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date: 19 March 2018

Alcohol and Drug Problems: Overview

Abstract and Keywords

Social workers commonly encounter individuals and families that have problems resulting from alcohol and other drug (AOD) misuse, abuse, and dependence. This entry provides an overview of AOD problems in the general population and within such subpopulations as young people, the elderly, women, ethnic and racial minorities, and the gay and lesbian community. Clinical and policy responses to these problems in the United States, the roles of social workers in this field, and directions for the future are addressed.

Keywords: substance abuse, alcohol and other drugs, AOD treatment, policy issues, impact on family, social work role

Problems resulting from AOD misuse, abuse, and dependence affect individuals, families, communities, and society as a whole. It is critical, therefore, that all social workers have some familiarity with the various substances of abuse and with relevant clinical and policy issues. Due to space limitations, treatment and policy issues related to tobacco use are not included.

Definition of Terms

Millions of Americans use alcohol, tobacco, or other drugs (ATOD), but most do not experience any negative consequences. It is therefore helpful to conceptualize ATOD use on a continuum from nonproblematic experimental and social use to substance misuse (such as using pain medication in order to get high) to abuse, which indicates problematic use that affects individuals and their relationships, and finally, to dependence or addiction, which implies compulsive use that may require medically supervised detoxification and/or formal treatment to abstain or curtail use (Straussner, 2004).

Many substances tend to be abused. They include those that are legally obtained, such as alcohol, tobacco, and caffeine; prescription medications (for example, OxyContin, Vicodin, Ritalin, and Adderall), various forms of inhalants (for example, glue, paint, and aerosols), and illicit drugs, such as marijuana, heroin, cocaine or crack, methamphetamine (known as “ice” or “crystal meth”), and hallucinogens (for example, LSD, PCP, and psylocybin mushrooms). Anabolic steroids and “designer” (synthetically produced compounds that mimic other psychoactive substances) or “club” drugs, such as MDMA (that is, Ecstasy), GHB, or Rohypnol (“the date-rape” drug) are often misused or abused, particularly by adolescents (Substance Abuse and Mental Health Services Administration [SAMHSA], 2005).

The most recent American Psychiatric Association's (APA, 2000) Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR) uses the term substance-related disorders (SRD) to classify all disorders related to problematic consequences of substance use. The SRD category is further divided into Substance-Induced Disorders (SID) and Substance Use Disorders (SUD). SID includes 11 different disorders ranging from substance intoxication or withdrawal symptoms to substance induced mood, anxiety, psychotic, or sleeping disorders. It is assumed that once a person stops their abuse or dependence on a substance, SIDs will disappear within a relatively short time. Individuals whose psychiatric symptoms do not disappear over time are likely to have additional diagnoses, variously referred to as having coexisting, co-occurring, or comorbid substance and mental disorders.

SUD consists of two subcategories: substance abuse and substance dependence. Substance abuse is defined as “a maladaptive pattern of substance leading to clinically significant impairment or distress” in one or more of the following within a 12 month time frame: the continued use of psychoactive substances despite experiencing social, occupational, psychological, or physical problems; inability to fulfill “major role obligations at work, school, or home”; recurrent use in situations in which use is physically hazardous, such as driving while intoxicated; and/or recurrent legal problems related to the use of a substance (APA, 2000, pp. 114–115). Substance dependence is defined as the existence of at least three of the following 7 symptoms within a 12 month period:

  1. 1. Tolerance, as defined by either a need for increased amounts of a substance to achieve a desired effect or diminished effect with use of the same quantity of substances

  2. 2. Withdrawal, as characterized by specific withdrawal syndromes, or using a substance in order to relieve or avoid withdrawal symptoms

  3. 3. Taking the substance in larger amounts or over a longer period than was intended

  4. 4. A persistent desire or unsuccessful efforts to reduce or control use

  5. 5. A great deal of time spent obtaining, using, and recovering from substance use

