Substance use costs the United States $600 billion each year in health care, lost productivity, and involvement with the criminal justice system, according to the National Association of State Alcohol and Drug Abuse Directors. It also causes massive human suffering — through car accidents, violent crimes linked to drugs, health problems and other ills.
Psychologists have, over the years, developed some effective interventions to reduce the toll of substance abuse. But improving those interventions, testing them and putting them into large-scale practice requires money from federal agencies, such as the National Institutes of Health and the Department of Veterans Affairs. As Congress is responsible for funding the federal research agencies, participants at the 2011 Science Leadership Conference, Oct. 22–24 in Washington, D.C., crafted messages to share with their own congressional delegations about why continued federal investment in psychological research is helping address many of the societal problems associated with substance abuse.
“Support for research on substance abuse is vital because the costs in human suffering and in financial outlays are too high to do anything else,” said Temple University psychology professor Nora Newcombe, PhD, chair of APA’s Board of Scientific Affairs.
But substance abuse research funding is in peril due to shrinking federal budgets. To emphasize the importance of such research to federal policymakers, APA’s Science Directorate convened almost 100 top scientists and students in Washington, D.C., to advocate for psychological science on Capitol Hill and attend two days of policy briefings by substance abuse researchers and policymakers. All told, the scientists conducted 150 meetings with members of Congress and their staff. Their message was twofold: substance-abuse research is critical to the nation’s well-being and Congress should not get involved in weighing the merits of specific studies.
“Peer review — not political review — is the gold standard for choosing the very best science to support with taxpayer money,” said Steven J. Breckler, PhD, APA’s executive director for science.
Fixing the funding slump
While the social and economic cost of substance abuse is rising, research budgets have been flat or contracting since 2007, said Patricia Kobor, of APA’s Science Government Relations Office. For fiscal year 2012, the Senate is considering a proposal that would decrease NIH’s budget by 0.6 percent from its $30.7 billion 2011 budget, while the House of Representatives is deliberating a 3.3 percent increase.
“The biomedical inflation rate for 2012 is 3 percent, so even with this increase, NIH wouldn’t get rich,” Kobor said.
The Department of Veterans Affairs is facing even tougher times. President Barack Obama has proposed a 12 percent, or $72 million, cut to its research program. The House passed a bill reinstating a portion of the funding cut by the president, and the Senate version would fully reinstate VA research support to its current level. The Department of Defense’s budget has not yet come under debate at this writing, but SciLC participants pre-emptively advocated for level funding of the DoD Peer Reviewed Medical Research Program, which funds research on a wide variety of topics, including mental health and substance-abuse issues, to improve the health and well-being of all military service members, veterans and beneficiaries.
Challenges to the DoD, VA and NIH’s research budgets are often motivated by the belief that the three agencies conduct redundant studies, said Heather Kelly, PhD, of APA’s Science Government Relations Office. SciLC participants aimed to disabuse legislators of that misconception. For instance, NIH funds research on the brain-mechanisms of addiction, the DoD develops substance abuse prevention strategies for military personnel, and the VA tries out new treatment programs for veterans. “Those three agencies work together collaboratively to leverage each [others’] expertise and focus. It’s not duplicative research, but complementary,” she said.
In order to provide background knowledge before the Hill visits, APA’s Science Directorate staff and invited researchers armed SciLC attendees with the latest information on the societal costs of substance abuse — and on how research could help reduce those costs and improve health and well-being.
Keith Humphreys, PhD, a psychologist and professor at the Stanford University School of Medicine who recently spent a year as a senior policy adviser at the White House Office of National Drug Control Policy, emphasized the need for scientists to deliver to policymakers clear, succinct messages about the importance of funding for research and evidence-based treatments.
“You need to have your ‘elevator speech’ ready,” he told attendees.
Henrick Harwood, director of research and program applications at the National Association of State Alcohol and Drug Abuse Directors, gave attendees an overview of the economic impact of substance abuse in the United States. That cost totals nearly $600 billion a year, which includes health-care expenses, productivity loss from sickness, premature death and many other factors. The costs are about evenly split among alcohol, tobacco and illegal drug use — alcohol misuse costs the United States $224 billion each year, smoking costs $193 billion and drug abuse costs $181 billion, Harwood said.
It’s easier to grasp the meaning of those massive numbers when you break them down per user, as Harwood did. The cost to the United States per alcohol “misuser” is $3,700 and $12,800 for every dependent/ abuser, he said. The cost per illicit drug “misuser” is $8,200 and $26,000 per dependent/abuser. And the cost per smoker is $3,100, it’s $5,400 per dependent smoker.
