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Maia Szalavitz Maia Szalavitz

Ten Ways Addiction Is Different in America


Whether it's our drug use, our laws, or the treatment options we have on offer, the US frequently stands out. And that's not always something to celebrate.

27 Substance
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Photo via

Why is addiction so different in the U-S-A? Photo via

We Americans like to think of ourselves as exceptional, the land of the free and the home of the brave, the City on the Hill and all that. When it comes to the politics and culture of drugs, we are indeed special—or at least dramatically different from the rest of the Western world. Too often, however, we are special for the wrong reasons.

1. We Try More Drugs Than Anyone Else

Americans are more likely to try illegal drugs than anyone else in the world, according to global survey data from the World Health Organization.

42% of American adults have tried marijuana, for example, while only 20% of the Dutch have done so—despite the Netherlands’ long-running policy of tolerating sales and possession without criminal penalties. We’re also number one in terms of the percentage of our population that has tried cocaine (16%), with most European countries (including Holland) having averages around 1% to 2%. In Colombia—a major source country for the drug—only 4% of the population has taken cocaine.

In terms of lifetime tobacco use—coming in at 74%—we’re also a serious outlier: In most of Europe, only around half the population tries smoking or other tobacco products.

Not surprisingly, we’re also number one in terms of annual prescription painkiller misuse—with 5.1% of the population reporting taking such drugs for nonmedical reasons, compared to 1% in Canada and 3% in Australia.

But we’re lagging behind on illegal opiate use, which includes drugs like heroin and opium. According to this year’s World Drug Report from the UN, in the Middle East and Southwest Asia, 1.25% of the population has taken these drugs at least once in the past year. In the US and Canada, that number is less than 0.5%. Clearly, we have some work to do!

2. We Incarcerate More People Than Anyone Else

The US prisoners for Drug use

The US is the world’s biggest jailer of drug users. Photo via Shutterstock.

Sadly, we’re not in any threat of losing our dominance in incarceration any time soon, at least in terms of the raw number of prisoners we hold. Some 2.2 million Americans are locked up at any given time—compared to a mere 676,000 in Russia and 385,000 in India.

17% of state prisoners and half of all federal prisoners are incarcerated for drug crimes—and this doesn’t count the percentage who committed other crimes linked to addiction problems, which is far higher.

Per capita, the tiny island nation of the Seychelles has matched our rate of 707 prisoners per 100,000 members of the population—but we are still far ahead of slackers like the UK, at 149, and the Netherlands, at 75.

Ya think that maybe incarceration isn’t a good way to stop drug use?

3. We Use More Opioids Medically (But Not for the Reasons You Might Think)

America is actually number two in terms of per capita consumption of opioid pain medication (measured by dose equivalence between the various opioids)—contrary to recent CDC claims citing old data; these days Canada wears the crown. Canadians take 812 mg of morphine equivalents per capita, compared to 748 for the US. Other high-consuming countries include Denmark and Australia.

But high per capita consumption for pain treatment doesn’t automatically translate into high rates of misuse and addiction. Canada has an annual prevalence of prescription opioid misuse of 1%; the rate for the US, as noted above, is just over five times that, despite our lower levels of medical use.

Another important fact to note about our elevated levels of medical opioid use is that it comes in the context of extremely low levels of use in the rest of the world. Around two-thirds of the world’s population live in countries where even if you are dying of cancer, strong opioids are basically unavailable. Only 7% of the global population is believed to have adequate access to appropriate pain relief, according to the World Health Organization. Compare that to the US, which has only 5% of the world’s population but consumes 80% of its opioids.We surely overprescribe in some cases—but everyone else’s cruel under-prescribing needs to be taken into account, too.

4. We’re in the Middle of the Road on Alcohol

America’s multicultural society means that we aren’t as extreme on alcohol as you might expect. Sociologists who have compared drinking patterns cross-culturally tend to find two broad patterns. The first is a “Northern” style of drinking where alcohol is seen as an intoxicant and heavy drinking is associated with masculinity and tends to take place in bars. Binging is the standard pattern of use here; daily drinking is seen as a sign of alcoholism. Countries with this pattern include the UK, Ireland, Russia and the Scandinavian ones.