  6. 6. Important social, occupational, or recreational activities are given up or reduced because of the use of the substance

  7. 7. Continued substance use despite knowledge of resulting serious physical or psychological problems

Once diagnosed with substance dependence, an individual can never be diagnosed with the less severe diagnosis of substance abuse. A substance abuse or dependence diagnosis also calls for one of six “course specifiers” delineating the longer-term outcome of these disorders. These specifiers can only be given after the individual stops using a given substance for at least 1 month. They include (1) early full remission, defined as being substance-free for more than 1 month, but less than 12 months; (2) early partial remission, where the individual resumes some use of a substance (sometimes referred to as having a “relapse”), and subsequently meets at least one criterion of abuse or dependence within the first year of recovery; (3) sustained full remission, defined as being substance-free for more than 1 year; and (4) sustained partial remission, in which the individual resumes substance use after 12 months of not having any symptoms, and then meets at least one criterion of substance abuse or dependence. The two final specifiers are (5) on agonist therapy, which is used when the individual is placed on an agonist medication (that mimics the action of a naturally occurring substance) or antagonist (that acts against and blocks an action) medication to treat the substance of choice, such as using methadone as a replacement for opiates; and (6) in a controlled environment, indicating that the individual is residing in a substance-free environment, such as a therapeutic community or prison.

The Scope and Impact of Substance Abuse Problems

Substance abuse causes more deaths, illnesses, accidents, and disabilities than any other preventable health problem (Robert Wood Johnson Foundation [RWJ], 2001). Worldwide, the use of substances is increasing most dramatically in low-income countries, which in the coming decades are expected to suffer from a disproportionate burden of substance-related disability and premature death (Anderson, 2006). According to research done for the World Health Organization, during the year 2000, tobacco was the number one addiction problem in the world, responsible for 4.9 million deaths, while an estimated 1.8 million people die annually due to alcohol-related problems; illegal drugs cause 223,000 deaths. However, over the past decade, “alcohol has become the number one risk factor in developing countries … above tobacco” (News in Science, 2003).

In the United States, according to 2005 data, an estimated 22.2 million persons (9.1% of the population aged 12 or older) were classified as abusing or dependent on a substance. Of these, 15.4 million were dependent on or abused alcohol, 3.6 million abused or were dependent on illicit drugs, and 3.3 million were classified with dependence on or abuse of both alcohol and illicit drugs (SAMHSA, 2005). An estimated 60.5 million persons or 24.9% of the population are current cigarette smokers (SAMHSA, 2006). It is expected that smoking will result in approximately 440,000 deaths each year, and an additional 8.6 million people will have at least one serious illness caused by smoking (Collins, 2005).

While the magnitude of alcohol problems has been overshadowed by the political and media preoccupation with illicit drugs, it is important to note that the consequences of alcohol-related problems are more devastating and widespread for both individuals and society.

Alcohol-Related Problems

  1. 1. Alcohol contributes to close to 100,000 U.S. deaths annually from drunk driving, stroke, cancer, cirrhosis of the liver, falls, and other adverse effects (Mokdad, Marks, Stroup, & Gerberding, 2004).

  2. 2. Nearly half of all violent deaths (accidents, suicides, and homicides), particularly of men below age 34, are alcohol related (RWJ, 2001).

  3. 3. Alcohol is a consistent factor in reports of child physical and sexual abuse, including incest, and in cases of rape and domestic violence (Isralowitz, 2004; RWJ, 2001).

  4. 4. Between 53% and 73% of homeless adults are affected by an alcohol disorder (Podymow, Turnbull, Coyle, Yetisir, & Wells, 2006).

Drug-Related Problems

The 6.8 million persons aged 12 or older classified as abusing or dependent on illicit drugs use a wide variety of substances including heroin, methamphetamines, inhalants, sedative-hypnotics, and designer drugs such as Ecstasy. The largest number of individuals, however, use marijuana (4.1 million), followed by cocaine (1.5 million), and narcotic or opioid pain relievers, such as OxyContin (1.5 million) (SAMHSA, 2005).

