Substance Abuse and Public Health Policy

Andrew S. O’Connor, DO

Case Western Reserve University

Department of Epidemiology and Biostatistics

Division of Public Health



I.                    Substance Abuse-Definitions

A.     What is it

B.     What’s being used and by whom

1.      Tobacco

2.      Alcohol

3.      Marijuana

4.      Cocaine/Crack, Heroin, “Ecstasy”, Methamphetamine,

5.      Inhalants

C.     Legal vs. Illegal/Illicit substance abuse

II.                 Whose Involved-the epidemiology of substance abuse

A.     Males vs. Females

B.     American Youth

C.     The Inner city and substance abuse

D.     The rise of rural issues and substance abuse

III.               The Impact of Substance Abuse

A.     Personal

1.      Physical issues—rising comorbities and associated health problems related to substance abuse

a.       HIV and addiction

b.      Hepatitis

c.       Chronic liver, lung, cardiovascular disease

d.      Sexually transmitted diseases and substance abuse

2.      Emotional/Psychological relationships of substance abuse

a.       introduction to addiction

b.      changes in the view of addiction as a personality flaw and deviant behavior to a medical model with emphasis on treatment of a chronic disease

3.      Personal economic impacts of substance abuse

B.     Substance abuse and the American family

1.      Rates of Divorce in families of substance abuse

2.      Children

a.       rates of violence/sexual abuse amongst children involved in substance abuse, psychological illness

b.      developmental delay and scholastic achievement

c.       physical illness—asthma, obesity

C.     Societal impact of substance abuse

1.      Loss of work and productivity decline due to impaired work force

2.      Increases in violence—the 1980’s and the inner city,

3.      Loss of life due to alcohol and motor vehicles

4.      % of GNP spent on “the war on drugs”

5.      Developing nations and drugs as a cash crop

IV.              Policies of education and substance abuse prevention

A.     The question of legalization and regulation of current illegal drugs

B.     Tobacco and environmental exposure—zero tolerance and implications on personal civil liberties

V.                 Addiction

A.     reemphasis on role of the medical model of addiction as a disease requiring treatment

B.     models of treatment

1.      total abstinence vs. attempts to “control” addiction

2.      heroin and methadone maintenance—trading one addiction for another in order to control the associated aspects of addiction and addictive behavior

C.     Issue of Mixed diagnosis and addiction



Few Americans can claim they have never heard of the term “substance abuse”. Pick up the local newspaper, turn on the radio, watch the evening news and references to “the war on drugs”, the health consequences attributed to substance use and abuse, or deaths associated with the use or abuse of illicit substances are wide spread.  The legal and illegal use of various organic and manufactured substances has become a true “hot topic” for politicians, employers, and heads of household.  But what do we mean when we say “substance abuse”?  Are we merely referring to the health, social, and economic consequences of “illegal” drugs such as heroin, crack cocaine and marijuana?  Do we mean the broader definition that includes these substances and the consequences of alcohol?  How about the health consequences of “legal” use of substances such as tobacco?  Is this encompassed by the term “substance abuse”?  And if so, how are we to view the use of various substances for “medicinal” purposes, such as the control of chronic somatic pain or the improvement of athletic performance?  How do we view the intake of caffeine, arguably one of America’s most widely ingested substances?  Is this also substance “abuse”, and if so, why is it not regulated by the legal system?  If this is not “substance abuse” then why not and where do we as a collective society draw the line between “acceptable” and “unacceptable” substance use and abuse?


Obviously the topic of substance abuse is a large one.  Entire textbooks and journals are devoted to the health, societal and economic impacts of the use and abuse of various substances.  A single chapter in a public health textbook could never do an adequate job of exploring each of these topics.  Instead, the focus of this chapter will be to introduce a framework for defining what is meant by “substance abuse”.  Specific substances will be touched upon.  An exhaustive list is outside of the scope of this text and the discussions will be limited several main psychoactive substances.  I will also examine estimates of the epidemiology of those involved both directly and indirectly in substance abuse and the impact that the use of various substances has on them.  I will examine the growing view of substance abuse as a chronic medical condition, and efforts to treat this condition.  Finally I will briefly discuss the “war on drugs”, efforts to decriminalize the use of specific substances, and to provide drug use education and prevention, as well as efforts to limit the health and societal impacts of substance use and abuse.


