One Choice for Health

**Click here to view or print a PDF copy of this commentary.***

One Choice for Health: A Data-Informed, Youth-Driven Prevention Message

The understanding of substance use disorder (SUD) or “addiction” as a chronic relapsing brain disease has improved over many decades and continues to evolve with science of evidence-based treatment and directly learning from individuals in long-term recovery. We know SUDs are most often pediatric-onset diseases: 9 in 10 adults with SUDs began drinking, smoking or using other substances before the age of 18.¹ Thanks to advances in brain imaging, we also know that the human brain is not fully developed until about age 25,² making adolescents uniquely vulnerable to substance use.^3-4 As the nation looks to improve public health and reduce the astounding toll of overdose deaths and addiction, now is the time for a renewed focus on primary prevention – and when early substance use is initiated, provide effective intervention.

New Context to Youth Prevention Messaging

Youth substance use prevention efforts are often focused on individual substances, specific settings (e.g., impaired driving), and even specific amounts (e.g., binge drinking). While specific prevention messages are useful, they lack the context of the common patterns of substance use reported by youth. Nationally representative data from the National Survey on Drug Use and Health show that for young people, all substance use (and non-use) is closely related: among youth aged 12-17, the use of any one substance – alcohol, cigarettes, or marijuana – significantly increases the likelihood of using the other two substances and other illicit drugs.⁵ Similarly, not using any one substance significantly reduces the likelihood of using any other substances.

Figure 1 compares youth aged 12-17 who reported no use of alcohol in the past month (on the left) to those who reported various levels of past month alcohol use (on the right). Compared to their peers who did not use any alcohol in the past month, those who reported some alcohol use in the past month were 5.8 times more likely to have used marijuana, 3.8 times more likely to have used cigarettes and 4.8 times more likely to have used other illicit drugs. Youth who reported binge drinking (i.e., consuming 5+ drinks in one sitting) or heavy alcohol use (i.e., binge drinking 5+ times in the past month) were even more likely to have used marijuana, cigarettes, and other drugs.

Figure 1. Past Month Alcohol Use is Associated with Higher Use of Other Drugs Among Youth Aged 12-17

Source: National Survey on Drug Use and Health; DuPont, R. L., Han, B., Shea, C. L., & Madras, B. K. (2018). Drug use among youth: national survey data support a common liability of all drug use. Preventive Medicine, 113, 68-73.

The correlation of use holds true for other substances as shown in Figures 2 and 3. These data provide evidence for a generalized risk of substance use. Rooted in the science of the vulnerable developing brain, the goal of youth prevention can be reframed as, One Choice: no use of any alcohol, nicotine, marijuana. or other drugs by youth under age 21 for reasons of health.

 Figure 2. Past Month Marijuana Use is Associated with Higher Use of Other Drugs Among Youth Aged 12-17

Source: National Survey on Drug Use and Health; DuPont, R. L., Han, B., Shea, C. L., & Madras, B. K. (2018). Drug use among youth: national survey data support a common liability of all drug use. Preventive Medicine, 113, 68-73.

Figure 3. Past Month Cigarette Use is Associated with Higher Use of Other Drugs Among Youth Aged 12-17

Source: National Survey on Drug Use and Health; DuPont, R. L., Han, B., Shea, C. L., & Madras, B. K. (2018). Drug use among youth: national survey data support a common liability of all drug use. Preventive Medicine, 113, 68-73.

Is Making One Choice of No Use a Realistic Goal?

