As the new generation of political leaders in Washington, state capitals and city halls grapples with America's collapsing judicial systems, rising medical costs, persistent poverty amid plenty and the defiant federal budget deficit that looms over future generations, they confront the same 800pound gorilla: drug, alcohol and tobacco abuse and addiction. The sooner these leaders see how substance abuse has fundamentally changed the nature of the pressing social and economic problems they face, the sooner they'll deal with them effectively.

For 30 years, we've tried to curb crime and renew our ailing court system with tougher punishments, bigger prisons, and more cops and judges; rein in health costs by manipulating payments to doctors and hospitals for delivering sick care; wage war on poverty with a welfare system that encourages dependence and drives families apart; and reduce the deficit by cooking the federal books. Trying to reform our court and criminal justice systems, restrain health care spending, reduce welfare rolls, trim the deficit and nourish the American family without confronting, front and center, substance abuse and addiction is like trying to clean coastal waters without stopping the flow of oil from the ruptured offshore well. It can't be done.

Criminals and Courts

Congress and state legislatures have been passing laws designed for celluloid gangsters and inmates played in classic 1930s movies by James Cagney and Humphrey Bogart. But today's prisons are wall to wall with drug dealers, addicts, alcohol abusers and the mentally ill (often related to drug and alcohol abuse).

In 1960, less than 30,000 Americans were arrested for drug offenses; by 1991, the number had soared to more than a million. Since 1989, more individuals have been incarcerated for drug offenses than for all violent crimes-and most violent crime is committed by drug and alcohol abusers. Alcohol and drug abuse are implicated in three­quarters of all spouse abuse, rapes, child molestations, suicides and homicides.

In 1994, the number of Americans in prison broke the one million barrier and, on its current trajectory, will double soon after the turn of the century. The United States is second only to Russia in the rate of citizens it imprisons: 519 per 100,000, compared to 558 in Russia, 368 in third­place South Africa, 116 in Canada and 36 in Japan.

Probation and parole are sick jokes in most American cities. With so many parolees needing drug treatment and aftercare as essential first steps to rehabilitation, they demand far more monitoring than their drug­free predecessors of a generation ago. Yet in Los Angeles, for example, probation officers must handle as many as 1,000 cases at a time. With most offenders committing drug or alcohol­related crimes, it's no wonder so many of them go right back to jail: 80 percent of prisoners have prior convictions and more than 60 percent have served time before.

Drugs have turned the private security industry from a less than four­billion­collar weakling in 1970 into a 70­billion­dollar behemoth in 1994, as office buildings and homes install sophisticated protection systems and commercial properties post guards around the clock.

Judges and prosecutors are demoralized as they juggle caseloads more than double the recommended maximums. The rush of drug related criminal cases has created intolerable delays for civil litigants: four years in Newark, five in Philadelphia, up to ten in Cook County, Illinois. In many jurisdictions, divorce and separation cases languish for years, as splitting parents and their children struggle to survive in a limbo of nasty uncertainty.

The safety and civility of urban life have been shattered by alcohol and drug­related crimes. Children kill children and innocents are downed by random gunfire from warring drug gangs. Elementary and high school students are required to pass through metal detectors in order to check for weapons, the deadly companions of the drug trade, and teachers are locked in classrooms for their own protection.

City dwellers can no longer buy out of the mess. Individuals walking Wisconsin Avenue in Washington D.C.'s Georgetown, Madison Avenue in New York, Newbury Street in Boston and the Miracle Mile in Chicago are accosted by angry, aggressive panhandlers, many seeking money for their next fix. The ugly scrawls of graffiti on city buildings mark not only the arrival of spray paint, but also the widespread abuse of drugs and alcohol.

Substance abuse is an equal opportunity killer, snaring addicts in every social and economic class. Store owners lock their doors during daytime business hours in fear of robbery by alcohol and drug­crazed criminals. Office managers bolt computers to desks to prevent theft. Customers and employees warily read headlines about murders and assaults, often committed under the influence of alcohol and drugs, that have torn apart the comfortable routines where America works, eats and shops- post offices, fast­food restaurants, banks and supermarkets. Two­thirds of illegal drug users are employed, adding an element of Russian roulette to going to work each day.

Health Care Costs

In 1995, drugs, alcohol and tobacco will trigger some $200 billion in health care costs.

