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Drug addiction is a worldwide problem of staggering proportions. In the United States in 2017, 30.5 million people (about 1 in 9 Americans) used an illicit drug in the past month. Substance use disorders (SUDs), representing clinically significant impairment caused by repeated use of alcohol or drugs, affected an estimated 19.7 million people in the U.S. in 2017. This includes about 14.5 million people with alcohol use disorder (AUD), and an estimated 7.5 million people with at least one illicit drug use disorder.
The 2017 National Survey on Drug Use and Health (NSDUH) defines illicit drug use disorder as meeting Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for dependence or abuse involving one or more of these illicit drugs: cocaine, hallucinogens, heroin, inhalants, marijuana, methamphetamine, or prescription psychotherapeutic drugs that were misused. The latter includes pain relievers, sedatives, stimulants, and tranquilizers. Anyone meeting the criteria for either dependence or abuse of an illicit drug is said to have an illicit drug use disorder.
For most illicit drugs, dependence requires at least three of seven of the following criteria. But, since withdrawal is not listed in the DSM as criterion for some illicit drugs, dependence for those substance means meeting three of the first six criteria.
For those individuals who did not meet the criteria for dependence while abusing a drug for the past 12 months, they were defined as having drug abuse for that drug if they said they had one or more of the following four criteria:
According to a statistic from the Office of National Drug Control Policy, 90 percent of Americans with a problem of substance abuse started drinking, smoking and doing drugs before the age of 18.
Cocaine use disorder occurs when an individual, due to recurrent cocaine use, has “clinically significant impairment” that includes having problems with health, physical withdrawal, persistent or escalating cocaine use, and failing to meet work, home, or school responsibilities. In 2017, an estimated 966,000 people aged 12 and older had cocaine use disorder. The breakdown includes about 19,000 adolescents, 243,000 young adults, and 703,000 adults. Long-term cocaine addiction, according to an article in Psychology Today, and numerous other sources, leads to extensive problems of a psychological and physiological nature.
Heroin addiction is officially known as heroin use disorder. An estimated 652,000 people had heroin use disorder in 2017, up from an estimated 626,000 the year before. The 2017 estimate includes about 4,000 adolescents, 165,000 young adults, and 483,000 adults. Cheaper and more readily available than prescription opiates, heroin has high street appeal. Indeed, about 80 percent of new users of heroin say they turned to the illicit drug when they could no longer get the prescription opiates they’d been misusing.
Marijuana addiction, or marijuana use disorder, affected about 4.1 million people in 2017. This includes an estimated 557,000 adolescents, 1.8 million young adults, and 1.7 million adults. Marijuana use disorder is the most commonly misused illicit drug, followed by prescription pain relievers.
Meth addiction, officially called methamphetamine use disorder, is clinically significant impairment caused by the chronic use of meth. Those diagnosed (or not) with meth use disorder display increasing or persistent use, restlessness, hyperactivity, numbness, emotional and physical withdrawal, bizarre behavior, hallucinations, isolation from family and friends, health problems, and difficulties at home, work, or school. An estimated 964,000 people aged 12 and older had a meth use disorder in 2017. This means that they met the diagnostic criteria for meth dependence or abuse.
The breakdown by age groups of the 964,000 people in 2017 with a meth use disorder includes 24,000 adolescents, 188,000 young adults, and 751,000 adults aged 26 and older. In 2016, by contrast, 10,000 adolescents, 135,000 young adults, and 539,000 adults had meth use disorder.
The misuse of opioids, says the NSDUH, includes two drug categories: heroin and prescription pain relievers. About 2.1 million people had an opioid use disorder in 2017, which breaks down into an estimated 103,000 adolescents, 445,000 young adults, and 1.6 million adults.
An estimated 1.7 million people in 2017 had a pain reliever use disorder. This number includes about 99,000 adolescents, 339,000 young adults, and 1.2 million adults. Prescription pain relievers include products containing hydrocodone (Vicodin®, Lortab®, Norco®, Zohydro® ER, and generic hydrocodone), oxycodone (OxyContin®, Percocet®, Percodan®, Roxicodone®, and generic oxycodone), tramadol, codeine, morphine, fentanyl, buprenorphine, oxymorphone, Demerol®, hydromorphone, methadone, or any other prescription pain reliever.