Parents and other adults may view adolescent substance use as inevitable or a rite of passage – but many American teens are already making One Choice today, and that number is growing.⁶ As shown in Figure 4, for decades, the percentage of American high school seniors who have not used any alcohol, cigarettes, marijuana, or other drugs in their lifetime has increased dramatically. The most recent Monitoring the Future data shows that in 2019, over 31% of high school seniors did not use any substances in their lifetime, and nearly 59% did not use any substances in the past month. These trends are also seen among 10th and 8th grade students.⁷

Figure 4. No Use of Alcohol, Cigarettes, Marijuana and Other Illicit Drugs by US High School Seniors, 1976-2019

Source: Monitoring the Future, 2019; Levy, S., Campbell, M. C., Shea, C. L., DuPont, C. M., & DuPont, R. L. (2020). Trends in substance nonuse by high school seniors: 1975–2018. Pediatrics, 146(6), e2020007187.

A New Health Standard for Youth

Just as the nation has embraced other health standards to support teen health – use a seat belt, wear a bicycle helmet, eat a healthy diet, avoid sugary drinks, and exercise regularly – together we can make no use of alcohol, nicotine, marijuana, or other drugs a new health standard for young people under age 21. This is not a reincarnation of the famous “Just Say No” campaign which focused on marijuana use. These data shows that alcohol, nicotine, and marijuana all dominate youth substance use and that the use of any of these three drugs is closely related to the use of all others.

Youth substance use is a health issue, not a moral issue. The One Choice goal is based on the science of the developing brain; highlights the long and strong youth-led trend in more young people refraining from substance use; follows legal age limits; and supports all other drug prevention efforts, including those that focus on single drugs and use in specific settings and specific amounts.

Teens are biologically driven to seek new and exciting behaviors which can put them at increased risk for substance use. Although use of alcohol, nicotine, marijuana, and other drugs is illegal for anyone under age 21 in the US, there are several factors that can make these substances more attractive to this age group including increased availability, normalization of use, and a decrease in perceived harm from use. As such, it is important to recognize the impact of Commercialized Recreational Pharmacology, defined as the super-stimulation of brain reward for profit.⁸ It is driven by the exploitation of people who use both legal and illegal substances and profits most off heaviest users. The US has a long and troubled history with the legal alcohol and tobacco industries related to youth, and now faces powerful, growing legal vaping and recreational cannabis (marijuana) industries that promote and profit from addiction to their products.

Take Action to Promote Adolescent Health and to Reduce the Toll of Future Addiction

Addiction is a preventable pediatric-onset disease; reducing the future prevalence of substance use disorders can begin with improving youth prevention. In this effort there are essential roles for parents, families, school and community leaders, health care providers and addiction professionals. What can caring adults do?

• Articulate the One Choice goal as a health standard for young people. Talk early and often about expectations of no use before the age of 21 of any substances including alcohol, nicotine, and marijuana and its foundation of the science of the developing brain. Fit the One Choice goal into your family’s and community’s vision for youth health and wellness.

• Identify substance use and intervene early. The American Academy of Pediatrics (AAP) provides guidelines for screening young patients for substance use, noting the importance of normalizing no use and of offering strong, supportive comments when no use is reported.⁹ When substance use is reported, brief interventions and, when needed, referral to treatment can make a positive difference in the health and wellness trajectory of a young person.

• Amplify youth voices. Each year, more young Americans are making the decision to not use any alcohol, nicotine, marijuana, or other drugs. Give this growing group opportunities to share the reasons why they make One Choice and how that decision is working out for them.

• Join the One Choice Community. The nation is searching for policies to reduce the burden of addiction on our nation’s families, communities, and health care, as well as how to save lives from opioid and other drug overdoses. We must begin this important work by promoting strong, clear public health prevention efforts based on the steady, sound, and clear support for no use of any alcohol, nicotine, marijuana, or other drugs for youth under age 21 for reasons of health.

We invite you to learn more about One Choice and how prevention groups are integrating the message and supporting data into prevention initiatives at www.OneChoicePrevention.org.