Hospital emergency rooms are piled high with the debris of drug use on city streets. From Boston to Baton Rouge, hospitals teem with the victims of gunshot wounds and other violence caused by alcohol abusers, drug addicts and dealers, and of a variety of medical conditions, such as cancer, emphysema and cardiac arrest, caused by alcohol, tobacco, cocaine and other drugs.

AIDS and tuberculosis spread rapidly and not just among intravenous drug users and crack addicts. Beyond sharing dirty needles and trading sex for drugs, individuals high on beer, other alcohol and pot are far more likely to have sex and to have it without a condom.

The more than 500,000 newborns exposed each year to drugs and/or alcohol during pregnancy is a slaughter of innocents of biblical proportions. Crack babies, a rarity a decade ago, crowd $2,000a­day neonatal wards. Many die. Each survivor can cost one million dollars to bring to adulthood. Fetal alcohol syndrome is a top cause of birth defects.

Even where prenatal care is available, women on drugs and alcohol are not likely to take advantage of it. Those who do seek help must often wait in line for scarce treatment slots. Mothers abusing drugs during pregnancy account for most of the $3 billion that Medicaid spent in 1994 on inpatient hospital care for illness and injury due to drug abuse.

Poverty in History's Most Affluent Society

Drugs have changed the nature of poverty in America. Nowhere is this more striking than in the persistent problem of welfare dependency.

At least 20 percent of Chicago and Maryland's Montgomery County adults on welfare have drug problems. And that may be low compared to other urban areas. Many of the million teenagers who get pregnant each year are high on alcohol or drugs at the time they conceive, and one of the surest ways to get locked in poverty is to become an unwed mother before graduating from high school. At least half the homeless men and women-some say 80 to 90 percent-are alcohol and drug abusers.

The American electorate is hell­bent on putting welfare mothers to work. But all the financial sticks and carrots and all the job training in the world will do precious little to make employable the hundreds of thousands of welfare recipients who are drug and alcohol abusers. For too long, reformers have had their heads in the sand about this unpleasant reality. Liberals fear that acknowledging the extent of alcohol and drug use among welfare recipients will incite even more punitive reactions than those currently in fashion. Conservatives don't want to face up to the cost of treatment.

This political denial ensures failure. Any reform that will move individuals from welfare to work must provide funds to treat drug and alcohol abuse. Supplemental Security Income, the welfare program that provides monthly checks to blind, disabled and poor adults, reveals the grim and expensive consequence of the alternative. Of 90,000 individuals receiving SSI primarily because of substance abuse, fewer than ten percent are in treatment. Not surprisingly, the U.S. Department of Health and Human Services found that thousands of these addicts and alcoholics receive benefits until they die.

Illegal drugs have added a vicious strain of intractability to urban poverty. Drugs are the greatest threat to family stability, decent housing, public schools and even minimal social amenities. Widespread drug use derails the emotional, social and intellectual development not only of the children who abuse them, but also of their peers and neighbors who must grapple with the violent consequences of rampant drugs in housing projects and schools. It becomes difficult-sometimes impossible-for children in this sordid environment to acquire the basic educational and social skills they need to get out of poverty.

The Federal Budget Deficit

In fiscal 1995, tobacco, alcohol and drug abuse will account for at least $77.6 billion in entitlement expenditures, an amount equivalent to 40 percent of the 1995 federal budget deficit.

Of that amount, $66.4 billion are costs to health and disability programs, such as Medicare, Medicaid and veterans' health and disability. Cigarette smoking is by far the biggest culprit. Two­thirds of the $66.4 billion-$44 billion-is attributable to tobacco. Alcohol accounts for 18 percent and drugs for 16 percent.

Substance abuse takes its biggest slice from the veterans' health care program. Nearly 30 percent of the dollars spent on veterans' health is due to substance abuse, more than half of that as a result of alcohol and drug abuse. Welfare payments to illegal drug addicts and alcoholics draw the rhetorical fire of legislators. But American taxpayers fork over $4.6 billion a year to individuals on Social Security disability as a result of smoking cigarettes.

Of the $77.6 billion, the remaining $11.2 billion is spent on welfare, food stamp and Supplemental Security Income recipients who regularly use alcohol and drugs and are unlikely to get off the rolls without treatment and aftercare.

