Under the Influence: Impact of Alcohol & Substance Abuse on the Safety Net

1. Under the Influence:Impact of Alcohol & Substance Abuse on the Safety Net Texas Initiative Program Success and Sustainability (TIPSS) Conference June 14, 2010 Ron J. Anderson,MD, MACP President & CEO—Parkland Health & Hospital System—Dallas, Texas

2. Long-recognized Problem From Emergency Medicine Annual, 1984. Volume III, pps 1-36

3. Alcohol & Substance Abuse Numbers Have Stayed Steady • Relatively unchanged since 2002 (Changes in survey make comparison to earlier years difficult). • 2007 National Survey on Drug Use and Health (NSDUH): National Findings for Americans 12 years and older    • 19.9 million (8%)  used an illicit drug, • 70.9 million (28.6%) used a tobacco product, and • 126.8 million (51.1%) used alcohol Source: http://oas.samhsa.gov/nsduh/2k7nsduh/2k7Results.pdf Accessed 6/8/2010.

4. Drug and Alcohol Use in Texas • National Survey of Drug Use and Health: • Illicit drug use • 2006-2007: 6.4% of the Texas population age 12 and older had used an illicit drug in the past month, which is below the national average of 8.0%. 2.7 percent of Texans were dependent on or abused an illicit drug in the past year, as compared to 2.8% nationally • 2004–2006: 6.5 percent of the population age 12 and older in the Dallas metropolitan area and 6.2 percent in the Houston area had used any illicit drug. • Alcohol is the primary drug of abuse in Texas. • 2008: 63% of Texas secondary school students (grades 7–12) had used alcohol, and 30% had drunk alcohol in the last month. • Lifetime use decreased by 5% and past-month use decreased by 3% between 2006 and 2008. • Of particular concern is heavy consumption of alcohol, or binge drinking, which is defined as drinking five or more drinks at one time. In 2008, 12% of all secondary students said that when they drank, they usually drank five or more beers at one time, and 13% reported binge drinking of liquor, which has remained relatively stable since 1992 Source: Texas Department of State Health Services. Substance Abuse Trends in Texas June 2009. http://www.utexas.edu/research/cswr/gcattc/documents/Texas2009_002.pdf Accessed 6/9/2010.

5. Alcohol & Substance Abuse Related Deaths in Dallas County, 2002 Source: Texas Department of State Health Services. http://www.tcada.state.tx.us/research/statistics/deaths01.php Data after 2002 is not available online. A special request from the statistics group is required.

6. Alcohol & Substance Abuse Costs Are Difficult to Calculate • Two important problems: • Establishing causation to differentiate between costs caused by, not just associated with, drug abuse • Many costs can’t be measured directly, i.e., lost productivity, pain and suffering • Among national estimates of the costs of illness for 33 diseases and conditions: • Alcohol ranked 2nd • Tobacco ranked 6th • Drug disorders ranked 7th Sources: About.com. Estimating the Economic of Alcoholism. http://alcoholism.about.com/cs/alerts/l/ blnaa11.htm Accessed 6/9/2010. and SAMHSA CSAP Substance Abuse Prevention Dollars and Cents: A Cost-Benefit Analysis. http://download.ncadi.samhsa.gov/prevline/pdfs/SMA07-4298.pdf Accessed 6/9/2010.

7. Everyone Agrees the Expenses Are Staggering • Estimates of the total costs of substance abuse in the US—including health- and crime-related costs and losses in productivity—exceed 500 billion dollars annually. • $181 billion for illicit drugs • $168 billion for tobacco • $185 billion for alcohol • Numbers do not fully describe the breadth of deleterious public health and safety implications: • Family disintegration • Loss of employment • Failure in school • Domestic violence • Child abuse • Etc. Sources: National Institute on Drug Abuse. NIDA InfoFacts: Understanding Drug Abuse and Addiction. http://www.drugabuse.gov/infofacts/understand.html Accessed 6/9//2010.