Robert L. DuPont, MD, IBH President

Caroline DuPont, MD, IBH Vice President

Corinne Shea, MA, IBH Director of Programs and Communications

References:

¹ The National Center on Addiction and Substance Abuse at Columbia University. (2011). Adolescent Substance Use: America’s #1 Public Health Problem. New York, NY: Author. Available: https://drugfree.org/reports/adolescent-substance-use-americas-1-public-health-problem/

² Gogtay, N., Giedd, J. N., Lusk, L., Hayashi, K. M., Greenstein, K., Vaituzis, A. C., Nugent III, T. F., Herman, D. H., Clasen, L. S., Toga, A. W., Rapoport, J. L., & Thompson, P. M. (2014). Dynamic mapping of human cortical development during childhood through early adulthood. PNAS, 101(21), 8174-8179. https://www.pnas.org/content/101/21/8174.full

³ DuPont, R. L. & Lieberman, J. A. (2014, May 9). Young brains on drugs [Editorial]. Science, 344(6184), 557. https://doi.org/10.1126/science.1254989

⁴ Volkow, N. D., Han, B., Einstein, E. B., & Compton, W. M. (2021). Prevalence of substance use disorders by time since first substance use among young people in the US. JAMA Pediatrics. https://doi.org/10.1001/jamapediatrics.2020.6981

⁵ DuPont, R. L., Han, B., Shea, C. L., & Madras, B. K. (2018). Drug use among youth: national survey data support a common liability of all drug use. Preventive Medicine, 113, 68-73. https://doi.org/10.1016/j.ypmed.2018.05.015

⁶ Levy, S., Campbell, M. C., Shea, C. L., DuPont, C. M., & DuPont, R. L. (2020). Trends in substance nonuse by high school seniors: 1975–2018. Pediatrics, 146(6), e2020007187. https://doi.org/10.1542/peds.2020-007187

⁷ Levy, S., Campbell, M. C., Shea, C. L., & DuPont, R. L. (2018). Trends in abstaining from substance use in adolescents: 1975-2014. Pediatrics, 142(2), e20173498. https://doi.org/10.1542/peds.2017-3498

⁸ DuPont, R. L., & Levy, S. (2020). The nation’s drug problem is commercial recreational pharmacology [From the Field]. Alcoholism & Drug Abuse Weekly, 32(35), 3-7. https://doi.org/10.1002/adaw.32827

⁹ Levy, S. J., Williams, J. F., & Committee on Substance Use and Prevention. (2016). Substance Use Screening, Brief Intervention, and Referral to Treatment. Pediatrics, 138(1), e20161211. https://doi.org/10.1542/peds.2016-1211

World Drug Day 2020

IBH President Robert L. DuPont, MD represents North America as a Member of the Board of Directors of the World Federation Against Drugs (WFAD). At the request of WFAD he wrote the following statement to celebrate International Day Against Drug Abuse and Illicit Drug Trafficking, better known as World Drug Day on June 25, 2020.

Click here to download or print a PDF copy of this statement.

Although the challenges posed by the COVID-19 pandemic are dominating our lives, let us not forget the equally deadly pandemic that continues to rage across the globe: drug abuse. This modern scourge, started in the late 1960s, continues to enslave and kill people of all nations in ever-changing ways. In Sweden, one of the first places the drug use pandemic hit, psychiatrist and professor, Nils Bejerot worked with the Stockholm police to fight the rising tide of methamphetamine and heroin use. Dr. Bejerot saw that the government’s initial response of providing users with physician-prescribed opioids and stimulants was futile. Not only did this policy fail to reduce drug use, but many of those drugs were diverted by users and ended up being sold on the street, leading to increased levels of drug use overall. Based on his first-hand experience with hundreds of patients, Dr. Bejerot concluded that providing addicts with drugs only prolonged their addiction and encouraged the spread of drug use throughout Swedish society. He saw that the only way to free users from the grip of addiction was to insist that they remain abstinent from all drugs. The world owes a debt of gratitude to Dr. Bejerot. Thanks to the instrumentality of his efforts over 50 years ago, Sweden’s commitment to abstinence-based drug use prevention and treatment was born.