I.          Substance Abuse, Definitions


            substance abuse: noun

Excessive consumption or misuse of substance: the excessive consumption or misuse of any substance for the sake of its nontherapeutic effects on the mind or body, especially drugs or alcohol (Encarta)

This is the dictionary definition of substance abuse.  Other authors have tried to categorize substance abuse or “drug problems” by the class of drugs that are used.  For instance, Goldstein categorizes drugs into seven categories: nicotine, alcohol and related drugs, opiates, cocaine and amphetamines, cannabis, caffeine and the hallucinogens. (Goldstein)  But what about other nonclassified substances, such as anabolic steroids and other performance enhancing drugs.  What about the misuse of various medicinal preparations for purposes other than what they were designed for (e.g. erythropoietin to increase blood volume and potentially improve athletic performance).  Is this also substance abuse?  


Using the broad definition of the term “substance abuse” listed above, these would be termed substance abuse.  A broader split would be to classify these potential substances of abuse into those with “psychoactive” effects (effects on mind, mood and thought processes) from those with effects on physical or performance processes.  Each of these classes of drugs or substances has particular ramifications on the overall health of the person using the substance. The Diagnostic and Statistical Manual of Mental Disorder 4th edition (DSM-IV) makes the distinction between dependence and abuse:



Three or more of the following:


One or more of the following occurring over the same twelve month period:

1.  Tolerance

1.  Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home


2.  Withdrawal

2.  Recurrent substance use in situations in which it is physically hazardous


3.  Substance is often taken in larger amounts or over a longer period than was intended


3.  Recurrent substance-related legal problems

4.  Any unsuccessful effort or a persistent desire to cut down or control substance use

4.  Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance

5.  A great deal of time is spent in activities necessary to obtain substance or recover from its effects



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



7.  Continued substance use despite knowledge of having had persistent or recurrent physical or psychological problems that are likely to be caused or exacerbated by the substance.



Addiction is defined as “compulsive drug seeking and using, even in the face of terrible personal and social consequences . . . A chronic, and complex, but treatable brain disease.” (McCrady, Epstein)


II.         The Epidemiology of Substance Abuse


Now that we have a rough idea of what substance abuse is and a broad structure for classifying potential substances of abuse, we should turn to examine what groups of people are abusing various substances. The hallmark investigation of the epidemiology of substance abuse in the United States is the National Household Survey of Drug Abuse(NHSDA). (A link to the statistic portion of this trial is provided in the reference section of this chapter)  One of the useful constructs of this survey is to split substance abuse into both legal (Alcohol and Tobacco) vs. Illicit drug use and abuse.  In this survey, the illicit drugs are split into 9 categories: marijuana, cocaine, heroin, hallucinogens, inhalants, non-medical use of pain relievers, tranquilizers, stimulants and sedatives.  Separate categories are provided to estimate the use of alcohol and tobacco, which can also be thought of as legal substances.  The NHSDA, which has been conducted by the federal government since 1971, is the primary source of statistical information on the use of drugs by the U.S. population, and is overseen by the Substance Abuse and Mental Health Services Administration (SAMHSA).  Data is collected by the administration of questionnaires to a “representative sample” of the population age 12 and older, through face-to-face interviews, and are updated yearly.  The interpretation of the data provided by the NHSDA is somewhat limited however.  This survey omits homeless persons not living in shelters as well as institutionalized subjects. This may lead to an underestimation of the use patterns of these groups (Goldstein).



ILLICIT Drug Use (highlights from NHSDA 2000 report)

-An estimated 14 million Americans were “current” illicit drug users (used within the month prior to interview).  This represents 6.3% of the population age 12 years and older.

-Men have higher rates of current illicit use than women (7.7% vs. 5.0%).