8. Alcohol and Drugs Played a Significant Role Healthcare in 2006 • Short-stay hospital discharges • 430,000 people had first-listed alcohol diagnoses • An additional 1,718,000 had an alcohol diagnosis not listed first • Emergency Department visits • 1.9 million (about 1.6% of total) associated with alcohol and/or drug use • Hospital admissions for psychiatric and general medical reasons higher for those with diagnoses of substance use disorders • Compared with others with behavioral health disorders, individuals with diagnoses of substance use disorders had significantly higher expenditures for physical health problems Source: National Institute on Alcohol Abuse and Alcoholism. Alcohol-related Short-stay Hospital Discharges. http://www.niaaa.nih.gov/Resources/DatabaseResources/QuickFacts/HospitalDischarges/default.htm Accessed 6/9/2010, SAMHSA. Drug Abuse Warning Network, 2007:National Estimates of Drug-Related Emergency Department Visits. https://dawninfo.samhsa.gov/files/ED2007/DAWN2k7ED.pdf Accessed 6/9/2010 and Clark, Samnaliev and McGovern. Impact of substance disorders on medical expenditures for medicaid beneficiaries with behavioral health disorders. Psychiatr Serv. 2009 Jan;60(1):35-42. http://www.ncbi.nlm.nih.gov/sites/pubmed Accessed 6/9/2010.

9. Emergency Department 2,594 encounters 2.7% of all ED encounters Inpatients 2,380 encounters 4.3% of all admissions Parkland Patients with Alcohol Diagnoses-- 10/1/2008-9/30/2009 All Alcohol Diagnostic Codes Selected Alcohol Diagnostic Codes alcohol withdrawal delirium; non-dependent abuse of drugs; liver disease & cirrhosis • Emergency Department • 2,217 encounters • 85.5% of all ED patients with alcohol diagnoses (2,594) • Payment shortfall = $1,208,914 • Inpatients • 385 encounters • 16.2% of all admissions with alcohol diagnoses (2,380) • Payment shortfall = $3,260,713 Source: Parkland Health & Hospital internal data.

10. Alcohol’s Impact on Trauma Is Huge and Under-reported • Alcohol-related car crashes are the #1 killer of teens. Homicide and suicide, the 2nd, and 3rd leading causes of death among teens have also been linked to alcohol consumption.1 • Alcohol is associated with: • 40 to 50 percent of traffic fatalities; • 25 to 35 percent of nonfatal motor vehicle injuries; • up to 64 percent of fires and burns; • 48 percent of hypothermia and frostbite cases; and • about 20 percent of completed suicides.2 • These numbers likely represent the tip of a much larger iceberg because they: • Do not include non-intoxicated victims involved in car crashes, assaults etc. • Miss people who are under the influence but do not present with obvious symptoms of intoxication 1 Marin Institute. Health Care Costs of Alcohol. http://www.marininstitute.org/alcohol_policy/health_care_ costs.htm Accessed 6/9/2010. 2Lowenfels, A., and Miller, T. Alcohol and Trauma. Ann Emerg Med 13:1056-1060, 1984.

11. Alcohol’s Impact on Trauma Recidivism • Survivors of car crashes and other injury events who test positive for alcohol or drug use are more than 2 times as likely to die in just a few years from a subsequent injury under similar circumstances as those who do not test positive.1 • Trauma patients who were intoxicated on 1st admission were 2.5-fold as likely to be readmitted than those not intoxicated.2 • Risk of alcohol-impaired driving recidivism among first offenders more closely resembles that of second offenders than that of non-offenders. Any alcohol-related driving violation—not just convictions—is a marker for future recidivism 3 1http://alcoholism.about.com/library/blsap0111119htm?terms=trauma=centers 2http://jama.ama-assn.org/cgi/content/abstract/270/16/1962 3 Rauch, et. al. Risk of Alcohol-Impaired Driving Recidivism Among First Offenders and Multiple Offenders. Am. J. Pub. Health: V 100_5, May 2010.

12. Parkland’s Trauma-Related Admissions with Positive Alcohol Levels, 2008 & 2009 Parkland’s Trauma-Related Admissions with Positive Alcohol Levels, 2008 and 2009 These figures are substantially low because many patients are not tested, and many patients are kept overnight because they are too drunk to leave but are not admitted. Sources: Tammy Morgan, Trauma Registry; Sue Pickens, Population Medicine

13. Parkland’s Trauma Volume Is Twice National Average Source: PHHS Trauma Registry, CY 2006 & National Trauma Data Bank, Report 2007 National Average is a 5 year average 2002-2006

