cause of parole and probation violations. Overall, two-thirds of people released from prison are arrested again within three years.¹⁷ Recidivism is a much larger problem among those with substance abuse problems. For example, of first-time offenders, 4 percent are regular heroin users. Of those convicted of a fifth offense, 27 percent are regular users. For regular cocaine users, the numbers are 16 percent for the first offense and 40 percent for the fifth. The ratio for crack users is 3:1 of those with five versus one offense. This represents 81 percent of five-time offenders with a history of regular drug use,¹⁸ compared to 41 percent of first offenders.¹⁹

As the prison population has increased during the past 25 years, so has spending on the criminal justice system. In 2001, state spending on corrections totaled $38 billion. In 1986, the total was just $15 billion, adjusted for inflation.²⁰ This represents the fastest growing parts of most state budgets, vastly eclipsing Medicaid. Approximately 80 percent of that money ($30.4 billion) was spent specifically on the aforementioned inmates who committed a crime while under the influence, to raise money to support their habit, or any drug- or alcohol-related offense.²¹

Substance Abuse and Health

Many of the health consequences of addiction and substance abuse are well documented. The best-known are the effects of cigarette smoking. A myriad of cancers, respiratory problems, cardiovascular diseases and reproductive problems are directly linked to smoking. Approximately 440,000 deaths are linked to tobacco use, with associated health-related economic losses of $157 billion annually.²²

Alcohol has the second biggest overall effect on public health. The most common illness associated with excessive alcohol use is alcohol liver disease (ALD), which can take one of three forms: cirrhosis, fatty liver and alcoholic hepatitis. Some symptoms include an enlarged liver, increased white blood cell count, hypertension and kidney failure. Conservative estimates show 2 million Americans with ALD.²³ Alcohol abuse also is linked to heart disease, a diminished immune system, breast cancer, loss of bone density and high blood pressure.²⁴

Alcohol and other drug use can affect those who are not directly ingesting the substance. A leading cause of birth defects and mental retardation is fetal alcohol syndrome (FAS), which can be caused when a woman drinks during her pregnancy. It can lead to a child developing abnormal facial features, growth deficiencies and central nervous system problems. The Centers for Disease Control and Prevention reports FAS rates ranging from 0.2 to 1.5 per 1,000 live births.²⁵ Nine percent of pregnant women have reported drinking alcohol in the past month, while 3 percent report binge drinking (five or more drinks at one sitting).²⁶ In addition, children born to mothers who drank during their pregnancy are at higher risk for alcoholism later in life.²⁷

Use of illegal drugs has many similar health consequences to those of alcohol and tobacco. Popular illegal drugs – such as cocaine, heroin and methamphetamines – are linked to cardiovascular, respiratory ands prenatal problems.²⁸ Drug abuse also is a major factor in the spread of HIV and hepatitis. The virus is spread by the use and exchange of needles among intravenous drug users, primarily through the use of heroin. Overall, 36 percent of AIDS cases in the United States are the result of intravenous drug use.²⁹

Addiction also can lead to HIV and hepatitis infection due to users' behavioral practices. Research from the National Institute on Drug Abuse has shown that alcohol and drug use can interfere with judgment and lead to risky behaviors. For example, a study from the Centers for Disease Control of young adults in three inner-city neighborhoods shows that crack smokers had an HIV infection rate three times greater than non-smokers.³⁰

The health problems of addiction significantly affect state health budgets, primarily the state’s Medicaid budget. In fiscal year 2004, states spent nearly $86 billion of their own funds on Medicaid.³¹ Roughly 25 percent of state Medicaid funding goes directly to substance abuse.³²

Substance Abuse and Homelessness

Addiction is a major cause of homelessness. Many already had addiction problems when they became homeless, and the lack of adequate housing makes treatment and recovery even more difficult. Of all homeless persons, between 30 percent and 40 percent have alcohol problems, and another 10 percent to 20 percent have problems with other drugs.³³ A number of studies have directly linked problems with alcohol, crack and heroin to housing instability.³⁴ Homelessness also can intensify existing drug and alcohol problems and cause a return to substance abuse even after a long period of abstinence.³⁵ Many homeless people also have severe mental health problems. Alcohol-dependent homeless people have a rate of schizophrenia that is nine times higher than alcohol-dependent people with homes, and bi-polar disorder is seven times as prevalent.³⁶

Substance Abuse and Veterans

Veterans are defined as individuals who have served in any of the U.S. Armed Forces. The primary substance of abuse among veterans is alcohol, with 68 percent of veterans reporting as such. By comparison, 52 percent of civilians report alcohol as their primary substance of abuse.³⁷ Heavy use of alcohol³⁸ is also more common among veterans, with 7.5 percent reporting doing so within the past month, compared to 6.5 percent of civilians.³⁹ Regular use of alcohol is also more common. On the other hand, veterans have lower rates of dependence on illicit substances.