With such a history it comes as no surprise that in 2009 the World Federation Against Drugs was established in Stockholm to create a better drug policy vision for the world by building on the Swedish experience. This was a vision in stark contrast to the increasingly dominant view that the most appropriate public health response to addiction was “harm reduction.” That strategy sought to reduce some of the harm produced by addictive drug use while permitting and even sometimes encouraging continued drug use.

WFAD is not opposed to harm reduction programs as a part of the response to the modern drug epidemic—as part of a continuum of care ending in treatment. However, WFAD insists that these programs be evaluated on the basis of their ability to help addicts become drug-free. That means seeing harm reduction as a step toward eventual abstinence. Although facilitating drug use among addicts is better than allowing them to die from overdose, such use is not in their own long-term interest as it carries many serious risks to physical and mental health. Harm reduction without eventual recovery “enables” continued drug use and addiction. That is not in the interest of addicted people or the societies in which they live. WFAD supports the use of medication-assisted treatment (MAT) for people suffering from opioid use disorders. When medications such as buprenorphine and methadone are used as prescribed and there is no other recreational or illicit use of substances, MAT patients are considered to be drug-free.

The UN Treaty on the Rights of the Child, the only UN treaty to focus on youth drug use, calls on all nations to help protect children from drugs. WFAD has the same clear goal for youth prevention as the ideal outlined in the treaty: that children be able grow up drug-free. For youth, there is no safe or healthy recreational use of drugs, including alcohol, nicotine, or marijuana. This drug-free, no-use, goal is based on the recognition of the unique vulnerability of the developing adolescent brain to drug addiction.

WFAD celebrates and supports the growing Recovery Movement worldwide. The recent emergence of millions of people who have overcome their own drug addiction not only inspires a world confronted by epidemic levels of deadly drug use, but it also reinforces the notion that true recovery is drug-free. People in recovery are the pathfinders for modern drug policy; this large and rapidly growing population offers hope to all addicted people.

WFAD is a world leader in promoting drug-free solutions for health and well-being. Composed of a diverse global array of organizations and individuals working together to combat drug addiction, WFAD is the antidote to the modern drug epidemic.

Health Care Professionals and Families Must Focus on Youth Substance Use Prevention

The peer-reviewed journal JAMA Network Open asked Robert L. DuPont, MD and Caroline DuPont, MD, President and Vice President, respectively, of IBH, to respond to a new research study by Bertha K. Madras, et al., "Associations of parental marijuana use with offspring marijuana, tobacco, and alcohol use and opioid misuse."

In their commentary, Drs. DuPont note that this study showed that when parents used marijuana, their children had increased risk of using marijuana too. "This underscores the need for engagement by both parents and health care professionals in youth substance use prevention and parental substance use disorder treatment." Drs. DuPont then connect the findings to IBH's own youth prevention work:

The association of parent use of marijuana with offspring use of marijuana and tobacco complements a recent finding suggesting that there is a common liability for substance use among adolescents. Among young people aged 12 to 17 years, the use of one substance is positively associated with the use of others, and nonuse of any one substance is positively associated with non-use of others. There is also evidence that there is a large and steadily increasing number of American youth who do not use any substances, including alcohol, tobacco, or marijuana. More than half (52%) of high school seniors have not used any substance in the past month and more than one-quarter (26%) have not used any substance in their lifetime, up from lows in 1982 of 16% and 3%, respectively. Together, these facts can empower parents when they are educated about their own substance use choices affecting the risks of their children using substances. They can also inform health care professionals that no use of alcohol, nicotine, marijuana, or other drugs is not only the health standard for youth but that nonuse by young patients is common and achievable.

This commentary extends the work of IBH to set a new health standard for youth prevention of One Choice: no use of any alcohol, nicotine, marijuana or other drugs by youth under age 21.

Video: Author Alex Berenson Presents at The Heritage Foundation, Co-Sponsored by IBH and SAM

Alex Berenson recently discussed his new book Tell Your Children: The Truth About Marijuana, Mental Illness, and Violence at a presentation co-sponsored by IBH and Smart Approaches to Marijuana (SAM) at The Heritage Foundation.

9 Things We Wish We'd Known - A Letter from Families Who Have Lost a Loved One to Addiction

Addiction Policy Forum, a nationwide non-profit organization dedicated to eliminating addiction as a major health problem, released a letter from families as part of the #192aDay awareness campaign to honor those lost to drug overdose and other complications of substance use. In their letter, families explain, “This letter to you is about the things we wish we had known — the things we’ve learned since we suffered our losses and wish we had done differently.” From learning the signs of a problem to paying attention to early substance use, to finding quality treatment and finding support, these hard-learned lessons can help other families across the country facing addiction. Read more.

Dr. Robert DuPont Speaks to the Justice Speakers' Institute about Prevention and Chemical Slavery

As a prison psychiatrist in the late 1960s, Dr. Robert DuPont came to understand that the rising crime at the time was directly linked to the heroin epidemic that raged in cities across America. In this conversation with the Justice Speakers Institute, Dr. DuPont discusses the journey from his realization to the present day national movement to end addiction. He discusses the science behind addiction and the important next steps humanity needs to take to finally end the drug epidemic.

Going Beyond the Surgeon General’s Report: Redefining the Goals of Prevention, Treatment and Recovery

Click here for a downloadable PDF copy of this commentary

Going Beyond the Surgeon General’s Report: Redefining the Goals of Prevention, Treatment and Recovery

The close of 2016 saw the release of Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, providing sorely needed direction to a nation grappling with a serious drug epidemic. [1] We at the Institute for Behavior and Health, Inc. (IBH) are particularly interested in how close this landmark Report comes to our recommendations about the fundamental goals of youth substance abuse prevention and treatment for substance use disorders. For young people under the age of 21, IBH defines the goal of substance abuse prevention as no use of any alcohol, tobacco, marijuana or other drugs for reasons of health. Similarly, IBH defines the goal of substance abuse treatment as sustained recovery with a standard outcome measure of treatment of no use of such substances for at least five years.

We recall that the impact of the 1964 Surgeon General’s Report, Smoking and Health, was profound. It resulted in a slow cascade over several decades of legal sanctions on the advertising, sale and place of consumer use of tobacco products and an impressive multifaceted and multitargeted public education campaign that conveyed scientific knowledge about the severe negative health consequences of tobacco (nicotine) use. The result was a sustained decline in the use of all tobacco products coupled with a temporarily robust smoking cessation and treatment movement. Today we take for granted that Americans of all ages, even the very young, know that tobacco use is unhealthy and that its use is actively discouraged. Why do we not do the same with other substances of abuse such as alcohol and marijuana, the two most widely used drugs that are typically precursors to other drug use including nonmedical use of prescription opioids and heroin? This Commentary discusses these important issues.

The Surgeon General’s Report on Prevention

We commend the Office of the US Surgeon General for its clear message that substance use disorders are preventable.

The substance abuse prevention programs described in the Report for ages 0-10 concentrate on reducing risk factors by strengthening parent-child relationships, improving parenting skills and encouraging children’s problem solving skills. The expectation is that such programs reduce substance use later in life. No information is provided about the health implications of substance use and no recommendation is made that youth refrain from any substance use for their health.

For substance abuse prevention for ages 10-18 the Report focuses on providing adolescents with “life skills” and “substance refusal skills”. It cites The Botvin LifeSkills Program which covers topics such as managing and reducing stress and anger and building healthy relationships as well as learning about the consequences of drug use and risk taking. However, the Report states that this program has little effect on marijuana and other drug use, though it may reduce drinking and polydrug use. The Report also mentions results of similar programs in rural settings that show little effect on substance use.

Many of the adolescent substance abuse prevention programs described in the Report focus on high-risk populations including youth with impulse control issues, aggressive behavior, and those from lower socio-economic backgrounds.

In considering substance abuse prevention programs for young adults over the age of 18, the Report focuses on preventing the progression of substance use to substance misuse or “problematic use”. These prevention programs include the use of screening, brief intervention and referral to treatment (SBIRT) in school and primary care settings.

The IBH Prevention Message

IBH defines the fundamental goal of substance abuse prevention as no use of any alcohol, tobacco, marijuana or other drugs for reasons of health. Today’s prevention efforts must go further than simply reducing risk factors and increasing protective factors, though these are both important. The key facts that most substance use disorders can be traced to early initiation of substance use [2] and that the vulnerable brain is still developing until about age 25 [3] place additional emphasis on the need for more specific and effective prevention. Prevention should provide brief, clear, age-appropriate messaging that any youth substance use is unhealthy as well as illegal. In fact it is specifically illegal for the young, because it is unhealthy. Consistent messaging should come from many sources including schools, communities, religious groups, physicians and other health care providers as well as the media. All have a stake in and responsibility for the healthy development of our nation’s youth. At present the prevention messaging to youth and their parents from these various sources is unclear, inconsistent or in some cases non-existent. The acknowledgement is almost non-existent that any substance use by youth is unhealthy.

While the Surgeon General’s Report considers high-risk youth as a specific target population, we contend that today’s substance use and resulting problems including addiction are “equal opportunity”. The modern drug epidemic is not isolated within populations traditionally viewed as high-risk nor is it concentrated in inner city disadvantaged communities. Communities across the country are struggling to reduce the terrible toll of substance abuse. The US Centers for Disease Control and Prevention (CDC) reports national increases in heroin use and related deaths for all demographic groups, particularly among non-Hispanic whites. [4][5] Armed with the knowledge that youth use of the purportedly “safer” drugs of alcohol, tobacco (nicotine) and marijuana are highly correlated with one another as well as the use of other illicit drugs [6], we emphasize that for youth the decision to use any one substance opens the door to the use of other substances. For that reason we contend that young people should make one decision not to use at all for reasons of health.

With broad cultural exposure to substances of abuse – from legal alcohol to the shifting legal status of marijuana to legal prescription medications – as well as possible exposure in the home by parents, siblings, friends and the media, educating parents early about preventing all substance use by their children is crucial. Both parents and their children’s health care professionals need to understand that the use of any substance is unhealthy and all of these adults are in important positions to advise youth explicitly to not to use any alcohol, tobacco, marijuana or other drugs for their health. Substance use prevention is healthy brain protection.

In a clinical report [7] and related policy statement [8] on screening, brief intervention and referral to treatment (SBIRT), the American Academy of Pediatrics emphasizes that no use is the ultimate health goal for young patients and encourages pediatricians to support the choices made by their patients to refrain from any use and when youth already are using substances to encourage them to stop using. At present, such action by physicians is uncommon.

School-based substance abuse prevention programs also have important roles to play in empowering youth to make the healthy choice to refrain from substance use. Already in some areas of the country prevention curricula are directed at 4th and 5th graders based on the premise that teaching young people about healthy decisions in the early school years is protective.

Consistent, age-appropriate substance abuse prevention messaging focused on the fundamental goal for youth of no use of alcohol, tobacco, marijuana or other drugs must be both available and easily located on websites frequently accessed by the public seeking scientific information about the health consequences of substance use. At present finding this health-focused goal on such website resources is difficult or impossible. Media campaigns using population cohort targeted platforms also should support this no-use for health prevention messaging.

From an early age and throughout adolescence young people should be educated about the importance of avoiding substance use so they are well-prepared before they have to make the choice whether or not to use.

