You might think Surgeon General Vivek Murthy, who acknowledges marijuana's medical utility, has relatively enlightened views on drug policy. But a report he released yesterday reveals that Murthy is utterly conventional in his attitude toward drinking and other kinds of recreational drug use, which he views as a problem to be minimized by the government. Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health claims "addiction is a chronic brain disease" caused by exposure to psychoactive substances, even while acknowledging that the vast majority of people who consume those substances do not become addicted to them. The report describes even low-risk, harmless, and beneficial drug use as "misuse," giving the government broad license to meddle with personal choices through policies aimed at making drugs more expensive and less accessible. Murthy argues that driving down total consumption, rather than focusing on problematic use, is the most effective way to reduce the harm caused by alcohol and other drugs. As he sees it, every drinker and drug user, no matter how careful, controlled, or responsible, is a legitimate target of government intervention.
Murthy's report eschews the term substance abuse, explaining that the phrase "is increasingly avoided by professionals because it can be shaming." Instead the report talks about "substance misuse," which "is now the preferred term." But substance misuse is just as judgmental, vague, and arbitrary as substance abuse. In fact, Murthy cannot quite decide what it means. On page 5 of the introduction, he says misuse occurs when people use drugs "in a manner that causes harm to the user or those around them." But elsewhere (including the very next page), the report uses a much broader definition. "Although misuse is not a diagnostic term," Murthy says, "it generally suggests use in a manner that could cause harm to the user or those around them." Could cause harm? That definition is wide enough to cover all drug use.
Murthy does seem to think drug use is problematic even when it causes no problems. As an example of drug misuse, Murthy repeatedly cites a 2015 survey in which 25 percent of the respondents, representing 66.7 million Americans, reported that they had engaged in "binge drinking" during the previous month. "By definition," Murthy says, "those episodes have the potential for producing harm to the user and/or to those around them, through increases in motor vehicle crashes, violence, and alcohol poisonings." But the government's definition of a binge—five or more drinks "on an occasion" for a man, four or more for a woman—encompasses patterns of consumption that do not harm anything except the sensibilities of public health officials. If a man at a dinner party drinks a cocktail before the meal, a few glasses of wine during it, and a little bourbon afterward, he is drinking too much, according to Murthy, even if he takes a cab home. By that standard, at least 44 percent of past-month drinkers are misusing alcohol.
Murthy also counts all consumption of federally proscribed drugs as misuse, no matter the context or consequences. As far as he is concerned, all 36 million Americans who consumed cannabis last year misused it, even if they lived in states where the drug is legal for medical or recreational purposes (which is now most states). Unauthorized use of prescription drugs also counts as misuse, whether or not harm results. "In 2015," Murthy says, "12.5 million individuals misused a pain reliever in the past year—setting the stage for a potential overdose." That makes the risk sound much bigger than it is. According to the CDC, there were 18,893 deaths involving opioid analgesics in 2014, the most recent year for which data are available. That year, according to the National Survey on Drug Use and Health, 10.3 million Americans used prescription painkillers for nonmedical purposes. On average, they ran a 0.2 percent change of dying as a result. For those who avoided mixing narcotic painkillers with other depressants (a typical factor in opioid-related deaths), the risk was even smaller—on the order of 0.02 percent, judging from New York City data.
Murthy also seems confused when he talks about addiction. "We now know from solid data that substance abuse disorders don't discriminate," he recently told NPR. "They affect the rich and the poor, all socioeconomic groups and ethnic groups. They affect people in urban areas and rural ones." But according to Murthy's report, "Prevalence of substance misuse and substance use disorders differs by race and ethnicity and gender." Furthermore, "genetic, social, and environmental risk factors" increase a person's vulnerability to addiction, while "protective factors" reduce it. Risk factors include "low parental monitoring," "high levels of family conflict or violence," "current mental disorders," "low involvement in school," and "a history of abuse and neglect." Protective factors include "involvement in school, engagement in healthy recreational and social activities, and good coping skills." Pace Murthy, it sounds like substance abuse disorders do discriminate, since they are more common among troubled people in difficult circumstances.
The fact that everyone is not equally prone to addiction tells us that Murthy's account, in which a "substance abuse disorder" is "a medical illness caused by repeated misuse of a substance or substances," cannot be accurate. According to the report, "prolonged, repeated misuse of any of these substances can produce changes to the brain that can lead to a substance use disorder, an independent illness that significantly impairs health and function and may require specialty treatment" (emphasis added). Those cans are carrying a lot of weight. In fact, as Murthy concedes, drug use typically does not "lead to a substance use disorder"; controlled use is much more common. "For a wide range of reasons that remain only partially understood," says the executive summary, "some individuals are able to use alcohol or drugs in moderation and not develop addiction or even milder substance use disorders, whereas others—between 4 and 23 percent depending on the substance—proceed readily from trying a substance to developing a substance use disorder." By saying "some" and "others" instead of "most" and "a minority," the report obfuscates the point that the vast majority of drinkers and drug users are not addicts.
Murthy's equation of addiction with cancer and diabetes is also misleading. "Now we understand that these disorders actually change the circuitry in your brain," he tells NPR. "They affect your ability to make decisions, and change your reward system and your stress response. That tells us that addiction is a chronic disease of the brain, and we need to treat it with the same urgency and compassion that we do with any other illness." All experiences change the brain; that does not make them diseases. Although the medical terminology is supposed to reduce the stigma associated with drug addiction and encourage people to seek help, it is not clear that describing the problem as an illness rather than a habit makes it any easier to change. Arguably it does the opposite, by depicting harmful patterns of drug use as something that happens to people rather than something that they do.