Alcohol is still the deadliest drug in the United States, and it’s not even close

August 19

This is more likely to lead to violence.

Which intoxicating substance is associated with the most lethal violence? Devotees of the Wire might presume that cocaine or maybe heroin would top the list, especially if you asked the worst causes of violence in poor, minority communities.

The correct answer, by far, is alcohol. It’s involved in more homicides than pretty much every other substance, combined. Alcohol’s relative importance has grown over the last fifteen years, as aging populations of cocaine users account for a declining proportion of violent crime. Here in Chicago, positive cocaine screens in the Cook County Jail are down by about half when compared with ten or twenty years ago. The same is true in many other cities.

Surveys of people incarcerated for violent crimes indicate that about 40% had been drinking at the time they committed these offenses. Among those who had been drinking, average blood-alcohol levels were estimated to exceed three times the legal limit. Drinking is especially common among perpetrators of specific crimes, including murder, sexual assault, and intimate partner violence.

Correlation does not equal causation, of course. If offenders all stopped drinking, we wouldn’t see a 100-percent reduction in their crimes. Yet alcohol does play a distinctive role. It lowers inhibitions and, among some people, fosters aggressive behavior that ratchets up the risk that violence will somehow occur. In my own career as a public health researcher, I’ve come into close contact with many intoxicated heroin and marijuana users. In these moments, I’ve never had reason to feel that my safety was at risk. I have been present for some scary incidents. Almost every time, alcohol was in the mix, often as things were getting a little late in a tough neighborhood near a liquor store.

Aside from its role among perpetrators of violence, alcohol use is widespread among victims, too. If alcohol makes you more likely to be a perpetrator of violence, almost by definition it makes you more likely to be a victim in the same incident. Downing some liquid courage may impair your judgment, which makes you a little less wary or a little more vulnerable in obvious ways. It may narrow your options and thus create other risks, too. You’re less likely to leave that cutting remark unanswered. If you’re unfit to drive, you’re more willing to accept that ride home from a helpful stranger.

Recent data from the Illinois Violent Death Reporting System (IVDRS) bear out these trends. At my request, researchers at the Stanley Manne Children’s Research Institute analyzed 3,016 homicides occurring in five Illinois counties between 2005 and 2009.

(Thanks to Tracie Smith, Suzanne McLone, Maryann Mason, and Rebecca Levin and the Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital, for providing these IVDRS results. Such epidemiological data are essential for evidence-informed violence prevention policy.)

Many of the IVRDS findings are depressingly familiar to anyone who reads a newspaper. Two-thirds of the victims were African-American; only 11% were non-Hispanic white. Eighty-six percent were men. Seventy-seven percent were victims of gun violence.

Almost 40% of the homicide victims tested had some blood alcohol in their systems when they were killed. These data do not indicate actual blood-alcohol levels. Our previous work indicates that many homicide victims have alcohol in their systems above the legal limits for driving.


Other intoxicating substances were far less prevalent. About 10% of homicide victims had cocaine in their systems. (And roughly half of this group had also been drinking.) Opiates, in contrast, were only present in about 3% of homicide victims and appears to be a very small part of the story.

Disparities by age are especially pronounced. Homicides among adolescents and young adults are a special problem in Chicago.

Alcohol is the only substance that frequently appears among young homicide victims. Cocaine (and, to a lesser extent, heroin) is a much more important part of the story among victims age 35 or older.


IVDRS researchers report other interesting patterns, too. Alcohol is a more important part of the story for intimate-partner and friend homicides than it is for stranger- and for gang-related homicides. Alcohol is more likely to be found among victims killed with sharp instruments or hand-to-hand than those killed with firearms. Whatever the method or circumstance, alcohol is almost always an important part of the story.

What to do?

Many different kinds of data could be added to underscore the obvious: Alcohol misuse is a core part of our violence problem. Alcohol misuse is a multi-faceted challenge, especially when alcohol is so deeply embedded within American life. No one policy can adequately address these broad problems. No one wants to prohibit alcohol, either. Prohibition is contrary to our national traditions and values. Fortunately, much can be done short of that.

Efforts such as South Dakota’s 24/7 sobriety program indicate that more careful monitoring of individuals who have committed alcohol-related offenses can reduce recidivism without imposing draconian penalties. Specific measures to support, deter, and monitor alcohol-involved offenders remain a special area of research and policy interest.

Treatment matters, too. In 2011, about four million Americans were both uninsured and satisfied criteria for alcohol disorders. Many have other characteristics that place them at especially high risk to become victims or perpetrators of violent crimes. The Affordable Care Act, the greatest expansion of alcohol treatment resources in American history, should improve treatment access to many within this group. ACA’s Medicaid expansion is particularly important for this group. Implementing strong service linkages with correctional and mental health care will be particularly important for violence prevention in this group. ACA provides the financial foundation. The practical nuts-and-bolts will matter greatly.

Aside from expanding access to conventional treatments, ACA provides funds for screening and brief interventions for problem drinkers who present in emergency departments and other medical settings. It also seeks to strengthen links between substance abuse treatment services and primary care. These unglamorous components of health reform are especially important given evidence that the dominant majority of problem drinkers will never access the specialty addiction treatment system.

No ordinary commodity

Perhaps the single most important measure would be to increase alcohol excise taxes, which have badly eroded with inflation. Duke University’s Philip Cook has estimated that the 1991 federal excise tax increase saved 7,000 lives just in its first year. Cook reports that increases in state alcohol taxes would appreciably reduce accident and injury fatalities, as well as deaths from liver disease.

We might also revisit some of the unfortunate ways alcohol permeates our popular culture, too. The push to sell beer at this year’s FIFA World Cup games rightly attracted criticism. Alcohol-related sponsorships of sporting and cultural events have also attracted controversy in several countries. Beer companies routinely sponsor ultimate fighting, boxing, and other combat sports, creating a particularly unfortunate resonance with alcohol’s role in promoting violence.

Maybe our first step is to recognize that we indeed have a national alcohol problem. In the words of a famous treatise in this area, alcohol is no ordinary commodity.

I sometimes hear people say that we should legalize and regulate marijuana the way we’ve handled alcohol. I certainly hope we do better.

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