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~ ~ . Alcohol and Drug Abuse Experts who testified about the Year 2000 Health Objectives identified the use and misuse of alcohol and drugs as a major national problem. Substance abuse affects overall health status, contributing to intentional and unintentional injuries, heart disease, cancer, cirrhosis, AIDS, fetal and infant death, and many other health problems. Its direct and indirect mortality, morbidity, and impact on health care costs are tremendous, according to testifiers. Furthermore, the broad array of licit and illicit drugs now available carries a range of social costs that extend well beyond those suffered by the users themselves. A total of 32 individuals focused their testimony on issues relating to the use and misuse of alcohol and other drugs, another 24 made major statements on these issues, and many others addressed them as part of their testimony on other subjects. Testifiers agreed, in general, that the nation has made progress on the 1990 Objectives but that, as William Wallace of the New Hampshire Division of Public Health Services says, "we have only scratched the surface." (#430) The National Association of State Boards of Education (NASBE) adds that upon reviewing the current status of the national health objectives for 1990 it is apparent "that our country still has far to go in some significant areas related to the misuse of alcohol and drugs." (~573) Many testifiers advocate continuing and strengthen- ing the objectives on alcohol and other drug use, including setting additional targeted reductions. In the words of Bob Dickson of the Texas Commission on Alcohol and Drug Abuse, "We must emphasize chemical dependency's significance as a major nation- wide health concern." He also stresses the need to focus much energy on preventing the disease. That means not only finding "genetic markers to warn susceptible individuals, but also changing attitudes in a societr that still glorifies drinking. (#312,} Along with other witnesses, Al Wright of the Los Angeles County Department of Health Services calls for strong health protection measures to fight alcohol and drug abuse. (#229) Marilyn Aguirre-Molina and Christine Lubinski, speaking for the National Council on Alcoholism (NCA), say that an assertive public p,; -fly, systematic and coordinated educational a loaches, and other interventions are required. . ruse alcohol control measures can be used to limit 104 Healthy People 2000: Citizens Chart the Course consumption, the control of alcohol availability is a public health issue.1 The NCA strongly urges The inclusion of economic incentives and other policy initiatives in the form of process objectives to facili- tate the achievement of a number of outcome objec- tives. This can best be accomplished through the cooperation of the public, voluntary, and private sectors to advance the formulation of such policies and to advocate for their enactment." Issues that the NCA believes should be addressed include increased prices through tax policy and health and safety warning labels. (#467) Anne Windle of the Department of Addiction, Victim, and Mental Health SeIvices of the Montgo- me~y County Government in Maryland, acknowledges that substance abuse is an emotional issue. Many of the potential solutions are highly political and have serious implications for this society. She adds that a national dialogue is needed to openly consider all options. "We must address the enormous financial incentives at every level of the drug trade. And we must acknowledge the societal realities that exclude some segments of our society from participating in means of earning a legal and acceptable living," she says. (#616) Donald Gragg of the Southern California Perma- nente Medical Group suggests that "much of the progress made on the 1990 Objectives seems to be a result of a slight shift in societal attitudes particularly with regard to the acceptability of drinking and dnvi- ng (and the use of illicit drugs). It is imperative that a major thrust be made to continue and accelerate this shift in societal values during the next decade, with special focus on adolescents and young adults." (~282) Many testifiers focused their comments on several particular areas of concern surrounding alcohol and drug abuse. By far, the two most commonly discussed areas were problems associated with alcohol and the issue of substance abuse among adolescents. Many other witnesses addressed the special substance abuse problems in minority populations. These three areas are discussed in detail below. Although not addressed in great detail, other topics were discussed that testifiers felt needed attention in the Year 20~)0 Health Objectives: substance abuse during pregnancy, especially the risk of fetal alcohol

