This column will feature a series of focused overviews with practical suggestions for managing the manifold tricky needs of your patient population. This series started with a primer for addressing the sexual health questions of patients—paired with a healthy dose of required self-reflection (“Teach them to fish: Addressing the sexual health needs of patients and practice culture”). The series will continue with this dive into problematic substance use and next to coverage of other important but thorny issues including personality disorders, patient safety in the home (exposure to violence, abuse, or self-harm), cognitive impairment vis-à-vis medical decision-making, and the de-escalation of agitated, angry patients. There are other dozens of other difficult conversations, so please get in touch with suggestions.
DRUG AND ALCOHOL USE
Conversations about drug and alcohol use are complicated but overdue. Just last month, data from the 2018 National Survey on Drug Use and Health (NSDUH) were released. The NSDUH report is extrapolated from a survey of about 67,500 people from all 50 states and DC. The 2018 data reflect some positive trends including a decrease in new users of heroin and pain reliever misuse (Substance Abuse and Mental Health Services Administration, 2019). But there were also significant increases in daily marijuana use by young adults (18-25), especially among young pregnant women. Those same young people reported their marijuana use to be associated with opioid misuse, heavy alcohol use, and depression. Those risks are plain in the 2018 data, which show an increasing rate of serious mental illness, major depression, and suicidality in this age group (Substance Abuse and Mental Health Services Administration, 2019).
All told in 2018, 164.8 million people over the age of 12 (60.2%) reported using substances in the last month (i.e., tobacco, alcohol, or illicit drugs; Substance Abuse and Mental Health Services Administration, 2019). About 139.8 million Americans (age 12+) drank alcohol in the previous month, and 67.1 million of those respondents described themselves as binge drinkers. More than 2 million adolescents (1 in 11 of people ages 12 to 17) reported drinking alcohol in the past month, and half of them reported binge drinking. In total, there were 4.9 million alcohol users in 2018 (Substance Abuse and Mental Health Services Administration, 2019).
With respect to illicit drugs, about 20% of people (age 12+) reported using an illicit drug in the past year (which represents an increase from previous years) with marijuana users topping that chart; 16% of the respondents reported using marijuana in the previous year (Substance Abuse and Mental Health Services Administration, 2019). In addition, there were more than 3.1 million new marijuana users in the past year. Prescription pain reliever misuse was steady last year with 3.6% of the population (age 12+) reporting misuse in the past year, most (63.6%) with complaints of pain. Last year there were 1.9 million new misusers of prescription pain relievers, which is lower than in previous years (Substance Abuse and Mental Health Services Administration, 2019).
At the far other end of the substance use continuum, 20.3 million people (age 12+) met the criteria for substance or opiate use disorder (SUD/OUD) in the past year (Substance Abuse and Mental Health Services Administration, 2019). That includes 14.8 million with alcohol use disorder, 8.1 million people with illicit drug use disorder, 4.4 million people with marijuana use disorder and 2.0 million people with opioid use disorder, which is down from 2.1 million in 2017. Notably, of the 2 million people with OUD, only 400,000 were heroin users, and the remaining 1.7 million people were abusers of prescription pain relievers. All told last year, more than 21 million people reported the need for substance use treatment. That includes 1 in 26 adolescents, 1 in 7 young adults, and 1 in 14 adults (age 26+; Substance Abuse and Mental Health Services Administration, 2019).
Increases in the use of drugs and alcohol reflect accessibility, growing psychosocial vulnerability, and changing social norms; but the few important reductions, including the slight reduction in opiate users, can be attributed to better drug and alcohol screening and brief interventions in medical settings.
Next page: Identifying problematic substance use.