Cost Offsets in Prevention and Treatment

Effective state-level prevention and treatment programs significantly reduce the problems associated with substance abuse. The first step is prevention, which seeks to stop individuals from using in the first place. From a cost-benefit standpoint, studies have shown that effective prevention programs have net benefits to society ranging from $2.64 to nearly $20 for every $1 spent.⁴⁰ Research from Washington shows savings from effective prevention programs ranging from $54 up to $9,316 per individual.⁴¹ The RAND Corporation’s Drug Policy Research Center estimates savings from school-based prevention programs at $840 per student.⁴² Research also has shown that, if children avoid using illicit substances or abusing alcohol before age 21, then they are virtually certain never to do so.⁴³

States can realize cost savings from effective treatment programs for those who already use illicit substances. The greatest potential for savings is in the criminal justice system. The cost of treatment for substance abuse is approximately $6,500 per year, while the average annual cost of incarceration is more than $20,000.⁴⁴ Successfully treating one prisoner would lead to savings of $68,800 in the first year alone. Treating just 10 percent of the addicted prison population would yield savings of $8.26 billion in the first year after release alone, and would lead to a reduction of more than 10 million violent and property crimes per year.⁴⁵ Specific states have found similar results. California found that providing treatment to prisoners led to cost offsets of $7 for every $1 spent, while Oregon found that, for every $1 spent on treatment programs for the population as a whole, the state realized $5.62 in offsets in the areas of corrections, health and welfare.⁴⁶

Conclusion

Addiction affects all Americans and much of the public sector. In addition, many of the aforementioned public issues intersect. For example, 2.4 million children have a parent who is serving time in prison.⁴⁷ This burdens both the state’s correctional system and the child welfare system. Chemically dependent inmates are in need of publicly financed health care. Chemically dependent homeless people are likely to end up in an institution or incarcerated.

States pick up much of the financial burden of addiction. Recent estimates show that states spend $81.3 billion to deal with substance abuse and addiction. Of this amount, only 4 percent was spent on prevention and treatment; the remainder was spent on the consequences of addiction.⁴⁸ Shifting focus toward effective substance abuse prevention and treatment would help to reduce many of the problems associated with addiction and also would lead to significant reductions in the amount of state funds spent.

1. John M. Wallace Jr., Valerie Myers, and Esohe Osai, Faith Matters: Race/Ethnicity, Religion and Substance Use (Baltimore, Md.: The Annie E. Casey Foundation, 2004),  2.

2. Nancy K Young, Sidney Gardner, and Kimberly Dennis, Responding to Alcohol and Other Drug Problems in Child Welfare: Weaving Together Practice and Policy (Washington, D.C.: CWLA Press, 1998), 6.