-Among youths age 12 to 17, 9.7% had used illicit substances within the 30 days prior to interview

-Approximately 2.1 million youths age 12 to17 had used inhalant some time in their lives (8.9% of youths) the primary inhalants used included glue, shoe polish, Toluene, gasoline and lighter fluid.

-Among youths who were “heavy drinkers” 65.5% were also current users of illicit drugs.  Amongst nondrinkers, only 4.2% were current illicit drug users.  For concomitant use of tobacco, 42.7% were current users of illicit drugs, for nonsmokers this number was only 4.6%.

-7.0 million persons reported driving under the influence of an illicit drug at some time in the past year.  This corresponds to 3.1% of the population age 12 and older, however this rate is lower than the rate for 1999 (3.4%).



Several important points can be taken from these figures.  First, substance use and abuse is a problem which affects a large number of people, and a great number of these people begin to use various substances early on in life.  Second, this brings up the theory of “gateway” drugs, such as tobacco, alcohol and marijuana, as leading into the potential use of more damaging and addictive drugs.  Finally, this table highlights that the substance abuse problem is not only impacting the persons who are using substances, but also has the potential to cause harm to others around them. 


Alcohol (highlights from NHSDA 2000 report)


Almost half of Americans aged 12 and older reported being current drinkers of alcohol in 2000 (an estimated 104 million people)


Heavy drinking was reported by 5.6% of the population aged 12 and older


One in ten Americans (22.3 million persons) had driven under the influence of alcohol at least once in the 12 months prior to interview.  Among young adults (age 18

25) 19.9% had driven under the influence of alcohol in 2000.



Tobacco use (highlights from NHSDA 2000 report)

An estimated 65.5 million Americans age 12 and older (29.3%) reported current tobacco use in 2000 (any product).  55.7 million used cigarettes, 10.7 million used cigars, 7.6 million used smokeless tobacco


Current cigarette use declined between 1999 and 2000 among youths aged 12 to 17 (14.9% to 13.4%) and young adults ages 18 to 25 (39.7% to 38.3%).  No changes were seen however to adults age 26 and older.


Among youths, females were slightly more likely to use tobacco products.  Among all age groups however, males were slightly more likely to use than females. 


Despite nationwide campaigns regarding the legal age to purchase tobacco products, among youth smokers age 12 to 17 more than half reported they personally bought cigarettes.


Is substance abuse a purely “inner city” problem?  The data from the NHSDA would speak otherwise.  Among all age groups, the rate of illicit drug use in metropolitan areas was higher than the rate in nonmetropolitan areas. Rates of use were 6.5 percent in large metropolitan areas, 6.7 percent in small metropolitan areas, and 5.1 percent in nonmetropolitan areas. Rural nonmetropolitan counties had lower rates of illicit drug use than other counties. Rates were 3.9 percent in completely rural counties and 4.5 percent in less urbanized nonmetropolitan counties.  This statistic however misses the fact that among youths ages 12-17 the rates of illicit drug use were essentially the same in rural areas as in metropolitan areas.  Another interesting and somewhat disturbing statistic is the use of alcohol in different geographic regions.  Among youths aged 12 to 17, rates of past month alcohol use as well as heavy alcohol use were higher in rural areas (18.9%) than in large metropolitan areas (16.1%). Among young adults aged 18 to 25, the rate of past month use was higher in large metropolitan areas than rural areas, while there was no difference in heavy use rates across these county types. For older adults (age 26 and older), past month use was greater in large metropolitan areas while heavy use was greater in rural areasAmong current users, the rates were the same for those who were classified as heavy drinkers among various age groups.  Similar patterns of use are also noted among tobacco user, with slightly higher use rates in rural areas than in metropolitan regions.  These changes in trends of substance abuse have important implications for metropolitan and rural health districts alike.  First with regards to the nation’s youth, patterns of substance abuse are often viewed as a continuum, with tobacco and alcohol viewed as “gateway” drugs, as mentioned previously.  Theoretically the early use of these substances leads to lifetime patterns of substance use, abuse and potentially addiction.  Also the lay press and political action groups have for years highlighted violence in the inner city as causally linked to substance use and abuse, with many of the effected being the youth of the nation.  However the rural areas of America have long been ignored despite statistics such as these that highlight patterns of use among rural youths.  Recent newspaper reports have highlighted that the rates of both nonviolent and violent crime associated with substance abuse have been rising.  What is particularly concerning about this is that many suburban and rural police departments and public health agencies are ill equipped to handle the rising issues of substance abuse.(NY times, Butterfield)  Tobacco use is likewise a dangerous and actionable area, given the long term consequences of lifetime exposure to tobacco.  Programs to educate the nations youth regarding the long-term health risks of tobacco, alcohol and drug use are necessary.