14. Why Intervention Is Important • Trauma Centers can be effective intervention sites because the occasion of an alcohol- or drug-related injury produces a “teachable moment” when the patient is more open to hearing information about treatment options.1 • Sommers, et. al. did interviews with binge drinkers hospitalized as a result of alcohol-related car crashes and found for almost 60% of those admitted that alcohol had played a role in the crash.2 • Gentilello, et. al. showed a 47% reduction in injuries requiring ER or Trauma admission after a year in a group of BAC+ patients who received a brief alcohol intervention, compared to a control group.3 1http://www.jointogether.org/news/features/2002/arcane-laws-hinder-er-for.html?print=t 2Sommers, et. al. 2000, American Journal of Critical Care 3Gentilello, et. al. 1999. Annals of Surgery. 230:4 473-483

15. Why Intervention Is Cost Effective • Gentilello, et. al., found that a brief alcohol intervention reduced recidivism and therefore costs: “The benefit in reduced health expenditures resulted in saving of $3.81 for every $1 spent on screening and intervention…If interventions were routinely offered to eligible injured adult patients nationwide, the potential net savings could approach $1.8 billion a year.” Gentilello, et. al. 2005. Annals of Surgery 241:541-550

16. Why Intervention Is Not Common • Lack of knowledge among trauma physicians • A 1999 study by Danielsson, et. al. listed reasons given by surveyed trauma surgeons for not screening: • Lack of time was most commonly cited reason • 76% were not familiar with commonly-used screening questionnaires • 83% reported they had no training in alcohol screening • 88% would be willing to devote time if shown that screening and intervention was effective1 1http://archsurg.ama-assn.org/cgi/content/abstract/134/5/564

17. Some Trauma Centers Must Screen But Mechanism Is Not Mandated • American College of Surgeons-Committee on Trauma requires that: • Level I and Level II trauma centers have a mechanism to identify problem drinkers • Level I centers have the capability to provide brief interventions for screen-positive patients • Level I and II trauma centers represent only 34% of all trauma centers in the US • Parkland began a screening and referral program before the ACS-COT requirement was announced Source: AAMHSA. SBI in Trauma Centers. http://sbirt.samhsa.gov/trauma.htm Accessed 6.11.2010, 2009 National Trauma Data Bank Annual Report, http://www.facs.org/trauma/ntdb/ntdbannualreport2009.pdf. Accessed 6/11/2010, and intenal data from Parkland Health & Hospital System.

18. Screening Is Still Less Common than Is Desirable • 35% of trauma victims screened for alcohol; 13.9% positive • 22% screened for drugs; 11% positive • 28% and 33% respectively were listed as NK/NR; if the trend among tested victims held for this group several thousand more people would have been found to be impaired Source: 2009 National Trauma Data Bank Annual Report, based on 627,644 2008 admissions from 567 facilities. http://www.facs.org/trauma/ntdb/ntdbannualreport2009.pdf. Accessed 6/11/2010.

19. Economic Barriers to Screening • A decades-old law, the Uniform Accident and Sickness Policy Provision Law (UPPL) allows insurers to sell health and accident insurance policies that will not pay for injuries that occur while the insured person is under the influence of alcohol or drugs. • In a 2005 study, 24% of trauma surgeons reported an alcohol- or drug-related insurance denial in the past six months. • Over 50% don’t routinely measure blood alcohol concentration (BAC) even though 91% believe such testing is important. Sources: University of Texas School of Public Health. Screening, Brief Intervention and Referral to Treatment. http://www.sph.uth.tmc.edu/uploadedFiles/Centers/IHP/SBIRT_Booklet%20Jan%202010.pdf Accessed 6/9/2010. Genitlello, Donato, Nolan, Mackin, Liebich, Hoyt and LaBrie. Effect of the Uniform Accident and Sickness Policy Provision Law on Alcohol Screening and Intervention in Trauma Centers. J Trauma. 2005;59:642-631). Accessed 6/92010.

20. Uniform Policy Provision Law Is Alive and Well in Over Half the States Distribution of Insurers' Liability for Health/Sickness Losses Due to Intoxication ("UPPL"), January 1, 1998 through January 1, 2009 Source: Alcohol Policy Information System. Accessed 6/4/2010. http://www.alcoholpolicy.niaaa.nih.gov/Insurers_Liability_for_Losses_Due_to_Intoxication_UPPL.html

21. Texas Is Among 28 States Allowing Denial of Benefits Insurers' Liability for Health/Sickness Losses Due to Intoxication ("UPPL") as of January 1, 2009 Source: Alcohol Policy Information System. Accessed 6/4/2010. http://www.alcoholpolicy.niaaa.nih.gov/Insurers_Liability_for_Losses_Due_to_Intoxication_UPPL.html?tab=maps