“These things are massive in their impact,” Harwood said, adding that the overall costs are equivalent to those of other, more publicized chronic illnesses like obesity, Alzheimer’s disease and cardiovascular disease.
Of course, some of the costs — for treatment programs and lost productivity, for example — are borne directly by substance abusers and their families. But the government shoulders nearly half that burden, Harwood has found, through disability payments, the court system and other costs. For alcohol, he’s estimated drinkers and their families pay about 41 percent of the costs directly, and the government pays about 42 percent. Insurance pays 8 percent, the rest is borne by victims and others. For drug abuse, the government’s share is even higher — 46 percent. Drug users and their families pay 44 percent, and insurance 3 percent.
The substance abuse burden is particularly high among some vulnerable populations, such as prison inmates and members of the military, experts told SciLC attendees. In the military, smoking and illicit drug use declined dramatically from 1980 to 2008, but binge drinking and heavy alcohol use remain substantial problems, according to conference speaker Robert Bray, PhD, a senior research psychologist at RTI International who has led nine Department of Defense surveys of health behaviors among active duty personnel.
Despite some improvements, he said, much work remains to be done. About one third of service members still smoke cigarettes, prescription drug abuse is an emerging problem and more than 40 percent of military personnel are binge drinkers. The most recent survey found that military members are more likely to be binge drinkers and heavy drinkers than civilians are, in every age group except people older than 46. The military needs more research funding to better understand the risk and protective factors for substance abuse among the troops and to test promising interventions, Bray said.
Prison inmates are another vulnerable group, Kevin Knight, PhD, of Texas Christian University, told attendees. Knight studies drug treatment programs for prison inmates. About one in 100 U.S. adults is behind bars, he said, and “crime and drug use go hand in hand.” About 70 percent of state prison inmates and 64 percent of federal prisoners are regular drug users when they come into prison; 95 percent relapse to drug use within three years of their release, and many end up re-arrested — in an ever-increasing loop of costs to society.
But research shows that effective drug treatment programs in the correctional system that are tailored to treating offenders — such as therapeutic communities and cognitive behavioral therapy — can help break that cycle, Knight said.
The key is to convince legislators to fund those treatments, rather than simply putting money toward building more prisons.
To do that, psychologists and other researchers will have to convince legislators that substance abuse interventions in prisons and elsewhere are not only effective, but cost-effective, according to Rosalie Pacula, PhD.
“Research into cost-effectiveness should drive policymakers,” said Pacula, a senior economist at the RAND Drug Policy Research Center. Pacula presented a “microsimulation” model that she and her RAND colleagues have been working on, which aims to more accurately estimate both the costs of drug use to society and the potential benefits of different interventions. The model considers the fact that drug and alcohol abuse are “dynamic” problems — a person who is arrested, for example, might have trouble finding a job later, which could affect his likelihood of relapse.
Using the model, Pacula and her colleagues found that devising an intervention that could convince kids who were likely to use marijuana to delay that use until age 14 (instead of age 12) could be more cost-effective than working to increase the effectiveness of a marijuana treatment program from 30 percent to 50 percent.
Such research would allow researchers to tell policymakers, “this is the right thing to be doing with your limited dollars,” Pacula said.
Protecting peer review
All too often, legislators criticize studies they see as frivolous — even when they have passed the rigorous scientific peer review process, said Karen Studwell, JD, senior legislative and federal affairs officer in APA’s Science Directorate. Looking to get headlines about saving taxpayers’ money, legislators tend to target substance abuse and sexuality research, she said.
“It used to be people said these studies had no scientific merit. Now you hear people say, ‘It’s just not a priority,’” she said.
Most recently, Rep. Darrel Issa (R-Calif.) proposed an amendment to rescind NIH funding for four studies, including two run by psychologists. One study was criticized because it investigated students’ malt liquor and marijuana use. The study used its $389,357 in federal funding in part to have students call in and report their previous 24 hours of substance use. That’s important research because more targeted prevention and intervention strategies are needed for young adults living in low-income urban communities who may combine alcohol and marijuana, increasing their risk of addiction, Studwell said.
The other study under attack found that giving rats a synthetic cannabinoid enhanced the effect of morphine the next day. Such research could lead to better treatments for the more than 50 million Americans who suffer from chronic pain, Studwell said. While the amendment was ultimately withdrawn and none of the projects lost their funding, Congress continues to question funding priorities across the federal government as it seeks to constrain government spending. To defend against future attacks on research funding, SciLC attendees explained how the peer-review process works to legislators and their staff. They emphasized that at most agencies, two different review boards vet proposals for their scientific merit and fit with the mission of the agency. “As you know, this isn’t just a case of people giving out money to their friends,” Studwell said.