In contrast, “Southern”–style drinking cultures see alcohol as a food, and drinking takes place daily with meals and is associated with family. Celebrations can include excess consumption, but drunkenness, not daily drinking, is seen as aberrant. This style has historically been associated with reduced harm in terms of violence, accidents and alcoholism (but not always cirrhosis). France and Italy are the exemplars here.

The US is primarily a Northern drinking culture, but it is not at the extreme end. Russia, for example, consumes 15 liters of alcohol per capita and has a 9% alcoholism rate (based on the DSM IV diagnosis). Americans, however, consume only 9.2 liters per capita and have a past-year alcoholism rate of 4.7%. Contrast this with Italy, where a mere 6.7 liters per capita are consumed and alcoholism affects only 0.5% of the population annually.

5. We Have the World’s Highest Legal Drinking Age

Although Kazakhstan, Japan, Iceland and several other countries also have a legal age of 21, most countries that set a legal drinking age choose 18.

Advocates of America’s high drinking age have argued that it has reduced accident deaths and high school binge drinking, which, contrary to media headlines, has actually declined substantially since the early 1980s. In 1983, 41% of 12th graders reported having had five or more drinks on one occasion in the past two weeks; the number for 2013 was 22%, a drop of nearly half. Drunk driving deaths have also plummeted, falling from some 21,000 in 1983 to around 10,000 in 2013.

But it’s not clear that the actual drinking age is the main factor here. Canada, with a drinking age of 19, has seen the same kind of declines and now has fewer lives lost to drunk driving in an age-adjusted measure, when compared to the US, 11.0 for them to 19 for us.

Reduction in drunk driving deaths may have had more to do with setting a uniform national drinking age so that people don’t drive to states with a lower drinking age to get drunk—rather than the age itself.

If a higher drinking age actually did prompt drinkers to begin boozing at later ages, it might reduce alcoholism risk, which increases with younger ages of initiation. It’s not clear that 21 age limits do so, however—and younger ages of initiation are also linked with things like growing up in an alcoholic family, which can independently affect risk, so postponing initiation might not help that much.

6. Our Treatment System Is Dominated by 12-Step Programs

95% of American addiction treatment programs refer patients to 12-step meetings as a matter of course and 90% base a good portion of their treatment on 12-step principles. Fundamental to treatment in this system is the idea that complete abstinence from all “mind and mood altering” substances is the basis of recovery, though some programs are changing to allow maintenance drugs like Suboxone to be seen as part of recovery. People who recover on their own are viewed with skepticism (possibly as “dry drunks”) and the idea that one can stay sober without meeting attendance is seen as “denial.”

This is not the case in many other countries, where treatment, particularly for alcohol, is more varied and can include attempts at moderation. In the UK, for example, the majority of treatment for alcohol problems consists of talk therapies like cognitive behavioral therapy.

7. Coercion Is a Common Route to Treatment

The majority of addiction treatment in the US is now outpatient—and 49% of all patients in these programs are referred to them (typically as an alternative to incarceration) by the criminal justice system. In long-term residential treatment, criminal justice referrals are also the main source of patients, accounting for 36% of all participants. 29% of residents in long-term treatment make the choice for themselves, while the rest are primarily referred by other treatment or healthcare providers.

It is not clear how this percentage compares to that seen in the rest of the world, although the US does arrest far more people for drug crimes than other countries do, so it is likely that this proportion is higher.

8. We Spend the Most Money on Addiction Research

The National Institute on Drug Abuse is the world’s largest funder of research on psychoactive drugs and addiction. In fiscal year 2012, its budget was $1.05 billion. But that’s not the only major federal funder of addiction research in the US: We have another two national institute that covers addiction, the National Institute on Alcoholism and Alcohol Abuse, whose 2012 budget was $459 million.

So we spend nearly $1.5 billion a year, mainly on basic neuroscience research that, while generating enormous value in terms of understanding fundamental brain systems, has not yet generated much that is of direct use in treatment.