22. UPPL Laws and Parity Laws • UPPL laws address whether an insurer can deny benefits to persons who are found to be intoxicated • Parity laws require that health plans—usually group plans offered by employers—provide the same levels of benefits for these disorders as they do for medical and surgical conditions. • Therefore, states can have a UPPL law that allows denial of benefits while also having a parity law that requires that benefits, if offered, must be the same Source: Alcohol Policy Information System. Accessed 6/4/2010. http://www.alcoholpolicy.niaaa.nih.gov/Health_Insurance_Parity_for_Alcohol-Related_Treatment.html?tab=Maps

23. Health Insurance Parity for Alcohol-Related Treatment Is Almost Stagnant Distribution of States with Health Insurance Mandates for Alcohol-Related Treatment, January 1, 2003 through January 1, 2009 • Must Offer: Health plans must offer an option of coverage for treatment of alcohol-related disorders, but are not required to cover unless offer is accepted. • Must Cover: Health plans must cover alcohol-related disorders. Source: Alcohol Policy Information System. Accessed 6/4/2010. http://www.alcoholpolicy.niaaa.nih.gov/Health_Insurance_Parity_for_Alcohol-Related_Treatment.html?tab=Maps

24. Texas Requires that Coverage Be Offered Health Insurance Mandates for Alcohol-Related Treatment as of January 1, 2009 • Must Offer: Health plans must offer an option of coverage for treatment of alcohol-related disorders, but are not required to cover unless offer is accepted. • Must Cover: Health plans must cover alcohol-related disorders. Source: Alcohol Policy Information System. Accessed 6/4/2010. http://www.alcoholpolicy.niaaa.nih.gov/Health_Insurance_Parity_for_Alcohol-Related_Treatment.html?tab=Maps

25. Removal of Barriers to Screening Won’t Solve Our Problems • While increased screening and intervention will reduce trauma recidivism and alcohol and drug use among some patients, those whose addictions require more long-term interventions may experience problems finding treatment, especially low-income individuals seeking in inpatient facilities

26. Many Need Treatment but Do Not Get It; Most Did Not Seek Treatment Treatment among Persons Aged 12 or Older Who Needed and Made an Effort to Get Treatment But Did Not Receive Treatment and Felt They Needed Treatment: 2005-2008 Combined • In 2008, 20.8 million people over age 12 (8.4% of that population) were classified by DSM-IV criteria as needing treatment for an alcohol or drug problem but did not receive it • 95.2% of these felt they did not need treatment • 3.7% felt they needed treatment but made no effort to seek it • 1.1 % sought treatment Source: SAMHSA Results from the 2008 National Survey on Drug Use and Health: National Findings. http://oas.samhsa.gov/nsduh/2k8nsduh/2k8Results.pdf Accessed 6/9/2010.

27. Alcohol and Substance Abuse Are Prevalent in Criminal Justice Populations • At some time in 2008: • 18.3%, or about 293,000, adults on parole or supervised release from prison were current illicit drug users • 23.9%, or about 1,243,000, adults on probation were current illicit drug users • Only 7.8% of the general population used illicit drugs • In a 2004 study: • 36% of state and 24% of federal prisoners reported committing their offenses under the influence of drugs • 56% of state and 50% of federal prisoners reported using illicit drugs in the month before committing their offenses Source: SAMHSA Results from the 2008 National Survey on Drug Use and Health: National Findings. http://oas.samhsa.gov/nsduh/2k8nsduh/2k8Results.pdf Accessed 6/9/2010.and Department of Justice. Drug Use and Dependence, State and Federal Prisoners, 2004. http://bjs.ojp.usdoj.gov/content/pub/pdf/dudsfp04.pdf Accessed 6/9/2010.

28. Parkland Is Responsible for Dallas County Jail Health • Dallas County Jail • 7th largest jail in U.S., booking about 275 people/day • Average daily census is around 6,000 • 74% of inmates are male • No reliable data on alcohol and drug use at arrest • 2nd largest mental health facility in Texas, Harris County Jail being the largest • Acute and chronic medical/psychiatric conditions screened within 1 hr • 50% at intake have acute or chronic medical/mental health conditions • 2600+ patients receive medications daily for both medical and mental health conditions • Average monthly admission to psychiatric services is 998 • Average daily mental health census is 20% or 1200+ patients Source: Parkland Health & Hospital System internal data.