3. Ibid., 2.
4. Department of Health and Human Services, “Blending Perspectives and Building Common Ground: A Report to Congress on Substance Abuse and Child Protection,” http://aspe.hhs.gov/hsp/subabuse99/subabuse.htm, 1999, accessed Oct. 4, 2006.
5. Wallace et al., 14.
6. Young et al., 3.
7. Pew Commission on Children in Foster Care, “State Ranking of Foster Care Population FY 2003,” http://pewfostercare.org/research/docs/Data102705a.pdf, accessed Oct. 19, 2006
8. Young et al.,  5.
9. GAO/HEHS-98-182
10. The National Center on Substance Addiction and Substance Abuse at Columbia University, Shoveling Up: The Impact of Substance Abuse of State Budgets (New York, N.Y.: Columbia University, January 2001), 17
11. US Department of Justice, Bureau of Justice Statistics, http://www.ojp.usdoj.gov/bjs/prisons.htm, accessed Oct 20, 06
12. National Center on Addiction and Substance Abuse at Columbia University. Behind Bars: Substance Abuse and America’s Prison Population (New York: CASA, 1998), 2.
13. National Center for Injury Prevention and Control, “Fact Sheet: Impaired driving,” http://www.cdc.gov/ncipc/factsheets/drving.htm, 2006, accessed Oct. 20, 2006
14. NCASA, 8-9.
15. Ibid., 30.
16. Ibid., 35-38.
17. Patrick A. Langan and David J. Levin, Recidivism of Prisoners Released in 1994, (NCJ 193427) (Washington, D.C.: US Department of Justice, Bureau of Justice Statistics, 2002).
18. Regular drug use is defined as weekly use over at least a one-month period.
19. NCASA, 73-74.
20. Department of Justice, State Prison Expenditures, http://www.ojp.usdoj.gov/bjs/pub/pdf/spe01.pdf, accessed Oct. 20, 2006
21. Behind Bars, 154.
22. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, The Health Consequences of Smoking: A Report from the Surgeon General. (Atlanta, Ga: Centers for Disease Control and Prevention, 2004), 6-7.
23. National Institute on Alcohol Abuse and Alcoholism, “Medical Consequences of Alcohol Abuse,” Alcohol Research and Health 24, no. 1 (Winter 2000).
24. Ibid.
25. Centers for Disease Control and Prevention, Fetal Alcohol Spectrum Disorders, 2006, http://www.cdc.gov/ncbddd/fas/fasask.htm, Accessed Oct. 25, 2006.
26. Wallace et al., 15.
27. Health Day, Drinking While Pregnant May Boost Child's Alcoholism Risk, http://www.nlm.nih.gov/medlineplus/news/fullstory_38294.html, 2006, accessed Oct. 25, 2006.
28. National Institute on Drug Abuse, Drugs of Abuse and Related Topics - Medical Consequences of Drug Abuse, http://www.nida.nih.gov/consequences/prenatal/, 2005, accessed Oct. 25, 2006.
29. NIDA InfoFacts, November 2004.
30. NIDA InfoFacts, November 2004.
31. Henry J. Kaiser Family Foundation, 50 State Comparisons: State Medicaid Expenditures, http://www.statehealthfacts.org/cgi-bin/healthfacts.cgi?action=compare&category=Medicaid+%26+SCHIP&subcategory=State+Medicaid+Spending&topic=State+Medicaid+Spending%2c+SFY2004, 2004, accessed Oct. 25, 2006.
32. NCASA, 17.
33. Robert E. Drake et al., “Homelessness and Dual Diagnosis,” American Psychologist 46, no. 11, (November 1991): 1149-1158.
34. Tammy L. Anderson et al., “Welfare Reform and Housing: Assessing the Impact to Substance Abusers,” Journal of Drug Issues (Winter 2002): 265-294.
35. Ibid., 268.
36. Drake et al., “Homelessness and Dual Diagnosis.”  
37. Substance Abuse and Mental Health Services Administration, The DASIS Report, Veterans in Substance Abuse Treatment, http://www.oas.samhsa.gov/2k1/VetsTX/VetsTX.pdf, 2001, accessed Oct. 25, 2006.
38. Heavy drinking is defined as five or more drinks on the same occasion on five or more days out of the past 30.
39. Substance Abuse and Mental Health Services Administration, The NSDUH report: Substance Use, Dependence, and Treatment among Veterans, http://oas.samhsa.gov/2k5/vets/vets.htm, 2005, accessed Oct. 25, 2006.
40. Debra Prosnitz, Cost-Benefit Analysis of Prevention Efforts (Washington, D.C.: National Conference of State Legislatures, 2005).
41. Steve Aos et al., Benefits and Costs of Prevention and Early Intervention Programs for Youth (Olympia, Washington: Washington State Institute for Public Policy, Sep.17, 2004).
42. Drug Policy Research Center, What Are the True Benefits of School-Based Drug Prevention Programs?, http://www.rand.org/pubs/research_briefs/RB6009/index1.html, 2002, accessed Oct. 24, 2006.
43. NCASA, 4.
44. Ibid., 80.
45. Ibid., 81.
46. Ibid., 82.
47. Wallace, et al., 15
48. NCASA, ii.

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