9. We Determine What Is and What Isn’t Legal Worldwide (But for No Rational Reason)

Ever wonder why marijuana is illegal but alcohol and tobacco are legal? It has nothing to do with the relative risks of the drugs—both legal drugs kill and addict larger proportions of their users than the illegal one does.

So why was marijuana prohibition retained while alcohol prohibition was ended? And why, for that matter, are heroin, MDMA, cocaine and LSD illegal? Drugs are made illegal based on who is perceived to take them and on racial politics—science is rarely considered in these decisions.

If a drug’s perceived primary users are not white, the drug tends to be banned—and stay that way. The US and Europe have legalized their own preferred drugs and banned those of all other nations—and those perceived as “corrupters of youth”—for the past century.

However, that may be changing. Since Colorado and Washington state have legalized marijuana, the US can no longer impose international prohibition with the vehemence it previously exhibited. With the world conventions governing the legality of drugs up for review at the UN next year, changes that would allow countries to experiment with a wider range of drug policies are more likely than ever before.

10. We’re Not Very Good at Measuring Addiction

I was going to conclude by comparing rates of addiction to various drugs in the US and other countries and how they’ve changed over time. However, while we’re pretty decent at tracking the percentage of people who try and who use drugs, we don’t look very hard at the proportion who actually develop the most serious problems with their drug use. Nor do we look too closely at cross-addiction, such as what percentage of those we’ve labeled as having cocaine addiction are also addicted to heroin or alcohol (and vice versa).

This may be because the rates of problem use are actually quite low compared to the rate of overall use, which is an inconvenient truth for drug warriors.

To be fair, it’s also somewhat hard to measure: Addicted people can be hard to find and survey accurately because of stigma and also because definitions of addiction have changed over time and are culturally sensitive. For example, if one country arrests a large proportion of drug users while another doesn’t, the group in the harsher country may have greater “addiction” rates because there are more negative consequences associated with their drug use—but that doesn’t mean the drug is causing those problems.

Nonetheless, here are the statistics I could find. New Zealand has the world’s highest rate of marijuana addiction, with 9% of its population meeting “cannabis dependence” criteria under DSM IV, at least as measured in 2000. Canada and the UK come in second, with 3% annual dependence rates for cannabis, measured in 2000 and 2007 respectively. The US rate is 1%—or was in 2007.

Iran is the record holder for opioid addiction, with a whopping 8.8% of its population having an addiction in the past year as of 2003. The current US rate for opioids is between 0.2% and 0.7%, depending on if you include prescription drug dependence or just heroin and depending on where on the scale of severity, based on DSM IV, you define the diagnosis.

We beat Iran on cocaine addiction, however, with 0.5% annual prevalence compared to their .07%. But meaningfulness of these comparisons and the accuracy of these statistics is dubious, given that they were collected in different years and include somewhat different population age ranges.

If you want to count the percentage of Americans overall with some type of substance problem, including alcohol, the latest figures from the National Institute on Drug Abuse show a rate of 9% in the past year, including both abuse and dependence. But good luck finding genuinely comparable international statistics!

What we can say for sure is that there’s no relationship between the harshness of a country’s drug policy and its rate of addiction—or if there is one, it may be inverse. Iran, for example, with its enormously high opioid addiction rate, executes people for drug crimes—and the US holds the world’s record on both the rate of many types of drug use and on incarceration of users.

As we celebrate the Fourth of July and our much-ballyhooed love of freedom and family, we should pause for a moment to reconsider our role both as the world’s largest jailer—and as the country in which children are most likely to try illegal drugs.

Maia Szalavitz is one of the nation’s leading neuroscience and addiction journalists, and a columnist at Substance.com. She has contributed to TimeThe New York TimesScientific American MindThe Washington Post and many other publications. She has also published five books, including Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids (Riverhead, 2006), and is currently finishing her sixth, Unbroken Brain, which examines why seeing addiction as a developmental or learning disorder can help us better understand, prevent and treat it. Her last column for Substance.com was about why the  media’s “new face of heroin” is not new but only newly (and finally) acknowledged.