Any honest attack by the President and the Congress on entitlement programs-from Medicare and veterans' health and disability to Medicaid and welfare-has to confront substance abuse and addiction. That means a significant investment in prevention and treatment of all abuse. Simply removing individuals who abuse alcohol and drugs from disability, welfare and health care programs will only shift costs to the states, cities and counties, which will then have to deal with the resulting illness, hunger, homelessness and crime. Indeed, a wholesale denial of benefits to alcoholics and drug addicts without providing treatment and aftercare will push up the crime rate and scatter thousands more homeless individuals on America's streets.

Is There Anything We Can Do?
We can begin by ending our national and personal denial of the tough truth denominator of the nation's hot buttons- crime and violence, health care costs, welfare reform and the budget deficit-is substance abuse. Our denial keeps our sights on the wrong targets. Indeed, 92 percent of federal health entitlement program costs attributable to substance abuse is spent to treat the consequences of tobacco, alcohol and drugs; only eight percent is spent to treat the tobacco, alcohol or drug dependence itself.

Our leaders and citizens focus on the top killers: heart disease (720,000 deaths in 1990), cancer (505,000), stroke (144,000), accidents (92,000), emphysema (87,000), pneumonia and influenza (80,000), diabetes (48,000), suicide (31,000), chronic liver disease and cirrhosis (26,000), and AIDS (25,000). But they give scant attention to the causes of these killers, which, according to a 1993 Journal of the American Medical Association study, include tobacco (435,000 deaths), alcohol (100,000) and illicit drug use (20,000).

Our obsession with the consequences and neglect of the causes is not limited to health care. We pump billions into combating crime-cops, courts, prisons and punishment-and pennies into preventing the drug and alcohol abuse and addiction that spawn so much criminal activity. We pour resources into shoveling up city slums- rebuilding gutted housing, putting more cops on unsafe streets and barbed wire around housing projects-and little into curbing drug and alcohol abuse. And we often use our hefty budget­cutting axes to chop down prevention and treatment programs, which are most likely to reduce the deficit over the long run

Dealing effectively with the causes requires up­front investments-the kind that corporations make every day to produce long­term results for their stockholders, the kind that parents make to give their children the best education they can get. It also requires that we scrub the stigma off drug and alcohol abuse and devote the kind of energy and resources to research on addiction and its prevention that we have committed to cancer and heart disease. And it requires common sense.

Here are a few starter suggestions:

• Provide federal funds to state and federal prison systems only if they provide drug and alcohol treatment and aftercare for all inmates who need such care.

• Instead of across­the­board mandatory sentences, keep inmates in jails, boot camps or halfway houses until they demonstrate at least one year of sobriety after treatment.

• Require drug and alcohol addicts to go regularly to treatment and aftercare, like Alcoholics Anonymous, while on parole or probation.

• Provide federal funds for police only to cities that agree to enforce drug laws throughout their jurisdictions. End acceptance of drug bazaars in Harlem, southeast Washington, D.C, and south-central Los Angeles, which would not be tolerated on the streets of New York's Upper East Side, Georgetown or Beverly Hills.

• Encourage judges with lots of drug cases to employ public health professionals, just as they hire economists to assist with anti­trust cases. Drug cases present far more complex human and medical problems than the economic issues posed by commercial litigation.

• Charge higher Medicare premiums to individuals who smoke.

• Cut off welfare payments to drug addicts and alcoholics who refuse to seek treatment and pursue aftercare. As employers and health professionals know, addicts from CEOs to chambermaids need lots of carrots and sticks, including the threat of losing their jobs and incomes, to get the monkey off their backs.

• Subject inmates, parolees and welfare recipients with a history of drug or alcohol abuse to random tests and fund the treatment they need. Conservatives who preach an end to recidivism and welfare dependency must recognize that reincarceration and removal from the welfare rolls for those who test positive is a cruel catch­22 unless treatment is available. Liberals must recognize that getting off drugs is the only chance these individuals (and their babies) have to enjoy their civil rights.

• Identify parents who abuse their children by their own drug and alcohol abuse and place those children in decent orphanages and foster care until the parents go into treatment and shape up.

These are only a few suggestions. The overriding point is that addiction and abuse-involving heroin, cocaine, hallucinogens, amphetamines, inhalants, marijuana, alcohol and tobacco-have fundamentally changed the nature of America's pressing social and economic challenges, and we must rethink how we address them. If a mainstream disease like diabetes or cancer affected as many individuals and families as drug, alcohol and tobacco abuse and addiction do, this nation would mount an effort on the scale of the Manhattan Project to deal with it.

J.A.C., Jr.

© 1996, The National Center on Addiction & Substance Abuse at Columbia University