“While overdose deaths and related outcomes, such as the prevalence of substance use disorders (SUDs), are helpful indices, they fail to capture the broader dimensions of drug-attributable harm, including non-overdose deaths, chronic disease morbidity, and other conditions that cause people who use drugs to live in a state of less than full health. [..]
The DALY [disability-adjusted life-years, the sum of years lived with disability and the years of life lost due to premature death] index captures the health burden beyond overdose deaths and SUDs, to encompass other morbidity and mortality attributable to substance use. Such outcomes could include conditions related to injection drug use (eg, HIV/AIDS, hepatitis B and C), chronic conditions caused by nonfatal overdose, and diseases attributable to tobacco (eg, cancer, cardiovascular and respiratory diseases) and alcohol (eg, alcohol-related liver disease, cardiovascular disease and cancer), as well as their sequelae.
DALYs and years lived with disability, which adjust for the severity of conditions by using a disability weight (a scale from 0, representing full health, to 1, or death), allow assessments to reflect the severity of conditions more accurately. This ability to assess the severity of conditions would enhance the NDCS [White House’s 2022 National Drug Control Strategy] goal of reducing the prevalence of opioid, cocaine, and methamphetamine use disorders by 25% by 2025: this index would also capture outcomes not accounted for in the NDCS, such as cannabis, hallucinogen, and inhalant use disorders. [..]
Rankings using DALY measurement and tracking would call attention to the discordance between death and DALY trends. In 2019, drug use disorders were the second leading cause of DALYs but the eleventh leading cause of death. Similarly, from 2017 to 2018, when the national number of opioid overdose deaths declined (from 70 236 to 67 367), overall drug-attributable deaths increased (from 98 621 to 101 471), as did the drug-attributable burden measured by DALYs (from 6.93 million to 7.09 million), highlighting the increasing harms of substance use despite the decline in overdose deaths. Additionally, many conditions that disproportionately affect older individuals—such as Alzheimer disease and stroke—account for more deaths than drug use disorders but fewer DALYs. [..]
Beyond the immediate goal of preventing the loss of health, policymakers should also work to help people who use drugs recover and achieve their highest attainable standard of health, as measured by quality-adjusted life-years (QALYs). DALYs represent years of healthy life lost; QALYs represent years of healthy life gained. Adopting both DALYs and QALYs would facilitate the selection and tailoring of policy interventions—including prevention, treatment, and harm reduction—targeted for maximum potential impact, such as to youth or those at higher risk of severe health harms. Policy decisions should also consider cost-effectiveness and implications for health equity. Simulation modeling represents one increasingly used strategy that allows the identification of “best buy” policy interventions.
This focus on reducing the drug-attributable burden of harm, alongside a commitment to restoring health, represents a new health-first drug policy platform. This approach can be extended to other fields, including tobacco and alcohol control, as well as throughout the nation’s public health agenda in future editions of Healthy People.
Last, recognizing that the Global Burden of Disease study’s estimate of DALYs is not all-encompassing, the NDCS should include supplementary indicators, such as drug-impaired traffic fatalities and crime stemming from drug use. These will account for outcomes that are not included in the Global Burden of Disease study and that perhaps cannot be measured in DALYs—they can also help identify inequities. Metrics should also be incorporated—or developed—that assess the direct and indirect harms of substance use on families and the broader community.
To pursue a true public health approach, the drug policy field must adopt more comprehensive and informative metrics—specifically DALYs—that are used increasingly in other public health settings. Integration of DALYs into a systematic SUD surveillance framework can improve monitoring and provide a better understanding of substance use as a risk factor for morbidity and mortality. Doing so would reorient policymaking efforts toward enhancing length and quality of life, thereby promoting health equity and improving individual and population health outcomes.”
Full editorial, VW Rees, C Kubeisy and HK Koh. JAMA 2024.7.18