29. Alcohol & Substance Abuse Data Is Better for Prisons, but Outcomes Are Not “if all inmates who needed treatment and aftercare received such services, the nation would break even in a year if just over 10% remained substance and crime free and employed. Thereafter, for each inmate who remained sober, employed and crime free the nation would reap an economic benefit of $90,953 per year” Source: Center for Substance Abuse Research (CESAR). Few U.S. Inmates with Substance Use Disorders Receive Treatment While Incarcerated. CESARFax Vol.19, Issue 22, April 5, 2010. Accessed 6/11/2010.

30. Best data available is from Epidemiologic Catchment Area (ECA) Survey (administered 1980-1984) and the National Comorbidity Survey (NCS), administered between 1990 and 1992. 42.7 percent of individuals with a 12-month addictive disorder had at least one 12-month mental disorder. 14.7 percent of individuals with a 12-month mental disorder had at least one 12-month addictive disorder. 47 percent of individuals with schizophrenia also had a substance abuse disorder (more than four times as likely as the general population). 61 percent of individuals with bipolar disorder also had a substance abuse disorder (more than five times as likely as the general population). Alcohol and Substance Abuse Problems Often Occur with Mental Health Problems Source: National Alliance on Mental Illness. Dual Diagnosis and Integrated Treatment of Mental Illness and Substance Abuse Disorder http://www.nami.org/Template.cfm?Section=By_Illness&Template=/TaggedPage/TaggedPageDisplay.cfm &TPLID=54&ContentID=23049 Accessed 6/9/2010.

31. Again the best data is not new, coming from a 2004 National Institute of Mental Health study What the chart means: Someone suffering from schizophrenia is at a 10.1 percent higher-than-average risk of abusing drugs and/or alcohol. Diagnosed Psychiatric Disorder Is a Predictor for Substance Abuse Increased Risk for Substance Abuse Based on Diagnosed Psychiatric Disorder Source: Cigna. Dual Diagnosis. http://www.cignabehavioral.com/ web/basicsite/bulletinBoard/dualDiagnosis.jsp Accessed 6/9/2010.

32. Dallas County Hospitals with Psychiatric Capacity *Pediatric and adolescent capacity Source: Texas DSHS Annual Survey, State Licensing DB as of 6/1/2010 and telephone interviews with facility representatives on services (6/8-9/2010) (Greg Eastin, Population Medicine)

33. Dallas County Residential Drug/Alcohol Treatment Programs Data from telephone conversations with facility representatives 6/2010.

34. Psychiatric Bed-to-Population Ratios, US and Other Nations *World Health Organization, 2005.Accessed 6/8/2010. http://www.who.int/mental_health/evidence/mhatlas05/en/index.html ** Texas Sate Data Center Population Projections 100-2007 scenario. Accessed 06/08/2010. http://www.dshs.state.tx.us/chs/popdat/ST2010.shtm ***Texas DSHS Lic. Data, Hospital Association Annual Survey, 2008, and local interviews with the facilities 6/2010.

35. Target Psychiatric Bed-to-Population Ratios for Certificate of Need Requirements, US States

36. The future is not something we enter. • The future is something we create. • Leonard I. Sweet • Theologian, Author, Futurist How Do We Attack these Problems?

37. Systematic Approach Needed • Primary: prevent accident • Median barriers, get safety feature from new cars • Secondary: accident occurs but injury lessened • Air bags, roll bars, ignition-interlock devices • Tertiary: Injury occurs but system in place to prevent mortality or long-term disability • High standards of trauma care, regional trauma centers • Quaternary: • Many injuries caused by alcohol/substance abuse; in this case treatment can be prevention

38. Behavioral Health Study for Dallas County Refine scope and schedule First meeting with Steering Committee Face-to-face meetings with Task Force members Finalized work plan specifying exact dates, interviews, focus groups, analyses, meetings, deliverables Information gathering, interviews, on-site program observation, initial focus groups Identify existing data sources, data collection Present emerging results to the Task Force – and accompanying Short Term Recommendations Initiate final round of data collection Deliver Community Based Assessment to the Task Force as basis for long term strategy • Deliver Draft Long Term Strategy Outline to the Task Force, obtain feedback • Complete all field work • Deliver final: • Vision • Short Term Recommendations • Community Based Assessment • Long Term Strategy Outline • Forums and communication of findings and results to stakeholders

