Preface to The Surgeon General’s Report on Alcohol, Drugs and Health

Before I assumed my position as U.S. Surgeon General, I stopped by the hospital where I had worked since my residency training to say goodbye to my colleagues. I wanted to thank them, especially the nurses, whose kindness and guidance had helped me on countless occasions. The nurses had one parting request for me. If you can only do one thing as Surgeon General, they said, “Please do something about the addiction crisis in America.”

I have not forgotten their words. As I have traveled across our extraordinary nation, meeting people struggling with substance use disorders and their families, I have come to appreciate even more deeply something I recognized through my own experience in patient care: that substance use disorders represent one of the most pressing public health crises of our time. Whether it is the rapid rise of prescription opioid addiction or the longstanding challenge of alcohol dependence, substance misuse and substance use disorders can—and do— prevent people from living healthy and productive lives. And, just as importantly, they have profound effects on families, friends, and entire communities.

I recognize there is no single solution. We need more policies and programs that increase access to proven treatment modalities. We need to invest more in expanding the scientific evidence base for prevention, treatment, and recovery. We also need a cultural shift in how we think about addiction. For far too long, too many in our country have viewed addiction as a moral failing. This unfortunate stigma has created an added burden of shame that has made people with substance use disorders less likely to come forward and seek help. It has also made it more challenging to marshal the necessary investments in prevention and treatment. We must help everyone see that addiction is not a character flaw – it is a chronic illness that we must approach with the same skill and compassion with which we approach heart disease, diabetes, and cancer.

I am proud to release The Surgeon General’s Report on Alcohol, Drugs, and Health. As the first ever Surgeon General’s Report on this important topic, this Report aims to shift the way our society thinks about substance misuse and substance use disorders while defining actions we can take to prevent and treat these conditions.

Over the past few decades, we have built a robust evidence base on this subject. We now know that there is a neurobiological basis for substance use disorders with potential for both recovery and recurrence. We have evidence-based interventions that prevent harmful substance use and related problems, particularly when started early. We also have proven interventions for treating substance use disorders, often involving a combination of medication, counseling, and social support. Additionally, we have learned that recovery has many pathways that should be tailored to fit the unique cultural values and psychological and behavioral health needs of each individual. As Surgeon General, I care deeply about the health and well-being of all who are affected by substance misuse and substance use disorders.

This Report offers a way forward through a public health approach that is firmly grounded in the best available science. Recognizing that we all have a role to play, the Report contains suggested actions that are intended for parents, families, educators, health care professionals, public policy makers, researchers, and all community members.

Above all, we can never forget that the faces of substance use disorders are real people. They are a beloved family member, a friend, a colleague, and ourselves. Despite the significant work that remains ahead of us, there are reasons to be hopeful. I find hope in the people I have met in recovery all across America who are now helping others with substance use disorders find their way. I draw strength from the communities I have visited that are coming together to work on prevention initiatives and to connect more people to treatment. And I am inspired by the countless family members who have lost loved ones to addiction and who have transformed their pain into a passion for helping others. These individuals and communities are rays of hope. It is now our collective duty to bring such light to all corners of our country.

How we respond to this crisis is a moral test for America. Are we a nation willing to take on an epidemic that is causing great human suffering and economic loss? Are we able to live up to that most fundamental obligation we have as human beings: to care for one another?

Fifty years ago, the landmark Surgeon General’s report on the dangers of smoking began a half century of work to end the tobacco epidemic and saved millions of lives. With The Surgeon General’s Report on Alcohol, Drugs, and Health, I am issuing a new call to action to end the public health crisis of addiction. Please join me in taking the actions outlined in this Report and in helping ensure that all Americans can lead healthy and fulfilling lives.

Vivek H. Murthy, M.D., M.B.A., Vice Admiral, U.S. Public Health Service, Surgeon General

To read The Surgeon General’s Report on Alcohol, Drugs, and Health click on the following link: https://addiction.surgeongeneral.gov/surgeon-generals-report.pdf

Youth in Crisis

Research tells a statistical horror story of what is happening every day in America regarding our youth. 1,000 unwed teenage girls become mothers. 1,106 teenage girls get an abortion. 4,219 teenagers contract a sexually transmitted disease. 500 adolescents begin using drugs. 1,000 adolescents begin drinking alcohol. 135,000 kids bring a gun or other weapon to school. 3,610 teens are assaulted, 80 of which are raped. 2,200 teens drop out of high school. 2,750 kids watch their parents separate or get a divorce. 90 kids are taken from their parents’ custody and placed in foster care, a group home, or institutional care. 7 kids age 10-19 are murdered. 7 juveniles age 17 and under are arrested for murder. 6 teens commit suicide. Every day!

Many of America’s 28 million teens face struggles and crises that most adults would find difficult to bear. For example, one in eight has an alcoholic parent. One in five lives in poverty. More than one in five (22%) live in single-parent homes. More than on in fifty live with no parent at all. Moreover, research and experience reveal that teens in evangelical churches are by no means immune to such problems. A survey of twenty-three national Christian youth leaders involved in denominational and parachurch ministries identified such issues as premarital sex, pornography, sexual abuse, emotional abuse, abortion, parental divorce, alcoholism, drug addiction, and suicide as issues faced by their kids – church youth, Christian youth. Issues those leaders consider both important and urgent for today’s youth and the adults who care for them.

Youth leaders helped identify the fifty most basic, pressing problems faced by adolescents today. Problems that range from emotional issues (like loneliness and depression) and relational issues (such as love, dating, and peer pressure) to sexual issues, abuse, addictions, and vocational issues (like finding God’s will and choosing a career or ministry).

The teen years are vital to establishing a strong foundation for adulthood. Problems such as addiction, mental illness, violence, pregnancy and suicidal thoughts are tough enough to face as adults. They are compounded in teens by emotional immaturity, lack of experience and judgment, impulsiveness, confusion, bullying, broken homes, academic pressures, and finding their place in society. Kids are quite vulnerable at this phase of their development. It is truly sinful that some adults prey on these vulnerabilities. What can be more evil than trafficking drugs to teens, taking advantage of their sexual curiosity, or manipulating them through playing on their emotions? Working with adolescents as an addictions counselor or mental health worker can be both frustrating and challenging, but it is some of the most vital work we can undertake as adults.

Drunkenness is a sin. The Bible is clear on this point. But once a person is an alcoholic, once he has allowed his will to be taken hostage by alcohol, he is sick. He can no longer help himself. To tell an alcoholic to shape up and stop drinking is like telling a man who has just jumped out of a nine-story building to fall only three floors. It just isn’t going to happen. If we define alcoholism as a physical disease, without including a spiritual dimension, we completely miss the fact that alcoholism affects a person physically, mentally and spirituality. An alcoholic will not get well unless he is treated on all three levels.

There is no single reason for teenagers to start using drugs and alcohol. They see their parents and other adults drinking alcohol, smoking, and, sometimes, abusing other substances. Also, the teen social scene often revolves around drinking and smoking pot. Sometimes friends urge one another to try a drink or smoke something, but it’s just as common for teens to start using a substance because it’s readily available. They see all their friends enjoying it. In their mind, they see drugs and alcohol as a part of the normal teenage experience.

Many factors influence whether an adolescent tries drugs, including the availability of drugs within their neighborhood or school, and whether their friends are using them. Family environment is also important. Exposure to violence, physical or emotional abuse, mental illness, or drug use in the household, increase the likelihood that an adolescent will use drugs. Also, an adolescent’s inherited genetic vulnerability, personality traits like poor impulse control or a high need for excitement, mental health conditions (such as depression, anxiety, or ADHD), and believing drugs are cool or harmless, make it more likely that an adolescent will use drugs.

Most teens do not escalate from trying drugs to developing an addiction or other substance use disorder, but even experimenting with drugs is a problem. Drug use can be part of a pattern of risky behavior, including unsafe sex, driving while intoxicated, or other hazardous, unsupervised activities. In cases when a teen does develop a pattern of repeated use of drugs or alcohol, it can pose serious social and health risks, including school failure, problems with family and other relationships, loss of interest in normal healthy activities, impaired memory, increased risk of contracting an infectious disease (like HIV or hepatitis C) via risky sexual behavior or sharing contaminated needles, mental health problems, and the the real risk of suffering a fatal overdose.

Unfortunately, teenagers who lack confidence report that they’ll do things under the influence of drugs or alcohol that they might not do otherwise. This is actually part of the appeal of drugs and alcohol; it gives the user courage to dance, or to kiss a girl they’re attracted to. Alcohol and other drugs tend not only to loosen inhibitions, they also alleviate social anxiety. Getting drunk or high with other teens makes you feel you have something in common with them. There is the mentality that if you do or say anything stupid, everyone will just think you had too many drinks or smoked too much weed.

The high produced by drugs represents a flooding of the brain’s reward circuits with much more dopamine than natural rewards generate. In fact, oxycodone is 20 to 30 times more potent than dopamine. This creates an especially strong drive to repeat the experience. The adolescent, already struggling with balancing impulse and self-control, is more likely to take drugs again without adequately considering the consequences. If the experience is repeated, the brain will reinforce neural links between pleasure and drug-taking, making the association stronger and stronger. Chronic drug use not only realigns the user’s priorities, but also may alter key brain areas necessary for judgment and self-control, thereby reducing the ability to control or stop getting high. This is why, despite popular belief, willpower alone is typically insufficient to overcome addiction. Drug use compromises the very part of the brain that make it possible to say no.

When substance use disorder occurs in adolescence, it affects key developmental and social transitions, and can interfere with normal brain maturation. These potentially lifelong consequences make addressing adolescent drug use an urgent matter. Chronic marijuana use in adolescence, for example, has been shown to lead to a loss of IQ that is not recovered even if the individual quits using in adulthood. Impaired memory or thinking ability and other problems caused by drug use can derail a young person’s social and educational development and hold him or her back in life. Persistent cannabis users show neuropsychological decline from childhood to midlife. Proceedings of the National Academy of Sciences of the United States of America Oct 2;109(40):E2657–E2664 (2012).

Adolescents are less likely than adults to feel they need help, and usually won’t seek treatment on their own. Given their shorter history of using drugs (as well as parental protection), adolescents may have experienced relatively few adverse consequences from their drug use; their incentive to change or engage in treatment may correspond to the number of such consequences they have experienced. Also, adolescents may have more difficulty than adults seeing their own behavior patterns (including causes and consequences of their actions) with enough detachment to tell they need help. Only 10 percent of 12- to 17-year-olds needing substance abuse treatment actually receive any services. When they do get treatment, it is often for different reasons than adults. By far, the largest proportion of adolescents who receive treatment are referred by the juvenile justice system. Given that adolescents with substance use problems often feel they do not need help, engaging young patients in treatment often requires special skills and patience.

When substance use disorders are identified and treated in adolescence, especially if they are mild or moderate, they frequently give way to abstinence from drugs with no further problems. Relapse is a possibility, and should not be seen as a sign that treatment failed. Rather, it should be seen as an occasion to engage in additional or different treatment modalities. Averting and detecting relapse involves cooperation by the adolescent, monitoring by parents and teachers, and follow-up through outpatient treatment providers. Although recovery programs are not a substitute for formal evidence-based treatment, they may help some adolescents maintain a positive and productive drug-free lifestyle that promotes meaningful and beneficial relationships and connections to family, peers, and the community both during and after treatment. Whatever services or programs are used, an adolescent’s path to recovery will be strengthened by support from family members, non-drug-using peers, the school, and others in his or her life.

This is truly a battle we must win. The future of our children depend on it. I feel both honored and challenged by the calling God has placed on my life to counsel teens and young adults who are struggling with addiction and mental illness. Rather than cry about how my life has turned out to this point as a result of nearly four decades of drug and alcohol abuse, I plan on focusing my attention and energy on helping teenagers avoid  a lifetime of substance abuse and the literally hundreds of complications that usually result. Please join me in praying for the young adults and their families being decimated by addiction.