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syndrome; cocaine, "crack," and heroin; and AIDS among intravenous drug users. Robert Welch and Robert Sokol of Wayne State University and the Hutzel Hospital in Detroit explain that even though nationwide efforts appear to have increased awareness of the adverse effect of alcohol consumption during pregnancy, "a segment of intractable, heavy drinkers who are unable to modify their behaviors still exists. With respect to cocaine, Welch and Sokol report that there is little mention of this drug in the 1990 Objec- tives and emphasize that since their publication, cocaine has "become more readily available and easier to take in the form of 'crack'." (#421J Finally, heroin is identified as important, not only because of the deleterious effects of addiction, but also because of perinatal AIDS. Patrick O'Malley and Lloyd Johnston of the Universitr of Michigan recommend, and others agree, that because of AIDS, reducing the prevalence of intravenous drug use should be a very important objective. (#419J The issue of AIDS is covered further in Chapter 19. ALCOHOL PROBLEMS Many witnesses testified about the problems caused by alcohol. Dave Anderson of the American Automobile Association, for instance, reports that about half of all highway fatalities-26,000 of the s2,000 deaths per yea~are alcohol related.2 (#008) Harold Jordan of Meharry Medical College adds that 18 million adults currently experience problems as a result of alcohol, and of these, 11 million suffer from the disease of alcoholism. The direct and indirect costs of alcohol- ism amounted to $117 billion in 1983, according to Jordan. (#254) To deal with the problem, Wallace calls for more attention to the causative agent itself and would eventually like to see an alcohol-free society. Short of that, he recommends warnings on alcoholic beverage containers similar to those on tobacco products; a ban on radio and television advertising of alcoholic beverages; an increase in taxes on alcoholic beverages to be used for alcohol-related programs; and a Major and massive" educational effort aimed at health professionals, the schools, and the public. (#430J The NCA recommends the enactment of com- prehensive legislation that requires education and training for servers of alcoholic beverages, third-party liability laws, and zoning ordinances specifying the location and density of alcohol gullets, with considera tion of their proximity to public and private transpor- tation. (#467) Linda Grant of the Washington State Association of Alcoholism and Addictions Programs says that "the information we have today is not the same as the information that was available when the objectives for 1990 were drawn up." For example, there is much evidence on the heavy genetic role of alcoholism. Thus, she says, drug abuse and alcoholism may require different approaches. (#692) In addition, the NCA believes that the term Abuse" should not be used in discussions of alcoholism. The term is vague, and no clear-cut line exists between use and abuse; it should be replaced, when warranted, with the word "problem." Along with others, the NCA agrees that the title of any chapter or section on alcoholism should convey a broad approach to the problem, that is, the objectives must focus on issues resulting from, as well as factors related to, its use. (~467) ADOLESCENT SUBSTANCE ABUSE According to Wayne Teague of the Alabama Depart- ment of Education, The most serious threat to the health and well-being of our children is drug abuse." f#675) Elaine Hill and Casey Clark of the University of Colorado Health Sciences Center add that Ha recent national survey, the National High School Seniors Survey conducted in 1986, demonstrated that 92 percent of high school seniors had used alcohol, 15 percent had tried cocaine, 10 percent had used some hallucinogen, 1 percent heroin, 17 percent inhalants, and 50.2 percent reported using marijuana.n3 It appears that alcohol use continues to predominate over illicit drugs, and that cocaine and crack have replaced heroin. Statistics also clearly indicate, they say, that children are now using drugs at younger ages.4 (#577) According to the American School Health Association (ASHA), adolescents involved in substance abuse are at high risk for many health problems, such as lack of physical endurance and respiratory problems. Furthermore, quoting Brenda Wagner, ASHA writes: One of the greatest concerns of professionals working with adolescents involved in substance abuse is the delay of accomplishing the adoles cent tasks necessary to reach emotional maturity. It is difficult to adequately accomplish these tasks if one's perception of self, time, and sequence is distorted or if one's interest and Alcohol and Drug Abuse 105

