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Substance Use Disorders and Family Problems in the Public Sector

Many individuals face a host of difficulties associated with substance use disorders, and these problems often become quite costly. For adults without health insurance, or those covered by Medicaid, these costs are often borne by government or public sector resources. By increasing access to treatment for substance use disorders, payers can contribute to improvement in other, co-occurring illnesses, ease violence and injury due to suicide, domestic abuse and accidents, and ultimately reduce costs.

Substance Use Disorders and Other Mental Illnesses

Many people who have substance use disorders also suffer from mental illnesses such as depression. When mental health and substance use disorders exist simultaneously, a person is said to have co-occurring disorders. Approximately one quarter of adults with a substance use disorder have experienced an episode of major depression in their lifetime.1 Phobias and post-traumatic stress disorders also commonly co-occur with substance abuse problems.2 When the illnesses occur at the same time, the symptoms become more severe, more disruptive to everyday life and more complicated to treat.3, 4 People with co-occurring substance use disorders and mental illnesses generally report higher rates of emergency room utilization and have poorer outcomes.1 As states look to their health plans to help manage the care of individuals and families with chronic mental illnesses, it is important that co-occurring substance use disorders are also addressed.

Unfortunately, financing issues often limit the degree to which individuals with co-occurring problems receive integrated services. Most state mental health resources are targeted to those with severe mental impairments, and most state substance abuse agencies do not have sufficient financial resources or qualified personnel to provide mental health services.


For one-third of depressed individuals with a co-occurring substance use disorder, treatment of the depression with medication alone has little or no effect on substance use.5 However, research has suggested that a combination of antidepressant medications and a type of psychotherapy called cognitive behavioral therapy may reduce both depression and substance use.6

Suicide and Substance Use Disorders

Suicide is the eleventh leading cause of death in the U.S. Suicide rates for people with alcohol problems are roughly 10 times greater than the general population, while rates for people with opioid drug problems are approximately 13 times greater.7 Although it is difficult to examine suicide rates by insurance status, some research has suggested that states with larger percentages of their population that are eligible for Medicaid tend to report higher suicide rates.8

Domestic Abuse

Violence in the home – one of the nation’s most pervasive forms of criminal activity, affecting between two and four million women and children each year – is closely linked to drug abuse. Recent research has suggested a significant relationship between intimate partner violence and both illicit drugs 9 and alcohol misuse.10

The repercussions of substance-related domestic violence reverberate far beyond the home. Being a victim of domestic violence can make it more difficult for a person to find and maintain stable employment. Batterers sometimes subject victims and their coworkers to violence in the workplace. Seventy-four percent of employed battered women report being harassed by their abusive partners at work by phone or in person. Between 1993 and 1999, approximately 1.7 million domestic victimizations of people 12 and older occurred at work.10
The Centers for Disease Control and Prevention estimate that the direct costs for medical and mental health services related to intimate partner violence were approximately 4 billion dollars in 2003.11 Updated to reflect 2009 costs, this figure would be closer to 5 billion dollars per year.12

Substance Use Disorders Increase Risk of Injury

Young people face a higher likelihood of dying from accidents than from any other single cause, with substance use substantially increasing the likelihood of serious injury or death. Research has clearly established that patients treated in both trauma centers and emergency rooms are significantly higher rates of alcohol and drug use than the general population.13, 14

Substance Use Disorders and Child Welfare

Substance use disorders are one of the primary reasons that parents and their children become involved with the child welfare system. Approximately 40-80% of families that come into contact with the child welfare system have problems with alcohol and/or other drugs.15 Research has suggested that adults with a substance use disorder are significantly more likely than other parents to abuse or maltreat their children. Children with a parent who has a substance use disorder are approximately three times more likely to be abused and four times as likely to be neglected than other children.16 The financial costs of protecting these children are enormous. Estimates conducted by the Urban Institute suggest that federal and state spending on child welfare activities exceeded 22 billion dollars in the 2002 fiscal year.17

SAMHSA’s National Center on Substance Abuse and Child Welfare is an excellent source for technical assistance on substance abuse issues in child welfare populations. The Center can help states and organizations to implement policy and practice changes to address substance use disorders among families identified by child welfare organizations.