III.        The Impact of Substance Abuse


We have already explored the definitions of substance abuse and addiction as well as estimates of the number of people who are involved in the use of various substances.  Now we should focus on the short and long term consequences of the use of some of these substances.  A useful framework for examining this aspect of substance abuse is to begin at a micro-, or personal level, and move to a more macro or family and societal level. 


On the personal or micro- level, substance abuse has both physical and psychological effects.  Since the early 1980’s the rates of Human Immunodeficiency Virus transmission have been linked with the “drug culture” of injectable drug use.  Doubtless, this was, and still is true.  However, due to early success in a drop in the number of new cases of HIV/AIDS that are injection drug use associated (36% initially down to 28% in 2000) some may take the view that the epidemic of HIV/AIDS is almost over. (CDC)  This attitude may have dangerous consequences for the individual and for the public health of the nation in general.  One recent report locally (Cleveland) is that for the first time since 1996 the number of new HIV diagnoses actually rose in 2001. (McEnery)  Whether this related to the rate of intravenous drug use is unclear, however the intravenous route of substance abuse is a clear route of blood borne transmission.  The danger of this is self evident both for the drug user and for those who have close personal contact with the potential HIV carrier.  The impact of substance abuse in terms of physical illness is not limited purely to the user him or herself.  Many cases of HIV, Hepatitis B and Hepatitis C are linked to the sexual transmission from the injection drug-using partner to his or her mate.  Also vertical transmission (mother to child) is a tragic and striking problem.  Strategies to limit the spread of these types of diseases among drug using populations include access to community out reach services, HIV testing and risk factor counseling, drug abuse treatment programs, and access to sterile syringes (needle exchange programs).(NIDA) But what about noninjection substance abuse-cocaine, crack, ecstasy, alcohol?  To the extent that the use and overuse of these substances leads to impairment in judgment, potential promiscuous sexual behavior, unwanted sexual advances, and violence the use of these agents are also causal pathways to many different diseases.  A recent well publicized report of college age individuals estimated that 1,400 deaths per year are directly related to alcohol abuse.  In addition approximately 500,000 injuries and 70,000 cases of sexual assault and date rape were related to alcohol.  Likewise, 400,000 students aged 18-24 reported having had unprotected sex as a result of drinking. (NIAAA)


Tobacco also has well documented negative physical and psychological impacts both on the user and on those exposed to environmental smoke.  Data from the U.S. Centers for Disease Control (CDC) put the number of deaths due to tobacco at 430,000 (the leading cause of preventable death in the U.S.), and approximately 10 million worldwide.  Aside from death, tobacco smoke exposure has negative effects on blood pressure, cardiovascular, pulmonary and immune function.  Approximately 87% of lung cancers are attributable to smoking as well as the majority of cases of emphysema and chronic bronchitis.  The economic costs in terms of direct health care expenditures and lost productivity to the United States are estimated at $97.2 billion each year.


The extreme psychological impact of substance abuse is addiction, which is described in the introductory section of this chapter.  Not until recently, however, has the topic of addiction been dealt with as a medical illness.  Prior to this time, persons who were addicted to various substances were viewed as having “weak wills” or personality flaws.  While these stigmas continue to exist, and impair discussions regarding substance abuse, increasingly addiction and substance abuse are being viewed as a medical illness.  This view has opened new and innovative strategies for treatment.  The CDC, for instance, has begun an online campaign to highlight what we can realistically expect of substance abuse treatment.  One of the highlights that this web site nicely points out is that treatment is an ongoing and evolving process, and that while a “cure” may not always (or potentially ever) be possible, effective treatment strategies are available.  Additional information on the topic of treatment will be highlighted below.