Stimulant use disorder affected an estimated 572,000 people in 2017. Those who met criteria for methamphetamine use disorder were not classified as having a stimulant use disorder unless, in addition, they also met the criteria for stimulant use disorder as a result of their misuse of stimulants. The 2017 total of people with stimulant use disorder included about 62,000 adolescents, 187,000 young adults, and 323,00 adults. Prescription stimulants include Dexedrine®, Adderall®, Ritalin®, and Concerta®.
Addiction to benzodiazepines, specifically tranquilizers, officially diagnosed as tranquilizer use disorder, affected an estimated 739,000 people in 2017, according to the 2017 NSDUH. This total includes about 80,000 adolescents, 278,000 young adults, and 380,000 adults aged 26 and older. One of the most commonly prescribed benzodiazepines is , followed by Valium. Research shows that about 40 percent of individuals who take Xanax daily for 6 weeks (the recommended duration is only 2-4 weeks) to cope with extreme anxiety will go on to become addicted to the drug.
The Food and Drug Administration (FDA) issued a statement attributed to FDA Commissioner Scott Gottlieb, M.D. in late February 2019 outlining the agency’s policy and regulatory thrust going forward to help act on and address the nation’s opioid epidemic. Gottlieb said the opioid epidemic is “one of the largest and most complex public health tragedies our nation has ever faced,” and the biggest public health crisis facing the FDA. Stating that addressing the opioid crisis is a top priority of the Secretary of Health and Human Services, as well as the entire administration, with the FDA playing a key part in that effort.
Since 2018, the estimated number of opioid painkiller prescriptions has fallen by 24 percent, according to the statement. Especially noteworthy, the prescriptions of higher strength opioids (90+ morphine milligram equivalents/unit) fell even more sharply since 2015, accounting for less than 1 percent of all opioid painkillers (such as tablets) dispensed in 2018. Still, the rate of overdose deaths continues to increase, due in part to increasing abuse of fentanyl products purchased online and sold as street drugs.
What is the FDA doing to address the opioid crisis in 2019? Among its many continuing initiatives, Gottlieb says that new FDA guidelines report will be ready by the end of 2019. To reduce the rate of new addiction, it’s necessary to reduce exposure to opioids. Gottlieb said that this means rationalizing prescribing, so that fewer opioid prescriptions are written, and that they’re for a dose and duration of use that is closely aligned with the patient’s clinical circumstance and medical need. For a tooth extraction, for example, this means no more than 30 tablet prescriptions. For many with acute pain indications where opioids are used, 1-2 days of dispensed medication is the appropriate quantity.
The FDA will also continue to strengthen enforcement against illicit opioid drugs, including drug busts at the border, as well as requiring drug companies to initiate studies on whether opioids are effective chronic pain treatment. Depending on the results of such studies, Gottlieb said, the FDA could change labeling requirements or even restrict the prescribing of some opioids long used to treat chronic pain.
As many research studies have found, overprescribing of opiate medications is common following surgical procedures. As reported in Anesthesiology News, researchers at the University of Michigan study conducted a prospective observational cohort study of 758 opioid-naïve patients who had undergone thoracic surgery, hysterectomy, total knee arthroplasty or total hip arthroplasty and were prescribed opioids for use at home after surgery. The primary study outcome was total opioid use in oral morphine equivalents. Breaking down the data, researchers found:
Researchers concluded that their data might be useful in informing clinical practice, such as giving fewer opioids to older patients, using the data to identify patients who may benefit from more careful postoperative monitoring for opioid abuse or new persistent use. In addition, educational interventions could help by setting realistic expectations for what level of postoperative pain is normal, and determining how accepting the patient is of alternative treatments besides opioid drugs. Behavioral techniques such as guided imagery and breathing exercises may play a role, as some studies have found they decrease perioperative anxiety and pain.
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