More information on the National Center on Substance Abuse and Child Welfare can be found at the following link:

  1. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. State Estimates of Substance Use from the 2004-2006 National Surveys on Drug Use and Health. OAS Series #H-33, DHHS Publication No. (SMA) 08-4311, Rockville, MD, 2008.
  2. Back, S.E., Sonne, S.C., Killeen, T., Dansky, B.S., and Brady, K.T. 2003. Comparative Profiles of Women With PTSD and Comorbid Cocaine and Alcohol Dependence. The American Journal of Drug and Alcohol Abuse, 29(1): 169-189.
  3. Virgo, N., Bennett, G., Higgins, D., Bennett, L., and Thomas, P. 2001. The Prevalence and Characteristics of Co-Occurring Serious Mental Illness (SMI) and Substance Abuse or Dependence in the Patients of Adult Mental Health and Addictions Services in Eastern Dorset. Journal of Mental Health, 10(2): 175-188.
  4. Carpenter, K.M., and Hittner, J.B. 1997. Cognitive Impairment Among the Dually-Diagnosed: Substance Use History and Depressive Symptom Correlates. Addiction, 92(6): 747-759.
  5. Pettinati, H.M. 2004. Antidepressant treatment of co-occurring depression and alcohol dependence. Biological Psychiatry. 15;56(10):785-92; Nunes, E.V. and Levin, F.R. 2004. Treatment of depression in patients with alcohol or other drug dependence: a meta-analysis. The Journal of the American Medical Association. 291(15),1887-96.
  6. Hesse, M. 2004. Achieving abstinence by treating depression in the presence of substance use disorders. Addictive Behaviors. 29(6),1137-41.
  7. Wilcox, H.C., Conner, K.R., and Caine, E.D. 2004. Association of alcohol and drug use disorder and completed suicide: An empirical review of cohort studies. Drug and Alcohol Dependence, 76 (1), S11-S19.
  8. Klick, J and Markowitz, S. 2003. Are Mental Health Insurance Mandates Effective? Evidence From Suicides. Available at:
  9. Moore, T.M., Stuart, G.L., Meehan, J.C, Rhatogan, D.L. Hellmuth, J.C., and Keen, S.M. 2008. Drug abuse and aggression between intimate partners: A Meta-analytic review. Clinical Psychology Review, 28, 247-274.
  10. Roberts, A.R. 1987. Psychosocial Characteristics of Batterers: A Study of 234 Men Charged With Domestic Violence Offenses. Journal of Family Violence, 2(1): 81-93.
  11. Centers for Disease Control and Prevention. Costs of Intimate Partner Violence Against Women in the United States. 2003. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Atlanta, GA.
  12. Updated using the medical cost category of the Consumer Price Index from December 2003-June 2009.
  13. Cherpitel, C.J. 1993. Alcohol and Injuries: A Review of International Emergency Room Studies. Addiction, 88, 923-937.
  14. Cherpitel, C.J. and Borges, G. 2002. Substance Use Among Emergency Room Patients: An Exploratory Analysis by Ethnicity and Acculturation. American Journal of Drug and Alcohol Abuse, 28(2), 287-305.
  15. Nancy Young, Sidney Gardner, & Kimberly Dennis. (1998). Responding to Alcohol and Other Drug Problems in Child Welfare. Washington, DC: CWLA Press.
  16. Reid, J., Macchetto, P., and Foster, S. 1999. No Safe Haven: Children of Substance-Abusing Parents. New York: National Center on Addiction and Substance Abuse at Columbia University. Available online at:
  17. Bess, R and Scarcella, C.A. 2004. Child Welfare Spending During a Time of Fiscal Stress. Report prepared by the Urban Institute. Available online at: