New Standards from the American College of Physicians: Health and Public Policy to Facilitate Effective Prevention and Treatment of Substance Use Disorders Involving Illicit and Prescription Drugs: An American College of Phy

Substance use disorders pose a heavy societal burden, endangering individual and family health and well-being, tearing through communities, and sapping resources from the health care system. These disorders are common in the general population and occur at even higher rates among those who are incarcerated. Access to care for this condition is limited. In 2014, 22.5 million people in the United States needed treatment for an illicit drug or alcohol use problem but only 18% received any treatment, far below treatment receipt rates for those with hypertension (77%), diabetes (73%), or major depression (71%) (1).

The use of illicit drugs is a drain on the nation's financial resources. In 2007, the indirect and direct cost of illicit drug use was estimated to be about $200 billion related to lost productivity, health care, and law enforcement ($11 billion annually) (2). The medical complications of untreated substance use disorder also drive health care system costs. Hospitalizations for opioid use disorder rose from nearly 302 000 to more than 520 000 from 2002 to 2012, and costs for such care quadrupled to $15 billion in 2012. Charges for hospitalization for opioid use disorder with serious infections also quadrupled over the same period to $700 million (3). Notably, evidence shows that for every dollar invested in drug prevention and treatment, the nation sees substantial savings (4, 5).

Over the past 40 years, many jurisdictions established rigid punishments for nonviolent drug offenses, including mandatory incarceration. However, there has been growing support for the idea that public policy should be reoriented to emphasize prevention and treatment of substance use disorders through public and individual health interventions rather than excessive reliance on criminalization and incarceration. One example of this shift is the promotion of specialized drug courts by federal, state, and local governments. Drug courts can offer the individual with substance use disorders a path to treatment rather than incarceration, in addition to supporting prevention and early intervention initiatives (6–8). The United Nations has called for a health-focused direction to the drug problem (9), and the public is also supportive of treatment rather than incarceration for drug users. According to a 2014 survey conducted by the Pew Research Center, 67% of Americans say that “the government should focus more on providing treatment for those who use illegal drugs such as heroin and cocaine” (10).

This document focuses on substance use disorders related to illicit drugs and misuse of prescription drugs, particularly opioids (Appendix). Although the American College of Physicians (ACP) recognizes that alcohol and tobacco use disorders are a serious public health problem, policies to address such issues are outside the scope of this paper. Recommendation 3 pertains to marijuana and recommendation 4 to opioids, whereas the other recommendations apply to all use disorders associated with illicit and prescription drugs. For purposes of this paper, the term “illicit drug” includes the following categories based on the National Survey on Drug Use and Health: marijuana (including hashish); cocaine (including crack cocaine); heroin; hallucinogens; inhalants; and the nonmedical use of prescription-type pain relievers, stimulants, and sedatives. Although many states have legalized or decriminalized use and sale of medical and/or recreational marijuana, it is categorized as an illicit drug for the purposes of this paper because its use and possession remain illegal under federal law and in many states. Furthermore, the paper offers public policy recommendations regarding the prevention and treatment of substance use disorders involving illicit and prescription drugs and not on the clinical aspect of preventing and treating these disorders.