Injecting drugs, such as heroin, with a contaminated needle leads to high risk of becoming infected with HIV and of developing AIDS. Having sex with an HIV-infected individual is also a high risk factor for HIV/AIDS. This mode of HIV transmission has become especially detrimental for women: Since the epidemic began, 58% of all AIDS cases in women have been attributed to injection drug use or sex with partners who inject drugs, compared with 34% in men. The transmission of HIV through drug injection or sex with an infected individual is disproportionally high among black and Hispanic men and women (Centers for Disease Control and Prevention [CDC], 2006).

Substance Abuse Problems Among Special Populations

Substance abuse and dependence vary according to age and gender, ethnic and racial factors, as well as sexual orientation.

Substance Abuse by Youth

Unlike the relatively constant rate of alcohol and drug abuse by adults over the years, young people's substance use has fluctuated over time, reflecting the availability of particular substances and their popularity among certain subgroups; some of the variation reported is also attributable to changes in government data collection methods (Straussner, 2004). After a relatively high use of illicit substances by young people in the 1960s and 1970s, the proportion of high-school and college students using any illicit drug has decreased significantly, with the exception of prescription opioids abuse (National Institute on Drug Abuse [NIDA], 2006). Currently, the most frequently abused substances by young people are alcohol, marijuana, the so-called club drugs, such as Ecstasy, and the nonmedical use of the pain reliever, Vicodin (NIDA, 2006).

The heavy use of alcohol by young people is often viewed as a “gateway” to other drugs; research studies have showed that among heavy drinking youths, 66% were also current illicit drug users, compared to only 4.2% nondrinkers who were current illicit drug users (RWJ, 2001). In addition, there is growing evidence of an association between young age of first use of alcohol or other drugs and problematic use of these substances during adulthood (SAMHSA, 2005). According to the RWJ (2001), “More than 40 percent of those who started drinking at age 14 or younger developed alcohol dependence, compared with 10 percent of those who began drinking at age 20 or older. High school students who use illicit drugs are also more likely to experience difficulties in school, in their personal relationships, and in their mental and physical health” (p. 30). Thus there is a growing focus on prevention programs aimed at postponing the age of initiation of drug use.

Substance Abuse by Older Adults

Compared to the general population, substance abuse problems are less common among older adults. However, the number of elderly persons who misuse or abuse illicit drugs and alcohol is increasing. This is due to the growing number of aging baby boomers who tend to have a history of higher rates of alcohol use, as well as abuse and misuse of prescription and over-the-counter medications (Bogunovic, Shelly, & Greenfield, 2004).

Gender and Substance Abuse

Studies over the last decade show that adult males are about twice as likely to be classified with substance dependence or abuse as females (12.0% versus 6.4%) (SAMHSA, 2005). However, the rates of nonmedical use of psychotherapeutic drugs (pain relievers, tranquilizers, stimulants, and sedatives) were similar for both males and females (1.8% versus 1.7%, respectively) (RWJ, 2001). Gender differences in substance dependence are diminishing among young people, portending a growing substance abuse problem among younger women as they age (SAMHSA, 2006).

While there are numerous issues unique to substance abusing women (see Straussner & Brown, 2002), one important aspect is the impact of their substance use on their children. Although studies show that most women tend to reduce their substance use during pregnancy (SAMHSA, 2005), some women, especially those dependent on alcohol, crack cocaine, or methamphetamine, continue their substance use (Sampson et al., 1998). These substances are then transmitted to the fetus resulting in a child who may be born addicted and/or who may suffer permanent brain or other physiological damage (Azmitia, 2001).

It is important to keep in mind that the impact of fetal exposure to AOD is determined by many factors, including the type of substance, the gestation age of the fetus at exposure, the route and duration of exposure, the dosage and frequency of drug intake, other substances consumed simultaneously, as well as environmental factors including nutrition and prenatal care (Nadel & Straussner, 2006).

Race and Ethnicity

SUD rates vary by race and ethnicity. In 2005, the rate of substance dependence or abuse for those age 12 and over was highest among American Indians and Alaska Natives (21.0%), followed by Native Hawaiians or other Pacific Islanders (11.0%), persons reporting two or more races (10.9%), Whites (9.4%), Hispanics (9.3%), and Blacks (8.5%). The lowest rate was found among Asians (4.5%), although rates vary greatly among different Asian populations (SAMHSA, 2006; Straussner, 2001).

Studies also reveal that among young adults (aged 18–29), White males have the highest risk for alcohol problems, while among those who are middle aged and elderly rates are highest for Black men and women (Isralowitz, 2004). Socioeconomic factors also correlate with race and gender: Limited education and poverty are related to alcohol dependence in Black males but not in White males (RWJ, 2001).

Sexual Identity

There has been much controversy regarding the rates of AOD use among gay men and women. After a careful review of the literature on alcohol use, Bux (1996) lists the following four conclusions:

  1. 1. Gay men and lesbians are less likely to be abstainers from alcohol than heterosexuals.

  2. 2. Gay men appear to have little increased risk of alcoholism over heterosexual men.

  3. 3. Lesbians appear to be at higher risk than heterosexual women for alcohol abuse, and match both heterosexual and gay men in heavy and problematic drinking.

  4. 4. Gay men appear to have reduced their consumption of alcohol by the mid-1990s.

The pattern of drug use among this population is similar to that of alcohol use: Gay men have been found to be less likely to abstain from marijuana and cocaine, but have similar rates of heavy use of these substances as heterosexual men. Marijuana and cocaine use by lesbian women, however, exceeded that of heterosexual women, but was similar to that of heterosexual and gay men. Finally, the usage of drugs by older gay men and women did not decrease as much as usage among the older heterosexual population (McKirnan & Peterson, 1989).

Certain drugs have particularly high usage in the gay male community. Methamphetamine, for example, has increased dramatically among gay and bisexual men who report rates 10 times greater than the general population (Halkitis, Shrem, & Martin, 2005).

Etiology of Substance Use Disorders

There is no single etiological factor that accounts for why some people develop a SUD and others do not. Among the factors often cited in the literature are

  1. 1. Biochemical and Genetic Factors. Substance dependence is increasingly conceptualized as biologically and genetically based, and as a “brain disease” rather than a “moral weakness or lack of willpower” (Brain Chemicals Trump Willpower in Addicts, 2006).Familial Factors. Early separation from one or both parents and inadequate care during childhood, as well as physical or sexual abuse during childhood are some of the familial factors contributing to substance abuse problems (Roberts, Nishimoto, & Kirk, 2003). Substance abuse has also been seen as serving as an important stabilizing force in dysfunctional families (Steinglass, Weiner, & Mendelson, 1971).

  2. 2. Psychological Factors. These factors encompass various perspectives, including classical and modern psychoanalytic theory, developmental and personality theories, and behavioral, conditioning, and cognitive theories (Beck, Wright, Newman, & Liese, 1993; Peele, 1998).

  3. 3. Environmental and Sociocultural Factors. This view links substance abuse to a variety of environmental, social, cultural, and economic factors (RWJ, 2001; Wagner & Anthony, 2002). Studies of female substance abusers, in particular those in lower socioeconomic classes, show a high correlation between their substance abuse and that of their spouses or boyfriends (Straussner & Attia, 2002).

  4. 4. Multifactorial Perspective. This perspective views substance abuse and dependence as resulting from a combination of factors, including biochemical, genetic, familial, environmental, and cultural ones, as well as personality dynamics. SUDs are thus seen as a multivariate syndrome in which multiple patterns of dysfunctional substance abuse occur in various types of people with varying prognoses requiring a variety of interventions (Pattison & Kaufman, 1982; Straussner, 2004).