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ability in evaluative thinking is impaired.5 (~5) Michael Jarrett of the South Carolina Department of Health and Environmental Control points out a problem with the 1990 objectives that address adoles- cent substance abuse, which must be corrected for the year 2000. "The problems and preventions needed for these age groups are quite different, and the 1990 objectives do not address rather significant problem areas. For example, the targeted ages in the plan are often too late to begin efforts to measure and reduce the problem." (~108) Claire Brindis and Phillip Lee of the University of California, San Francisco foresee problems in reaching this group with interventions because "no one ap- proach will respond to the various segments of the adolescent population and the different needs of new immigrants, refugees, the middle class, and the poor." To combat the problem, they suggest that "a diversity of programs under the umbrella of a common goal may be an effective way of responding to the needs of different individuals and groups in the community. For example, drug education programs directed at high school students may be more effective if programs also are available for parents and pre-high school students." (#027J Yet strategies for reaching youth must not rely solely on formal educational programs, according to Gragg. To be effective, they must also use everyday television, music, and other media. (#282) To deal with the problem of substance abuse in adolescents, the ASHA calls for prevention inte~ven- tions that "combine and coordinate multiple forces of the community with those of the school." (~005) Teague says that parents, school officials, and com- munity leaders all must commit to the task. (#675) Health care professionals, including physicians, nurses, pharmacists, and dentists, need to be educated about the prevalence and availability of alcohol and illegal drugs to school age children, as well, add Hill and Clark. They also suggest that other states follow Colorado and legislate drug education in kindergarten through high school classes. (#577J The NASBE calls for an even more comprehensive strategy in efforts to reach young people. Health risk behaviors overlap and, equally important, are associated with low academic achievement, school failure, and dropout. For this reason, society cannot afford to address health problems piecemeal through discrete 106 Healthy People 2000: Citizens Chart the Course programs aimed at reducing substance abuse, teenage pregnancy, AIDS, and other issues. Rather, they must see these problems as part of a more general, at-risk syndrome that requires a comprehensive approach, including school and community. To this end, the NASBE advocates the active involve- ment of parents, peers, law enforcement agencies, social service agencies, health care givers, the churches, business, industry, and the media in any programs aimed at adolescents. In addition, the NASBE says that education programs must be de- signed to alter knowledge, attitudes, and most impor- tant, behavior. "Mere public awareness of the risks associated with drinking is not sufficient. Knowledge must be transferred Into changed attitudes and changed behavior." (#573) "Risk-taking adolescents do not believe that it is harmful, or that the risks outweigh the thrills in the areas of driving, drinking, drugs, and sex," says Herbert Rader of the Salvation Army in New York. Thus, it is also important that youth activities be organized to enhance self-esteem, promote new skills acquisition, and promote life skills that encourage healthy behaviors, as do the youth programs of the Salvation Army. (#432) The NCA calls for legislation mandating equal time for health and safety messages to counterbalance alcohol ads on radio and television. (~467) Gragg suggests that by the year 2000, 75 percent of the references to alcohol or drugs in television, drama, hum, and popular music reflect negative connotations about the use of these substances. (~282) Preven- tion strategy for the nation must send the message that "it's all right not to drink" and that the abuse of alcohol is unacceptable behavior, according to Jacqueline Morrison of Wayne State University. (#723J SUBSTANCE ABUSE BY MINORITY GROUPS Given the differences between ethnic and racial minorities and the rest of the population in the rates of alcohol morbidity and mortality, the NCA suggests the "development of sub-objectives with specific targets for minority populations." (~467) Mario Orlandi of the American Health Foundation in New York adds that "ethnic variability presents a dilemma to health planners who are responsible for developing substance abuse prevention initiatives." Programs, he continues, must have not only demonstrated eff~ca~