In terms of the impact of substance abuse on the integrity of family units and the costs of substance abuse to American society, the outlook is also grim.  Estimates of the incidence of substance abuse in the millions of reports of child maltreatment (ranging from physical and psychological abuse, to neglect) range from 25 to 84 %( Moyers, Hester) with an average of 26%.  A 1989 report by the National Committee for the Prevention of Child Abuse estimated that 10 million children were living in household with an adult substance abuser and that 675,000 children annually were seriously maltreated by substance abusing caretakers. (Daro, Mitchell)  Another well established link between parental substance abuse and child issues is the development of fetal alcohol syndrome and later life rates of developmental delay in these effected children.


The belief that alcoholism causes domestic violence is a notion widely held both in and outside of the substance abuse field, despite a lack of concrete information to support this. Research indicates that among men who drink heavily, there is a higher rate of perpetrating assaults resulting in serious physical injury than exists among other men.  However, the majority of abusive men are not high-level drinkers and the majority of men classified as high-level drinkers do not abuse their partners. (Zubretsky)  Regardless of this the rates of injury to partners, risk to children, and of sexual assault are higher in relation to substance abuse.  The integrity of the familial unit among substance abusing partners is also in jeopardy.   


The societal impacts of substance abuse are also readily apparent.  Substance abuse not only impacts the individual and the family of the substance abusing individual, but also has impacts on completely non-related parties.  The substance abuser has frequent contact with the criminal justice system through DUI, violence, the courts and incarceration.  Statistics from the National Highway and Traffic Safety Administration(NHSTA), estimates that the number of people who are injured in an alcohol related MVA is 25-40% of all accidents, or roughly 438,000 crashes per year (this may be an underestimation due to nonreporting either by or to law enforcement).  The economic estimates of these crashes cost the US public over $110 billion in 1998 (>$40 billion in monetary costs and an estimated $70 billion in loss in quality of life.) (NHSTA website)


The United States workforce also bears a major burden of substance abuse.  Although the rate of substance abuse among the unemployed is higher than among the employed, the vast majority of substance abusers (77%) work.  (National Household survey of drug abuse).  Among full-time workers, it is estimated that 6.5% are current illicit drug users, (>8.5% of part-time workers).  The impact from this substance abuse is on both the employer, and fellow employees.  Costs can be direct (lost days at work, accidents, errors) and indirect (illness rates, employee morale).  The monetary impact is large, at approximately $81 billion in lost productivity per year. (USDHHS)


The costs of substance abuse to the U.S. economy in general are also very large.  The federal government has waged a widely publicized “war on drugs” since the mid-1980’s.  Spending to finance this war has steadily increased since 1988, to an estimated $19.2 billion in 2000.  States governments are estimated to provide an additional $40 billion each year on anti-drug policies. 


To the extent that the use of many substances is illegal, the trafficking, sale, and use of many drugs also have a huge impact on the criminal justice system.  The average cost per prison inmate per year to taxpayers is approximately $20,000.  For the year 2000, 1.375 million adults were arrested for “drug abuse violations” and an additional 203,000 juveniles were likewise arrested.  Among state prisons 57% of inmates admitted to using drugs in the month prior to their arrest (45% among federal prisoners) in 1997.  For use anytime in life these numbers were 83% and 73% respectively.  These statistics represent a significant increase from a 1991 survey by the Department of Justice, Bureau of Justice Statistics.  Strategies to combat these rising numbers of incarcerated who are involved in substance abuse are wide ranging.  For instance in 2000, California Proposition 36 or the Substance Abuse Crime Prevention Act (SACPA) was passed by 61% of voters.  Under this law, “low-level” and non-violent drug offenders convicted of possession solely for personal use are diverted into community based treatment programs rather than incarceration.  The program is still too new to determine success or failure, however in seven California counties, over 9,500 persons who would have been otherwise incarcerated, have been referred to treatment.  The economic justification for this program is that while a year in prison costs taxpayers approximately $20,000/year, certain non-violent first time users can be provided drug treatment and rehabilitation for approximately $5,000/year.  A similar program however has been in existence in Arizona since 1996 (Arizona proposition 200).  According to proponents of the program, Arizona taxpayers were saved $6.7 million dollars in 1999. (Drug Policy Alliance)


