Why the Mixed Messages When it Comes to Substance Use?

Growing up, you were probably taught to “just say no” to drugs like marijuana or heroin. But after learning about their dangers, you may have come home to see your parents drinking a beer or having a glass of wine with dinner.

While alcohol is addictive and intoxicating (i.e., it has powerful, potent and predictable psychoactive effects similar to those of other “drugs,”) our culture regards it differently. Not only is alcohol use legal for those over 21, drinking alcohol is often regarded as the norm. Its use is viewed as integral to celebrations (e.g., popping champagne at weddings) or even regularly expected within certain religions (e.g., communion in the Catholic church).

That is not to say that we should demonize alcohol more than other drugs. Moderate alcohol consumption can add pleasure to life, and because it has the potential to temporarily dissolve anxiety, it often serves as a “social lubricant.” Yet, alcohol is more similar to other drugs than we might think — and its use is just as complicated.

Despite its wide cultural acceptance, we need much greater awareness of the ongoing impact alcohol has on a very large number of Americans. This includes the physical health risks, the potential for addiction, the costs to society and stigmatization. These are all on par with any other drug. Sadly, data suggests that a small percentage of people in the U.S. account for half of all alcohol sales (35 billion drinks per year), indicating that harmful alcohol consumption makes up the majority of the alcohol industry’s annual profits.

Similarities and Differences Between Alcohol and “Drugs”

Although we tend to describe it differently in a cultural context, there is absolutely no escaping the fact that alcohol is a drug. While we often see the term “drug” used to only include illicit substances, the actual definition includes any chemical substance that can be taken to produce physiological effects.

Addiction and dependency do not discriminate between opioids, illicit substances and alcohol. No matter the primary substance, substance use disorders are diagnosed using the same criteria. All substance use disorders have similar rates of co-occurring mental health conditions, including depression, anxiety, mood disorders and trauma.

Despite the larger cultural acceptance of alcohol, alcohol use disorder is similarly stigmatized. According to the World Health Organization (WHO) alcohol and other drug use rank among the top five most stigmatized conditions. Regardless of the specific substances they struggle with, people with substance use disorders face discrimination and barriers to finding care. Stigmatizing terms such as “alcoholic” and “alcohol abuser,” are pervasive and regularly used, and have been found to stop individuals from seeking help for alcohol use.

In 2020, the opioid epidemic hit a tragic milestone, with more than 100,000 opioid deaths in the U.S. However, what many people do not know is that every single year, over 140,000 Americans die of alcohol related causes, shortening the lifespan by 26 years on average. Also, the number of deaths is thought to be grossly underestimated (Some estimate the true number to be closer to half a million deaths annually.) This is, in part, because whereas opioid overdose deaths are easily attributable to a direct cause of poisoning, alcohol-related deaths are often a result of causes indirectly related to alcohol, and can be harder to attribute. Because of this, and because the stigma associated with being “an alcoholic,” there can be a desire to disguise or hide the fact that alcohol was responsible for a premature death. Clinicians and coroners alike may feel that they are “doing the family a favor” by downplaying any causative role for alcohol, especially when the death was not directly related to alcohol poisoning.

A recent study from researchers at Florida Atlantic University found threefold increases in deaths from alcohol-related cirrhosis (i.e., advanced stage liver disease) in the U.S. since 1999. This trend was particularly alarming in individuals aged 24-35. In addition to liver disease, chronic alcohol use is correlated with more than 50 diseases as well as injury, accidents, heart attack and cancer (including breast cancer).

Quite strikingly, one in 10 deaths among working-age adults aged 20 to 64 years are due to alcohol. Worldwide, alcohol kills 10 times more people than all illicit drugs combined. Many of these deaths are caused by accidents and injuries that result from acute intoxication — getting drunk and falling down the stairs or crashing a car, for example. Many are also caused by toxicity related effects such as liver disease or by cancer. Many people do not know, for example, that alcohol is also a Level I carcinogen in the same category as tobacco smoke and asbestos for increasing cancer risk. It also causes “alcohol use disorder,” the most severe form of which (severe alcohol use disorder ) is alcohol addiction.

Despite these grim statistics, there is hope. Similar to any other addictions, alcohol use disorder (sometimes referred to also as alcoholism) is actually considered a good prognosis disorder. Although it can take quite a while, a growing number of evidence based treatments are available, and the majority of people who experience alcohol use disorder eventually achieve sustained remission.

The Costs of Separating “Drugs” and Alcohol

Despite its potential harms, not only is the use of alcohol more widely accepted than other drugs, in some cases, it’s actually encouraged by cultural norms. The notion however, that alcohol is less addictive or less dangerous than other drugs is completely false.

This idea may originate, in part, from federal drug scheduling policies, which regard drugs like heroin and cannabis as having a high potential for misuse but do not regulate the sale or consumption of alcohol in the same way. Just because alcohol is not a controlled substance does not make it any less addictive for those predisposed to become dependent. It is estimated that approximately half of an individual’s susceptibility to alcohol use disorder is linked to genetic factors.

The myth that alcohol is neither addictive nor dangerous is not only wrong — it is also costly. According to the U.S. Centers for Disease Control and Prevention (CDC) alcohol costs the U.S. nearly $250 billion per year in direct and indirect health care costs, criminal justice expenditures, and lost workplace productivity. That’s a public “tax” of approximately $2 for every drink consumed. Preliminary data suggest this problem is only increasing due to the socioeconomic stressors of living in a global pandemic. During COVID-19, alcohol sales in the U.S. have risen by more than 32% according to the World Health Organization and the National Institute for Alcoholism and Alcohol Abuse (NIAAA) and deaths related to alcohol have risen 25%.

We have a lot of work ahead of us.

As we look to stem the rising tide of opioid overdoses, we also need to recognize the overwhelming (and often greater) public health, personal and economic costs that alcohol continues to have. When we draw back the curtain on the mixed messages of both encouragement to use, and not use alcohol, with special attention to impact, we can begin to engage honestly with the reality of alcohol use disorder in our country. It is only with equal attention, equal awareness, and equal funding for research, treatment and services that support remission and recovery, that we can we begin to curb the tide of alcohol-related deaths and suffering.


Alexandra Plante
Senior Advisor, Substance Use Disorder in the Strategy and Growth Office
National Council for Mental Wellbeing
See bio

Guest Authors

John F. Kelly, PhD, ABPP
Director, MGH Recovery Research Institute
Elizabeth R. Spallin Professor of Psychiatry, Harvard Medical School