Clinical Issues

Less than one-fourth of all individuals who need help for their abuse or dependence on alcohol or other drugs receive treatment (SAMHSA, 2005). Nonetheless, studies indicate that for those who do obtain treatment, treatment does work (RWJ, 2001). Horgan (1995) notes: “The improvement rate for people completing substance abuse treatment is comparable to that of people treated for asthma and other chronic, relapsing health conditions.” During 2005, almost 4 million persons aged 12 or older (1.6% of the population) received treatment for SUD.

Clinical interventions with substance abusers, as with all clients, need to begin with a comprehensive screening and assessment followed by appropriate intervention. A growing number of social workers are using standardized screening and assessment instruments (King & Bordnick, 2002). Among the most frequently used are various versions of the CAGE for assessing alcohol problems and the CAGE-AID that assesses for other drugs (Brown & Rounds, 1995; Mayfield, McLeod, & Hall, 1974); the Substance Abuse Subtle Screening Inventory (SASSI) (Feldstein & Miller, 2007); the Michigan Alcohol Screening Test (MAST) (Selzer, 1971); the Alcohol Use Disorders Identification Test (AUDIT) (Babor et al., 1992); the Drug Abuse Screening Test (DAST); the Addiction Severity Index (ASI) (McLellan et al., 1992), and CRAFFT for assessing adolescents (Knight et al., 1999).

An important area of assessment is differentiating between substance abuse and other psychopathology. Individuals with a diagnosis of SUD may also suffer from another major psychiatric (Axis I on DSM VI-R) disorder and/or have an underlying personality disorder (Axis II) necessitating a comprehensive psychiatric assessment in addition to assessment of their substance abuse (Straussner & Nemenzik, 2007).

A comprehensive assessment must also consider the client's motivation for treatment. As a rule, substance abusers do not enter treatment voluntarily. While a highly motivated client is likely to make better use of treatment, recovery from substance abuse is not always dependent upon whether or not the initial contact with treatment was voluntary. In fact, studies show that some individuals who are coerced into treatment have as good a recovery rate as those entering treatment voluntarily (Kelly, Finney, & Moos, 2005).

Practice Interventions

An important task for social workers is to determine appropriate forms of treatment for clients with SUDs. Medically supervised detoxification is often the first step in the treatment of those physically addicted to opioids, alcohol, barbiturates and other sedative hypnotics, and amphetamines. It is not required for those dependent on cocaine, crack, or marijuana.

Traditionally, all detoxification had been carried out on a medical or psychiatric inpatient unit, however with the advent of managed care, it is now often provided in outpatient clinics or by physicians in private practice. Heroin addicts can be detoxified on an outpatient basis with the help of such chemicals as clonodine or decreasing doses of methadone.

Detoxification is usually only the beginning of a long process of recovery. Short- and long-term inpatient and outpatient rehabilitation programs, drug-free residential therapeutic communities, and ongoing supportive counseling can help substance abusers examine the impact of alcohol and/or other drugs upon their lives and the necessary changes in their lifestyle that they must undertake if they want to recover from substance abuse (Straussner, 2004).