39. Manage Alcoholism and Addiction Like Other Chronic Diseases Model for Management of Chronic IllnessAmerican College of Physicians • Alcoholism can be silent for many years even though huge damage can be done to family, livelihood, etc. • Eventually organ damage occurs and internal medicine admissions com in a staccato • Pancreatitis • Alcoholic hepatitis • Neuropathy • Cardio neuropathy • Alcoholic dementia • Withdrawal syndrome Source: American College of Physicians. Accessed 3/20/2008. http://www.acponline.org/clinical_information/journals_publications/ecp/augsep98/cdmfg1.htm

40. Barbeque • “Barbeque” was a 30-something Black man who lived in a lean-to shelter behind a barbecue stand in downtown Dallas in the 80s. He was an alcoholic who also developed a dependence on IV cocaine. • He was admitted several dozen times for substance-abuse-related complications until he was severely burned in a fire that consumed his makeshift shelter. • An ER physician commented that he had the impression that “it would have been cheaper to put him in a villa on the French Riviera and give him $50,000 a year” compared to what was spent on hospitalization over the last 5 years of his life.

41. Murray Barr is a hopeless alcoholic who lives on the streets of Reno, Nevada, and spends more weekends than not in hospital or drying out in a police cell. Barr's routine involves getting drunk, falling over and being taken to hospital. When he is released, he starts all over again. Over 10 years Barr's hospital bills mount up. "It cost us $1m not to do something about Murray," says one of the police officers who routinely arrests Barr. What the Dog Saw

42. Prevention Is Most Effective Way to Reduce Addiction • Institute of Medicine report, Prevention of Mental, Emotional and Behavioral Disorders Among Young People, concluded that • Prevention of addiction and mental illness has been proven to be scientifically feasible • Only public-health approaches are demonstrably effective. “Currently, treatment interventions tend to isolate single problems, but there is growing evidence that well-designed prevention interventions reduce a range of problems and disorders and that these efforts are sustained over the long term," Source: Join Together. Future of Prevention Funding Lies in Broad, Public-Health Approach. http://www.jointogether.org/news/features/2010/future-of-prevention-funding.html Accessed 6/9/2010.

43. We Must Re-direct Funding To Prevention • For every dollar the federal and state government spent on prevention and treatment, they spent $59.83 shoveling up the consequences: • 95.6 % or $357.4 billion of federal and state‡ substance related spending went to carry the burden to government programs of our failure to prevent and treat the problem • Only 1.9 % was spent on preventing or treating addiction • 0.4 % was spent on research • 2% was spent on alcohol and tobacco tax collection • 71.1 percent of total federal and state spending on the burden of addiction is in two areas • 58% of federal and state spending on the burden of substance abuse and addiction (74.1% of the federal burden) is in the area of health care where untreated addiction causes or contributes to over 70 other diseases requiring hospitalization. • 13.1% of substance-related federal and state spending is the justice system Source: The National Center on Substance Abuse and Addiction at Columbia University. Shoveling It Up II: The Impact of Substance Abuse on Federal, State and Local Budgets. http://www.jointogether.org/resources/shovelingup/shoveling-up-ii-final.pdf Accessed 6/9/2010.

44. Texas Spending for Substance Abuse and Addiction • Texas ranks 41st in per capita spending on that burden: $272 compared to the US average of $420 • Range is $216 (South Carolina) to $1,316 (District of Columbia). • Texas ranks 16th in the percent of the state budget (15.8%, compared to an average of 14.8%) devoted to the burden of Substance Abuse and Addiction on State programs (justice, education, health, child/family assistance, mental health/ developmental disabilities, public safety and state workforce) • Range is 4.3% (Wyoming) to 26.9% (Maine) Source: The National Center on Substance Abuse and Addiction at Columbia University. Shoveling It Up II: The Impact of Substance Abuse on Federal, State and Local Budgets. http://www.jointogether.org/resources/shovelingup/shoveling-up-ii-final.pdf Accessed 6/9/2010.

45. Not In My Backyard!

46. Where Do We Go From Here? • Prevent abuse and addiction from happening. • Education, education, education • Social pressure, positive peer pressure • Legal ramifications, like strong DUI enforcement, enforcement of sales-to-minors laws, • Mitigate the consequences of addictive behavior. • Early intervention and treatment • Engineer safety to prevent accidents or minimize injury • Optimize the response when addictive behavior leads to destructive outcomes. Remember: Treatment is a form of prevention.

47. Prevention is better than cure.Desiderius Erasmus 1466-1536

48. What a 1971 Fram® Ad said still holds… Pay me now, or pay me later!