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but also cultural relevance for particular minority or ethnic groups and subgroups. (#167) Blacks Morrison, who also represented the National Black Alcoholism Council, calls alcoholism The number one public health problem in the Black community, as it is related to cancer, vehicle accidents, domestic violence, homicide, school dropout, hypertension, fetal alcohol syndrome,n and many other problems. Morrison calls for more culturally sensitive individual and communin,r-level alcoholism awareness and education programs. She also calls for more attention to programs for children of alcoholics. In addition, Morrison calls for more data on Blacks and alcohol- related driving accidents and for public information and educational programs targeted to the Black community. (~723) Hispanics According to Sylvia Andrew of Our Lady of the Lake University In San Antonio, Texas, alcohol and drug abuse are problems among Me~ncan-American youth as well. In terms of prevention, attention should be given to the overaccessibility of alcohol in barrios. (#495J Ricardo Jasso of Nosotros Human Services Deve- lopment in San Antonio calls attention to the prob- lem of inhalant abuse among Mexican-Americans. To deal with the problem, Nosotros is developing a com- prehensive continuum of programs, including counsel- ing for individuals, groups, and families, as well as psychiatric assessments; alternative activities; chemical abuse education, general educational programs, and job skill training; job placement programs; social services and referrals; and residential treatment programs for teenagers. (#494) Native Americans JoAnn Kauffman of the Seattle Indian Health Board reports that many deaths among Native Americans 45 years old or younger are alcohol related.6 A large part of the Native American adolescent suicide problem, discussed in greater detail in Chapters 6 and 16, is alcohol related. Currently there are not adequate resources to treat Indian alcoholism or substance abuse. There are even fewer resources available to meet the treatment needs of children of alcoholics. The multi-generational cycle of family dysfunction perpetuates alcoholism, violence, sexual abuse and self-destructive be- haviors. To break the cycle requires breaking through family and community denial, and striving for cultural revitalization and adequately trained treatment providers. (#696) The Indigent, Homeless, and Disadvantaged The terrible toll exacted by substance abuse, as seen in the breakdown of personal health and the breakup of families and neighborhoods, is even more pronounced among the disadvantaged. Rader reports that a major expansion of drug detoxification and rehabilitation programs, including adequate residential facilities, is needed for the large number of intravenous (IV) drug abusers who would be willing to come off the street. "Some recent surveys suggest that many IV drug abusers on the streets of New York would voluntarily enter residential drug treat- ment programs if they were available," says Rader. (~432) Programs are successful, Rader explains, because something has been kindled within a person. Attainment of this change of outlook, which results in a dramatic change in behavior, seems to create a contagious hope within others. The answer to a great deal of drug abuse is not education alone or provision of clean needles or addressing chemical dependency only, but pro- viding emergency shelter, secure safe houses, psychosocial support and counselling, health care, education and training for living, camps away from the streets, community centers where opportunity for personal achievement, self- esteem, and respect for others are developed, employment counselling, etc. (#432J IMPLEMENT. ATION A variety of strategies were proposed for achieving the year 2000 alcohol and drug objectives. Dickson calls for a strong and focused attack on substance abuse. It is time for the chemical dependency field, and the general public, to turn from the "drug-of- the-month~ hysteria of the media, place our country's manpower and resources into the fray, Alcohol and Drug Abuse 107

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and begin a major offensive against substance abuse. Everything that we have gained could well be lost if we once more are forced to endure the perception that chemical dependency is a weakness, a sign of moral deficiency, rather than a treatable neuro-chemical disease. Our progress depends on the final answering of this question that, indeed, it is a disease. (#312) The NCA views "a policy to substantially increase the tax rates among alcoholic beverages" as an important element in a successful implementation strategy. Tax rates among beverage classes should be equalized by alcohol content. Such a move would, in and of itself, raise four billion dollars and serve to undermine