The use of methadone as a substitute for opiates or narcotics can lead to better prognosis for rehabilitation and allow narcotic addicts to avail themselves of counseling and educational or vocational training; it can also help them improve the overall quality of their lives once the daily concern about obtaining drugs is alleviated (Friedman & Wilson, 2004). Moreover, the potential for becoming infected with HIV is an important factor in referring intravenous narcotic users to methadone maintenance programs. While used less extensively, opioid antagonists such as naltrexone can prevent addicts from experiencing the effects of narcotics. Unlike methadone, naltrexone has no narcotic effect of its own and is not physiologically addictive. Under the trade name of ReVia, it also is being used for people with alcohol dependence. The use of other medications, such as Acamprosate (for alcohol dependence) and buprenorphine (for opioid dependence), has been increasing (Erickson & Wilcox, 2001). A chemical that is sometimes used to help alcoholics is disulfiram, commonly known as Antabuse. This medication blocks the normal oxidation of alcohol so that acetaldehyde, a by-product of alcohol, accumulates in the bloodstream and causes unpleasant, and at times even life-threatening, symptoms, such as rapid pulse and vomiting. The use of Antabuse thus serves as a conscious deterrent to drinking. A number of substance abuse treatment settings have also incorporated nontraditional treatment approaches such as acupuncture, yoga, and meditation.

Twelve-Step Programs, such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Pills Anonymous, and Cocaine Anonymous, have proven to be particularly helpful and are free and available in every community. These groups allow members not only to receive help but also to give help to others, thereby enhancing self-esteem (Spiegel & Fewell, 2004). Other self- or mutual-help groups for substance abusers, such as Women for Sobriety, Rational Recovery, SMART groups, Social Workers Helping Social Workers, and Double Trouble/Recovery groups for those with co-occurring mental disorders, are available in many communities.

Patients with SUDs also experience various social problems. Thus, an essential aspect of helping this population is the provision of financial and social supports, including adequate housing, vocational rehabilitation, and legal assistance.

Harm-reduction approaches, which can range from needle exchange programs to the provision of housing, social and psychological services without focusing directly on the elimination of substance use, have been increasing throughout the United States (Sieger, 2004). These approaches remain controversial since abstinence is not their primary goal.

Treatment of substance abusers must take into account the clients' ethnocultural norms and values (see Straussner, 2001), history of trauma, as well as issues of sexual behavior including safe sex practices. Treatment of minorities, particularly African Americans, needs to take into account that they are more likely to enter treatment through the courts than through formal intervention processes or 12-step programs. Also, they are more likely to access treatment much later and thus have a more difficult recovery process (O'Connell, 1991). Lastly, it is important to remember that substance abuse, “like many other medical problems, is a chronic disorder in which recurrences are common and repeated periods of treatment are frequently required” (U.S. Department of Health and Human Services [USDHHS], 1991, p. 4).

Impact of Substance Abuse on the Family

Between 9% and 29% of all children in the United States are exposed to familial drug or alcohol abuse (SAMHSA, 2003). While many children from substance abusing families are highly resilient and do not exhibit blatant problems (Peleg-Oren & Teichman, 2006; Werner & Johnson, 2000), research indicates that a large number are at risk of developing a variety of physical, psychological, and social problems (Anda et al., 2002; Gruber & Taylor, 2006; Johnson & Leff, 1999).

Child neglect and, in more disturbed families, violence between parents, child abuse, and incest are some of the consequences and correlates of substance abuse. Substance abuse is present in at least two-thirds of the families known to public child welfare agencies (Hampton, Senatore, & Gullotta, 1998). Studies highlight the need to address the intergenerational cycle of substance abuse and child abuse if effective progress is to be made on either problem. During 2006, expert panels of social work educators, practitioners, and researchers, working under the auspices of the National Association for Children of Alcoholics (NACoA) and chaired by one of the authors (Straussner), developed a set of core competencies needed by social workers in order to work effectively with this population (NACoA, 2006).

Couples and family therapy, including multifamily groups, are effective modalities for families with substance abusers who are already chemically free or working on their recovery. One evidence-based family-oriented treatment approach is Community Reinforcement and Family Training (CRAFT) (Miller, Meyers, & Tonigan, 1999). It is also beneficial to refer family members to such mutual-help groups as Al-Anon, Pill-Anon, Co-Anon, or Nar-Anon. These groups help adult family members examine their own role in the “enabling” behavior. There are also support groups for adolescent children of alcohol- and narcotic-abusing parents, such as Alateen and Narateen. Adult Children of Alcoholics (ACOA) groups may be helpful for mature adolescents and adult children of alcoholics.