IV.       Treatment and Prevention of Substance Abuse


The two state programs mentioned above are good examples of changing attitudes toward substance abuse.  Rather than viewing this as a criminal and punishable activity, abuse is now being seen as a treatable condition, much the same as mental illness.  For the current substance abuser or substance addict, what are the prospects for rehabilitation and treatment?  Is the substance abuser doomed to a lifetime of relapse and recovery?  What are the different treatment options available and which one (s) work the best?


As knowledge of drug and substance addiction has increased, there has been less of an emphasis on substance abuse as a matter of personal choice or “lack of will power” on the part of the substance abuser. The reality of treatment and the medical model of substance abuse and addiction is that the substance abuser by and large cannot get drug free without assistance.  Also as addiction has been increasingly viewed as a medical condition, there has been less of an emphasis on a quick “cure”, and more on control of addiction much like a chronic disease.  The disease of addiction is multi-factorial, with roots in biology, physiology and behavior.  The most successful treatment programs address all of these factors.  The goal of substance abuse treatment is to help the individual reduce or stop substance abuse altogether.  The National Institute on Drug Abuse has pointed out several keys to successful substance abuse treatment:



-Treatment should be readily available to individuals who need it

-Individuals need to be engaged in treatment for an adequate period of time  Participation in outpatient or residential programs for less than 90 days is of limited or no effectiveness  Individuals should receive a minimum of 12 months of methadone maintenance treatment

-Treatment involves dynamic decision processes requiring a person to decide to stay sober on a daily basis.  Recovery often involves relapse and multiple episodes of treatment

-Addiction is often accompanied by many physical and mental health problems (so called dual or multiple diagnoses), and treatment must incorporate considerations of these other diagnoses.

-Treatment works best if tailored to the individual, i.e. there is no “one” right way to treat the substance abuser/addict.  Likewise it should be reassessed and adjusted as needed.


Links to the NIH/National Institute on Drug Abuse are provided in the bibliography.  Interested readers are strongly recommended to review these documents as many useful, evidence-based guidelines for effective substance abuse treatment are provided in these documents.


More important than treatment of the active substance abuser are effective strategies to prevent the initiation of substance abuse.  The above link to the National Institute on Drug Abuse also has many useful links regarding tested programs that are effective in preventing substance abuse.  These “Prevention Principles” include designer programs to enhance “protective factors” and eliminating or reducing “risk factors” for substance abuse.



Protective factors for substance abuse

Risk factors for substance abuse

Strong and positive bonds with a prosocial family

Chaotic home environments especially where parents are active substance abusers

Parental monitoring

Ineffective parenting

Clear rules of conduct that are consistently enforced

Lack of mutual attachment and nurturing

Involvement of parents in the lives of their children

Overly shy or aggressive behavior

Success in school performance

Failure in school performance

Strong bonds with other prosocial institutions

Poor social coping skills

Adoption of conventional social norms about drug abuse

Affiliations with deviant peers


Perceptions of approval of drug using behaviors in family, work, school etc




Clearly prevention of substance abuse is not as simple as teaching slogans such as “Just Say No”.  Instead the focus has to be on teaching life skills and on identification of “at risk” youth and targeting these individuals with programs designed to avoid the initiation of substance abuse.


Summary and conclusions


Substance abuse is not a condition that an individual willfully engages in..  Instead patterns of behavior, coexisting mental and physical health issues often lead into repetitive use, dependence and addiction over a gradual basis.  Over time and in the most severe cases, the securing of a steady source and the use of various addictive substances can overwhelm even the most rational minds.    Fortunately as time has passed and attitudes have slowly evolved, the negative label of drug addiction has somewhat worn off, and more effective treatment and prevention programs have been developed. However given the number of people who are injured every year due to the direct and indirect consequences of substance abuse, we as a nation clearly have a long way to go in terms of effective prevention and treatment strategies.