public perceptions that beer and wine are more ~moderate" alcoholic beverages. (~467) The worksite has great potential for combatting alcohol and drug problems, according to Dickson: "Random drug screening, to create a drug free work- place, coupled with an EAP (employee assistance program) is the most effective method so far for dealing with chemical dependency. (#312) Many testifiers were concerned with uniformity in data collection. The NCA strongly recommends, and others agree, that the Year 2000 Health Objectives also include a process objective for implementing and monitoring an improved and coordinated information REFERENCES system within and between federal, state, or local governments and the private sector, and for both health and human services information. This would be based on the concept of uniform minimum data sets and would include greater precision and standardization in the definition of terms that describe drinking and levels of problem use. (~467J Accurate surveillance of alcohol problems among minority groups also requires the implementation of a uniform demographic information collecting system, the NCA adds. It recommends that in addition to collecting data on age and gender, a uniform racial and ethnic identifier be included on all pertinent records. (#467) Although prevention and treatment of both alcohol and drug problems, as well as data collection and surveillance, will be critical to the achievement of the year 2000 alcohol and drug objectives, society must Understand that factors of public policy, urban economics, family life, and education are among the risk factors for both these problems," states James Sail of the Detroit Department of Health. Putting it into an even broader framework, he adds that "while disease-specific objectives and monitoring of health status will continue to be legitimate, we are acting on the assumption that, at least among the urban under- class, the following health areas share a common group of underlying risk factors: sexually transmitted diseases, maternal and infant health, teenage pregnan- py, internal injuries, stress-related mental illness, and alcohol and drug abuse." (~389) 1. Bruun K, Edwards G. Lumio M, et al.: Alcohol control policies in public health perspective. Finnish Foundation for Alcohol Studies, vol. 25. WHO and Addiction Research Foundation, 1975 2. U.S. Department of Transportation, National Highway Traffic Safety Administration: Fatal Accident Reporting System 1988. A Review of Information on Fatal Traffic Crashes in the United States in 1988 (DOT Publication No. HS 807 507), 1989 3. Bachman JO, Johnston LD, O'Malley PM: Monitoring the Future: Questionnaire Responses from the Nation's High School Seniors, 1986. Ann Arbor: Institute for Social Research, University of Michigan, 1988 4. Ibid. 5. Wagner BJ: Intervening with the adolescent involved in substance abuse. J Sch Health 54(7):244-246, 1984 6. U.S. Department of Health and Human Services: Report of the Secretary's Task Force on Black and Minority Health. Washington, D.C.: U.S. Government Printing Office, 1987 108 Healthy People 2000: Citizens Chart the Course

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TESTIFIERS CITED IN CHAPTER 11 005 Allensworth, Diane; American School Health Association 008 Anderson, Dave; American Automobile Association 027 Brindis, Claire and Lee, Phillip; University of California, San Francisco 108 Jarrett, Michael; South Carolina Department of Health and Environmental Control 167 Orlandi, Mario; American Health Foundation 229 Wright, Al; County of Los Angeles Department of Health Services 254 Jordan, Harold; Meharry Medical College 282 Gragg, Donald; Southern California Permanente Medical Group 312 Dickson, Bob; Texas Commission on Alcohol and Drug Abuse 389 Sail, James; Detroit Department of Health 419 O'Malley, Patrick and Johnston, Lloyd; University of Michigan 421 Welch, Robert and Sokol, Robert; Wayne State University/Hutzel Hospital (Detroit) 430 Wallace, Jr., William; New Hampshire Division of Public Health Services 432 Rader, Herbert; The Salvation Army in the United States 467 Aguirre-Molina, Marilyn and Lubinski, Christine; National Council on Alcoholism 494 Jasso, Ricardo; Nosotros Human Services Development (San Antonio) 495 Andrew, Sylvia; Our Lady of the Lake University of San Antonio 573 Wilhoit, Gene; National Association of State Boards of Education 577 Hill, Elaine and Clark, Casey; University of Colorado Health Sciences Center 616 Windle, Anne; American Public Health Association, Public Health Education Section 675 Teague, Wayne; Alabama Department of Education 692 Grant, Linda; Washington State Association of Alcoholism and Addictions Programs 696 Kauffman, JoAnn; Seattle Indian Health Board 723 Morrison, Jacqueline; Wayne State University Alcohol and Drug Abuse 109