Dear Mr. President: A Modest Proposal
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Unless you live under a distant rock, you know that last week's presidential debate on the economy ignited the campaigns of President Barack Obama and Governor Mitt Romney. Romney, according to the punditocracy, won handily; Obama, accordingly, was flat. The big subject? Spending. And although Obama and Romney don’t agree on much, they both say that reducing the budget is a priority. What neither candidate realizes (or acknowledges) is a substantial cut that's hiding in plain sight: call addiction a disease. Taking this simple step would not only reduce the federal tab, it also would cut state and local spending, lower crime, traffic accidents, suicides, domestic violence, homelessness, birth defects and a host of other devastating and costly health and social ills. This relatively simply policy change also would improve the health and productivity of Americans across the country. It's a no-brainer.
Except that it's not. While the science on addiction is generally clear, public policy, opinion and health care practice lag decades behind at a huge cost to society. Here are the facts: Addiction is a complex disease of the brain that is reflected in pathological pursuit of reward or relief through substance use. Looking only at addiction involving tobacco, alcohol and other drugs, it is an epidemic affecting 16 percent of the United States over age 12—more than those with cancer, diabetes or heart disease. Another 32 percent of Americans are classified as risky users of addictive substances, meaning people may not have the disease of addiction, but use substances in ways that everyone's health and safety.
Americans turn a blind eye to the disease of addiction and instead deal with its consequences—a tab that costs every person in America nearly $1,500 each year. Our public policy approach is one of shoveling up after preventable disasters.
The National Center on Addiction and Substance Abuse at Columbia University (CASAColumbiaTM) documented in a recently-released report, Addiction Medicine: Closing the Gap Between Science and Practice, a broad range of effective screening, intervention and treatment options exist, but they are not routinely offered to patients. Less than 11 percent of people with the disease receive any form of treatment. Compare that to the 70 to 80 percent who receive treatment for other diseases like hypertension, diabetes and major depression. Rather than providing treatment for addiction, we turn a blind eye to the symptoms and instead cope with the costly consequences.
The result, as quantified in CASAColumbia’s 2009 report on the costs of risky substance use and addiction to government, is that federal, state and local governments spend at least $467 billion each year on these problems. That was approximately 10 percent of the federal budget and 16 percent of state budgets in 2005. Of that spending, less than two cents of every dollar goes to prevention and treatment, two and one-half cents go to research, taxation, regulation and interdiction while the rest of the money—almost 96 cents of every dollar—goes to cope with the consequences of our failure to prevent risky use and treat addiction. Just covering the bill for these consequences costs every person in America nearly $1,500 each year.
The two largest areas of government spending on the consequences of risky substance use and addiction are health care and crime. Approximately one third of all hospital inpatient costs result from risky use and addiction which drive more than 70 other diseases requiring medical care. And in America, 86 percent of all inmates in our prisons and jails are substance-involved; two-thirds report meeting medical criteria for addiction. America’s public policy approach to this disease is one of shoveling up after completely predictable and preventable disasters.
Rather than educate the public about this very real public health crisis, its risk factors, how to prevent it and provide quality treatment and disease management as we do for other health concerns, public policy makers choose to wait for a crisis to occur. Then we pay, and pay, and pay. For example, on average we spend over $25,000 per year to incarcerate each substance-involved offender but fail to provide treatment for their disease, insuring that they will be far likelier to be a repeat offender and be re-incarcerated. The American public pays for these consequences not just in the form of tax dollars, but in human suffering. And, we pay with our lives as millions of Americans each year succumb to this deadly disease. The fact is, very few people in this country have not been affected by addiction in one or more of its manifestations.