Substance abuse is clearly a tremendous problem and as previously stated this introductory chapter only introduces a framework for identifying some of the issues involved with substance abuse and addiction.  Substance abuse is certainly a topic with its roots in public health, from the epidemiology of spread of addiction among at risk populations to health care economics and health care policy.  The interested reader is strongly recommended to several of the selected references in the following section for further information and statistics about this huge and growing area of public health and public policy.


References and suggestions for further reading


American Lung Association.


Butterfield F; “As drug use drops in big cities, small towns confront upsurge”; NY Times, section A, page 1, column 1


Centers for Disease Control and Prevention    Links are available to specific information regarding HIV transmission, surveillance and efforts to limit the spread of HIV disease


Chung PH, Garfield CF, et al; “Youth Targeting by Tobacco Manufacturers since the Master Settlement Agreement”; Health Affairs, 21(3):  254-163, (2002).


Cook PJ, Moore MJ; “The Economics of Alcohol Abuse and Alcohol Control Policies”; Health Affairs, 21(3): 120-133, 2002.


Daro D, Mitchell L; “Child Abuse Fatalities continue to rise:  Results of the 1988 annual fifty state survey” (fact sheet #14) Chicago:  National Committee for Prevention of Child Abuse.


Des Jarlais DC, Marmor M, Friedmann P, et al; “HIV incidence among Injection Drug Users in New York City, 1992-1997:  Evidence for a Declining Epidemic”; American Journal of Public Health; 90(3) 352-359, 2000.


The Drug Policy Alliance, Substance Abuse and Crime Prevention Act of 2000, California Proposition 36.


Drug Policy Alliance; Substance Abuse and Crime Prevention Act of 2000, progress report; March 2002.


Goldstein, A; Addiction, from biology to drug policy; 1994, W.H. Freeman and company.


Grossman M, Chaloupka FJ, Shim K; “Illegal Drug use and Public Policy”, Health Affairs, 21 (3):  134-145, (2002)


Gruber J; “The Economics of Tobacco Regulation”; Health Affairs, 21(3):  146-162, (2002).


Kosterman R, Hawkins JD, Guo J, et al; “The Dynamics of Alcohol and Marijuana Initiation:  Patterns and Predictors of First Use in Adolescence”; American Journal of Public Health; 90(3) 360-366, 2000.


McCrady BS, Epstein EE, Addictions a comprehensive guidebook, ed McCrady BS, Epstein EE, Oxford University Press, New York, 1999


McEnery, R; “HIV diagnoses in Cleveland rise for 1st time since ‘96”; The Cleveland Plain Dealer, March 3, 2002, b1.


National Highway Traffic and Safety Administration. search alcohol and impaired driver.


National Household Drug Abuse Survey, statistics on drug use and abuse indexed by various subgroups (inner city vs. rural, age groups, etc). Office of Applied Statistics of the Substance Abuse and Mental Health Services Administration (SAMHSA) division of the U.S. department of Health and Human Services. link to the office of applied statistics.


National Institute on Alcohol Abuse and Alcoholism,


National Institute on Drug Abuse.  Principles of drug addiction treatment:  a research-based guide.  NIH Publication No. 99-4180.


“Substance Related Disorders” in Diagnostic and Statistical Manual of Psychiatry, 4th edition; Washington, DC  American Psychiatric Association


United States Department of Labor working partners, small business workplace kit.


United States Department of Justice, Bureau of Justice Statistics


United States Department of Health and Human Services, substance abuse and mental health services administration “substance abuse and mental health services sourcebook”.  1995.


Woody GE, Cacciola J; Diagnosis and Classification:  DSM-IV and ICD 10 in Substance Abuse a Comprehensive Textbook 3rd edition, Editors Lowinson, Ruiz, Millman and Langrod.  Williams and Wilkins.


Zubretsky, Theresa M. and Karla M. Digirolamo. 1996. "The False Connection Between Adult Domestic Violence and Alcohol." Helping Battered Women, 1st edition. Ed., Albert R. Roberts.