There is a tendency on the part of some of even the most knowledgeable people to shrug off substance abuse prevention efforts as useless because “all kids experiment”. Anecdotal stories abound about educators and medical practitioners who sanction such “trivial” substance use behavior. It is important that parents and other adults, including prevention professionals, not assume either that most young people will try alcohol and other drugs or that a little use does not pose health risks.

Using data from the nationally representative Monitoring the Future survey, IBH has shown that over the past three decades an increasing number of American high school seniors have abstained from using any alcohol, cigarettes, marijuana and other illicit drugs.[9] Among American high school seniors in 2015, 26% never, not even once in their lives, used any alcohol, tobacco, marijuana or other drugs and fully 50% have not used any alcohol, tobacco, marijuana or other drugs in the past 30 days. These new data on the growing population of youth who do not use drugs need to be publicized widely. New prevention strategies need to be developed that empower young people who do not use any drugs to talk with their peers about their healthy choices. Adults need to acknowledge and support this growing cohort of young people who are abstaining. Just as healthy eating and regular exercise are encouraged in the interest of health, so too can be an alcohol- and drug-free lifestyle.

Substance use disorders are entirely preventable when young people make the single decision not to use any substances of abuse. We hope that many more young people will continue to make this choice armed with information through new prevention efforts about how substance use negatively impacts health, and in particular, how it harms the developing brain.

The Surgeon General’s Report on Treatment and Recovery

Laudably, the Report stresses the importance of making long-term recovery the goal of substance abuse treatment. This ideal is expressed in a “continuum of care”, defined as “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.” The full continuum of care promises to integrate specialty substance abuse treatment into the larger health care system, rather than treating it as an orphan outsider. Ideally health care would extend from primary prevention of the use of any substance through diagnosis of a substance use disorder, intervention and treatment to post-treatment long-term monitoring and intervention in case of relapse. Such a continuum holds the promise of drastically reducing not only the initiation of the use of alcohol and other drugs, but also addiction and subsequent relapse.

The Surgeon General’s Report does not provide a single definition of recovery but instead suggests several. For example, one definition is from the Betty Ford Institute’s Consensus Panel: “a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship”. This definition highlights sobriety – no use of alcohol, marijuana and other drugs – as an essential element of recovery. Recovery, however, is more than abstinence from the use of alcohol and other addicting drugs. Recovery also includes meaningful character development and citizenship.

A less specific definition of recovery is that of the Substance Abuse and Mental Health Services Administration (SAMHSA): “a process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential”. Of the two definitions presented in the Report, IBH favors that of the Betty Ford Center which matches the standard of 12-step fellowships including Alcoholics Anonymous and Narcotics Anonymous.

The IBH Standard of Treatment and Recovery

IBH defines the fundamental goal of substance abuse treatment as sustained recovery, with a standard outcome measure of treatment of no use of such substances for at least five years. It is unfortunate that the Surgeon General’s Report is not explicit about the long-term sustained sobriety that characterizes recovery, considering the high prevalence of relapse after entering treatment among individuals with substance use disorders. Such relapse is similar to rates for many other chronic illnesses like diabetes and hypertension. [10] Of particular concern is the risk of overdose and death that awaits individuals with opioid use disorders who cut back their use of heroin or other opioids. Cutting back results in a loss of tolerance to a certain level of previous use, and overdose results when use is resumed at the previous dose level.

For individuals with substance use disorders, any use, even low levels of alcohol and drug use, puts them in danger of a severe relapse. There are numerous elements that support recovery: substance abuse treatment, 12-Step fellowships or similar peer-based recovery support, or an individual decision to stop using. For many individuals in recovery, a “sobriety date”, the last date on which they used alcohol or other drugs, is a core identity feature. The vast majority of people who are in recovery define it in terms of abstinence. [11] While the road to recovery is varied, its destination clearly is long and sustained abstinence.