Policy History

Treatment programs and practices are driven not only by clinical needs, but also by social policies. Substance abuse policies in the United States are generally consistent with prevailing ideology and tend to parallel public attitudes, and not necessarily the prevalence of a particular substance (Isralowitz, 2004). For example, in Colonial America and the early 1800s, drinking and even drunkenness were seen as acceptable behaviors. It was only during the latter part of the nineteenth century that any use of alcohol was perceived as problematic, resulting in the growth of the temperance movement. At the same time, during the 1800s, opiates and cocaine were legal and used widely, particularly as patent medicine by middle-class women (Straussner & Attia, 2002).

Beginning in 1906 the Pure Food and Drug Act, the Harrison Narcotic Act of 1914, the Volstead Act that ushered in Prohibition in 1919, and the 1937 Marijuana Tax Act led to public policies that criminalized the users of various substances while at the same time limiting their access to medical treatment (Isralowitz, 2004). Following the repeal of Prohibition in 1933, the social use of alcohol once again became widely acceptable, while problematic alcohol use was seen as a sign of an individual's shortcoming (Nadel & Straussner, 2006).

The passage of the Hughes Act in 1970, authorizing the establishment of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA), had a profound impact on the treatment of both drug and alcohol abusers. It provided the impetus for the decriminalization of public drunkenness; increased federal funding for substance abuse research and model treatment programs; and prompted coverage by health insurance companies for AOD treatment.

Faced with growing drug use among young people and concern about heroin-addicted servicemen returning from Vietnam, on 17 June 1971, President Nixon declared that drugs were America's number one enemy, marking the start of the United States' “War on Drugs.” Nixon appointed Dr. Jerome Jaffe to head the new Special Office for Drug Abuse Prevention. Between 1971 and 1973, Jaffe developed a network of methadone treatment facilities all over the United States, and in 1973, the Drug Enforcement Administration (DEA), whose mission was to fight the drug war, was established (Frontline: Interview with Dr. Jerome Jaffe, n.d.)

In 1988, under the Reagan administration, the Office of National Drug Control Policy (ONDCP) was created to coordinate drug-related legislation, security, research, and health policy throughout the government. The director of ONDCP, commonly known as the Drug Czar, was raised to cabinet-level status by Bill Clinton in 1993 (A History of the War on Drugs, n.d.).

Other important legislation has been the passage of the 1997 Adoption and Safe Families Act (ASFA) [P.L. 105–8.9] that addressed the need for children in out-of-home placements to have a permanent home. Child protection workers are mandated to terminate clients' parental rights and free their children for adoption if substance abusing parents/caregivers do not improve within 15 months. Although ASFA identified the need for addiction treatment, few new resources have been provided to meet this need (Gustavsson & MacEachron, 1997).

Current federal policy efforts, under the auspices of The White House ONDCP and the Substance Abuse Mental Health Service Administration (SAMHSA), may be conceptualized as consisting of a three-pronged approach: domestic and international law enforcement, or interdiction, focusing on the “supply” of drugs to the United States public; and two approaches addressing the “demand” side: (1) drug prevention and prevention research and (2) drug treatment and treatment research (Nadel & Straussner, 2006).

The “Supply-Side” approach tries to prevent drugs from reaching U.S. consumers and focuses on foreign crop eradication, border and marine interdiction, and arrests of distributors and drug dealers. These programs claim the largest percentage of the federal substance-abuse budget—more than the other two areas combined (Veillette, 2006). Substance abuse prevention and treatment, the “demand-side,” seeks to prevent or decrease the use of drugs through various education/prevention activities, treatment programs, and research on treatment effectiveness and program evaluation (Nadel & Straussner, 2006).

