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This article was initially published in the Fall 2025 newsletter of the American Academy of  Addiction Psychiatry.

By Connor Kubeisy, MPH

As the Trump administration crafts its National Drug Control Strategy (NDCS), there is an opportunity to adopt an overarching goal of reducing the burden of harm attributable to drugs, measured by disability-adjusted life years (DALYs). This goal would broaden the scope of the field to account for all drug-attributable harms––not only overdoses––thereby representing the natural next step in the evolution of drug policy.

Although there have been minor differences between presidential administrations, federal goals have recently transitioned through three broad stages: from focusing on criminal justice measures like arrests and drug seizures, to focusing on reducing the prevalence of drug use (Bush 41, Clinton, and Bush 43), then to focusing on reducing the number of overdose deaths (Obama, Trump 45, and Biden). Beyond working to reduce an incomplete list of harms, the drug policy field has an opportunity to reduce all health-related harms attributable to drugs.

The 2016 Surgeon General’s report, Facing Addiction in America, summarized the short- and long-term harms of drug use, which may include cardiovascular, neurological, kidney, liver, respiratory, dental, reproductive, and musculoskeletal damage, among other harms. Even so, presidential administrations have been focused on overdoses. The Trump administration’s 2020 NDCS stated that “this Strategy is focused on achieving a singular and overarching purpose: to prevent Americans from dying of a drug overdose.” Similarly, the Biden administration said that “the 2024 Strategy is aimed at addressing the overdose crisis from multiple angles.” As the number of overdose deaths increased, policymakers understandably focused on this outcome.

An overdose-specific goal, however, omits all other deaths due to drugs. In 2023, there were 105,007 overdose deaths, which are often cited as the extent of the drug crisis. Yet there were 109,067 drug-induced deaths that year: 105,007 overdose deaths plus 4,060 non-overdose deaths that cited a drug-induced condition as the underlying cause of death. The CDC has identified more than 100 ICD-10 codes that factor into the tally of drug-induced mortality, ranging from drug-induced fever (R50.2) to mental and behavioral disorders due to multiple drug use (F19). When deaths that list a drug-induced condition as either the underlying or contributing cause of death are included, the number of drug-related deaths in 2023 rises to 447,749, based on an analysis of the CDC’s WONDER database.

The untimely death of Whitney Houston is an example; her death was ruled a drowning with cocaine use and heart disease cited as contributing factors. In 2023, 653 deaths cited drowning as the underlying cause of death and a drug-induced condition as a contributing cause.

The DALY metric offers a standardized way to compare disparate harms by combining years of life lost due to premature mortality with years lived with disability, adjusting for the age at the time of death and the severity of non-fatal conditions. In effect, the loss of 1 DALY is equivalent to the loss of 1 year of healthy life. Notably, the DALY metric has been referenced by the federal government for decades, including by SAMHSA, the CDC, the AHRQ, and the NIH. DALYs, specifically referencing drugs, were even cited in 1999 in the Surgeon General’s Report on Mental Health.

The White House Office of National Drug Control Policy has the opportunity to incorporate the DALY metric into the NDCS as an overarching policy goal. This policy was called for in a 2024 Viewpoint in the Journal of the American Medical Association (JAMA).

Indeed, Australia has already adopted a DALY-based goal in their National Drug Strategy. Through the Australian Burden of Disease Study, they measure a range of drug-attributable harms––from cannabis-attributable anxiety disorders and cocaine-attributable suicide to injection-attributable infections and amphetamine-attributable traffic injuries––and convert the associated health loss into DALYs. While this study does not measure all harms for all drugs, it provides a proof of concept and demonstrates the metric’s potential for informing policy.

A focus on reducing the burden of harm attributable to drugs would have a few implications. Given the focus on lost life years and disability, it would follow that interventions would target younger populations and conditions that are more severe, respectively. It would also highlight the need to further quantify the health loss attributable to drugs, especially for conditions that develop over time, as has been done for tobacco and alcohol.

This perspective also calls for cautious optimism about the recent decline in overdose deaths. Between 2017 and 2018, when overdose deaths decreased from 70,237 to 67,367, drug-related deaths nevertheless increased from 402,564 to 408,105, according to WONDER. Likewise, the burden attributable to drugs increased from 6.63 million to 6.93 million DALYs over this period, according to the Global Burden of Disease study. In this case, it appears that more people who use drugs died from non-overdose conditions, while the larger drug crisis continued to worsen.

A focus on reducing the short- and long-term harms of drug use would bring the drug control field in line with the tobacco and alcohol control fields, where the chronic harms of these substances are central to public health strategies (e.g., tobacco-related lung cancer and alcohol-related liver disease). This approach is also consistent with the Make America Healthy Again movement, which is focused on reducing the burden of chronic disease.

Of note, a DALY-based goal is not all-encompassing and can be complemented by other metrics, as is done in Australia. The Global Burden of Disease study’s estimate of the drug-attributable burden does not include traffic fatalities, for example. It would also be wise for policymakers to readopt a goal focused on reducing the prevalence of drug use for all age groups, given that continued drug use is the root of long-term harm.

By mapping a list of the short- and long-term harms of drug use and working backward from there, the limits of prevailing approaches to drug policy become apparent. The Trump administration has the opportunity to usher in the next era of drug policy by accounting for and working to reduce the full range of drug-related harms.