The recent emergence of the national recovery movement is one of the most positive changes in the nation’s long-term battle to overcome addiction. IBH encourages an open dialogue with people in recovery from substance use disorders to ask how they define “recovery” and how they achieved it. Stories of recovery often come in three parts: first, what life was like when a person was using; second, what happened to get the person to make the transformation into recovery; and third, what life is like in recovery. These are inspiring stories. The testimony of people in recovery is clear and convincing.

Conclusion

With the publication of Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, the Office of the Surgeon General has catalyzed and challenged the nation to constructively confront the drug epidemic. We encourage national leaders and organizations that focus on substance abuse prevention and treatment to read the Report carefully and to consider our formulations of the fundamental goals of prevention and treatment and our related recommendations. Then we ask them to assess and redouble their commitment to prevention, treatment and recovery. Together we will heed and strengthen the Surgeon General’s most important messages: substance use is preventable and treatment leading to sustained recovery is possible.

Robert L. DuPont, MD, President, Institute for Behavior and Health, Inc.

---

[1] U.S. Department of Health and Human Services (HHS), Office of the Surgeon General. (2016). Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS. Available: https://addiction.surgeongeneral.gov/

[2] E.g., Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2014, July 17). The TEDS Report: Age of Substance Use Initiation among Treatment Admissions Aged 18 to 30. Rockville, MD. Available: https://www.samhsa.gov/data/sites/default/files/WebFiles_TEDS_SR142_AgeatInit_07-10-14/TEDS-SR142-AgeatInit-2014.pdf

[3] E.g., National Institute of Mental Health. (2011). The Teen Brain: Still Under Construction. NIH Publication No. 11-4929. Available: https://www.nimh.nih.gov/health/publications/the-teen-brain-still-under-construction/index.shtml ; Johnson, S. B., Blum, R. W., & Giedd, J. N. (2009). Adolescent maturity and the brain: the promise and pitfalls of neuroscience research in adolescent health policy. Journal of Adolescent Health, 45(3), 216-221; Partnership for Drug-Free Kids. (2017). The teen brain. Available: http://www.drugfree.org/why-do-teens-act-this-way/adolescent-brain-development/

[4] Rudd, R. A., Seth, P., David, F., & Scholl, L. (2016, December 30). Increases in drug and opioid-involved overdose deaths — United States, 2010–2015. Morbidity and Mortality Weekly Report, 65(50-51), 1445-1452. Available: https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm

[5] Jones, C. M., Logan, J., Gladden, R. M., & Bohm, M. K. (2015, July 10). Demographic and substance use trends among heroin users­ – United States, 2002-2013. Morbidity and Mortality Weekly Report, 64(26), 719-725. Available: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6426a3.htm

[6] Data from the 2014 National Household Survey on Drug Use and Health provided by the Substance Abuse and Mental Health Services Administration’s Center for Behavioral Health Statistics and Quality.

[7] Levy, S. J., Williams, J. F., & AAP Committee on Substance Use and Prevention. (2016). Substance use screening, brief intervention, and referral to treatment. Pediatrics, 138(1), e20161211. 

[8] AAP Committee on Substance Use and Prevention. (2016). Substance use screening, brief intervention, and referral to treatment. Pediatrics, 138(1), e20161210.

[9] DuPont, R. L. (2015, July 1). It’s time to re-think prevention: increasing percentages of adolescents understand they should not use any addicting substances. Rockville, MD: Institute for Behavior and Health, Inc. Available: https://www.ibhinc.org/s/IBH_Commentary_Adolescents_No_Use_of_Substances_7-1-15.pdf

[10] McLellan, A. T., Lewis, D. C., O’Brien, C. P., & Kleber, H. D. (2000). Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcome evaluation. JAMA, 284(13), 1689-1695.

[11] White, W. L. (2015, May 15). Recent life-in-recovery surveys. William White Papers Blog . Available: http://www.williamwhitepapers.com/blog/2015/05/recent-life-in-recovery-surveys.html