Roles of Social Workers

Despite the historically limited focus on substance abuse education in schools of social work (Amodeo & Litchfield, 1999; Straussner & Senreich, 2002), social workers in the United States have always been involved with addicted individuals and their families. As early as 1917, Mary Richmond, one of the founders of social work, rejected the moral definition of alcoholism of her day with its characteristic view of alcoholics as “sinners.” In her groundbreaking book, Social Diagnosis, Richmond (1917) stated that “inebriety is a disease” and provided a description that is entirely consistent with the disease model of alcoholism as described almost half a century later by Jellinek (1952) and reflected in the latest version of the APA's (2000) DSM IV-TR. Richmond viewed social workers as having an “important role to play in gathering the pertinent social data,” offering the assistance necessary to supplement the medical treatment, and “providing the long period of after-care which is usually necessary” (Richmond, 1917/1944, p. 430).

Currently, social workers contribute greatly to the field of addictions. The profession's unique biopsychosocial perspective, its flexibility in adapting to new streams of thought and incorporating them into practice, and its ability to integrate disparate programming into a systemic whole make it a profession extremely well suited to the ever changing field of addictions. Thus, social workers are important players in program development, organizing community collaborations, administration, and treatment of substance abusers and their families, and are increasingly involved in addictions research, education, and policy development. Concern regarding the spread of HIV and AIDS among their clients has led many social workers to become active in the growing harm-reduction movement and in various prevention programs.

As the largest group of mental health professionals in the United States, all social workers must become knowledgeable about screening, assessment, motivational interviewing, treatment, and referrals of those with substance abuse problems. They also need to have a much greater role in primary and secondary prevention. The currently diminished role of social workers with families of substance abusers resulting from the lack of managed care payments for such services calls for greater advocacy in this area and for greater innovative practices to help families. Finally, social workers need to demand federal and state drug policies that are more equitable and effective in addressing this tremendous individual, familial, and social problem.

Current health insurance benefits for substance abuse treatment are unequal to mandated medical insurance for other medical and mental health conditions. This lack of parity continues to be a serious concern as it excludes many from needed substance abuse treatment. The lack of insurance coverage is partly responsible for the ethnic treatment disparities with African Americans less likely than Whites to have access to substance abuse or mental health care (25.4% versus 12.5%), and with Hispanics receiving delayed or less care than Whites (22.7% versus 10.7%) (Wells, Klap, Koike, & Sherbourne, 2001).

Another challenge for social workers is addressing the impact of drug-related arrests. The United States has the highest incarceration rate in the world. As of 2006, a record 7 million people were behind bars, on probation, or on parole (compared with second-ranked China, with 1.5 million people). At the end of 2003, federal prisons held a total of 158,426 inmates, the majority (55%) of whom were drug offenders. It is important to note that more than two-thirds (70%) of the 260,000 people in state prisons serving time for nonviolent drug-related charges are Black or Latino (Huffington, 2007), vastly over-representing their numbers in the general populations.

Trends and Future Directions

The field of substance abuse or addictions is constantly evolving with new substances of abuse, new populations to treat, new treatment approaches, and changing policies. An important current issue is the incorporation of evidence-based practice (EBP). The harm reduction movement, well established in most of western Europe, Canada, and Australia, appears to be growing rapidly in the United States, although how it will be incorporated within traditional AOD treatment facilities in this country remains to be seen.

From an international perspective, illicit substance use and its consequences (for example, crime and violence, military and police intervention, lost work, family destruction, property confiscation, and massive allocations of funding resources for treatment and health maintenance) constitute a major public concern. For the drug trade, nationalities and borders do not exist, and its negative impact on individuals and communities in the United States, as well as on our public policies will continue to be an issue for social workers in the future (Isralowitz, 2004).


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Further Reading

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McKirnan, D. J., & Peterson, P. L. (1989). Alcohol and drug use among homosexual men and women: epidemiology and population characteristics. Addictive Behaviors, 14. 545.Find this resource: