The Economic Costs of Alcohol and Drug Abuse in the United States - 1992
Mortality

Synopsis

Alcohol and drug abuse caused more than 132,000 deaths in 1992. The estimated loss of productivity resulting from these deaths was $45.9 billion using a 6-percent discount rate - 107,000 alcohol-attributable deaths cost an estimated $31.3 billion, and 25,000 deaths due to drug abuse cost an estimated $14.6 billion. This study, using 1992 mortality and cost data, found that the number of deaths attributed to alcohol had increased 13 percent since the previous study conducted by Rice et al. (1990) using 1985 data. Alcohol-attributable deaths increased from 94,768 in 1985 to 107,360 in 1992. The number of deaths attributed to drug abuse alone increased by 20 percent, and when other drug abuse-related conditions (tuberculosis, AIDS, and hepatitis) were added, the number of drug abuse deaths tripled from 7,454 to 25,493. The number of deaths during 1985 estimated by Rice et al. (1990) was 50 percent higher than the estimate of Harwood et al. (1984) for 1980. Table 5.2 summarizes the number of deaths and cost effects for alcohol and drug abuse.

Economic costs were estimated using the "human capital" approach to valuation of loss of expected years of life and productivity that would been undertaken over the course of life. These values are dependent on the age and gender of the decedent to reflect both the life expectancy as well as expected value of market and nonmarket/household productivity. This approach is in contrast to the "willingness-to-pay" approach, which attempts to reflect both expected loss of productivity (the essence of the human capital approach) as well as the "value" of pain and suffering. Studies performed for the U.S. Department of Health and Human Services and the Public Health Service have predominantly used the human capital approach, although cost-benefit studies (for example, studies of highway safety and pollution control) often use the willingness-to-pay approach (Miller et al. 1991). Human capital values are materially lower than "typical" willingness-to-pay values and, thus, will yield "conservative" estimates for economic costs relative to estimates based on the willingness-to-pay approach. Most of the prior studies on the economic costs of alcohol and drug abuse have used the human capital approach (an exception is Miller et al. 1997a,b). It has never been addressed whether special willingness-to-pay estimates would be needed for alcohol and drug abuse.

The following sections report the numbers of deaths attributed to alcohol and drugs and the estimated economic costs of those deaths using the human capital approach.

Methodology for Estimating Deaths

This study uses the same approach employed in the studies by Rice et al. (1990) and Cruze et al. (1981). The approach entails:

• Identifying the causes of death (ICD-9 diagnoses) that can be entirely or partially attributed to alcohol and drugs,
• Obtaining estimates of appropriate "attribution factors" by diagnosis,
• Accessing data on the number of deaths for each diagnosis by age and gender group, and
• Applying economic values by age and gender group for the present discounted value of expected lifetime productivity.

Mortality data are from 1992, the year for which detailed estimates have been developed. This study estimates values using discount rates of 3 percent, 4 percent, and 6 percent and primarily uses the 6-percent values in order to remain consistent with Rice et al. (1990) and previous studies. The concepts of expected lifetime productivity and discounting are discussed earlier, in section 3.3.3, as well as following, in section 5.2.3.

Deaths Attributable to Alcohol Abuse

This study first identified the ICD-9 codes - listed as the primary cause of death - that, according to the most recent research, are attributable entirely or partially to alcohol abuse. As a first step in this analysis, a list of applicable diagnoses, the proportion of deaths attributable to alcohol for each diagnosis (as designated by the attribution factor, or AF), and the corresponding age ranges were drawn from The Eighth Special Report to the U.S. Congress on Alcohol and Health (National Institute on Alcohol Abuse and Alcoholism [NIAAA] 1993). This list was supplemented with data from a report published by NIAAA in 1993 (Stinson et al. 1993). The final list of diagnoses, along with respective AF values, was reviewed and supplemented slightly by NIAAA staff.

The number of alcohol-related deaths for each ICD-9 code was calculated by multiplying the AF for each diagnosis by the total number of deaths in the relevant age range indicating the particular ICD-9 code as the primary cause of death. Mortality data with detailed age and gender distributions by diagnostic code for 1991 were initially obtained from the most recent public-use National Center for Health Statistics (NCHS) ICD-9 mortality data series (see table 5.3). Subsequently, this study gained access to NCHS mortality estimates for 1992, which have been used to adjust the 1991 values (NCHS 1996b).

The parameters for the alcohol analysis differ only modestly from the Rice et al. (1990) analysis. This study includes some of the deaths related to diseases in four categories not included in the Rice et al. (1990) study that have been recently studied for their relationship with alcohol abuse. The net effect of these additional categories is an extra 10,900 deaths attributed to alcohol abuse in the current study than would have been counted using the categories employed by Rice et al. (1990). These additional four diagnoses are the following:

• Hypertension,
• Cerebrovascular disease,
• Chronic hepatitis, and
• Other chronic liver diseases.

In addition, biliary cirrhosis has been dropped.

This study uses specified age breaks (e.g., age 15 and older) for 15 of the disease categories that were used by Rice et al. (1990) without age restrictions. This approach was adopted in accordance with current understanding of disease etiology (Stinson et al. 1993). Despite these restrictions, the number of deaths attributed to those categories for which there were age restrictions and for which there were no other methodological changes was slightly higher for this study than for the Rice et al. (1990) study.

Finally, there were 11 diagnostic codes for which the previous nonzero AF was reduced (e.g., automotive crashes and falls) or was increased (e.g., suicide, homicide, drowning, and fires). The net impact of such attribution changes applied to 1992 mortality in the indicated age groups is to increase attributed deaths for these 11 diagnoses from about 44,800 (using factors applied by Rice et al.) to 46,300 (using factors in this study).

Deaths Attributable to Drug Abuse

A similar process to that used for alcohol-attributable deaths was followed for identifying deaths attributable to drug abuse. The Rice et al. (1990) study (and previously Cruze et al. [1981]) employed a list of drug abuse-related causes (diagnostic codes) originally designated by the National Institute on Drug Abuse for use by the Drug Abuse Warning Network (Gottshalk et al. 1977, 1979). This list includes diagnoses representing abuse of and dependence on psychoactive drugs as well as accidental and intentional (i.e., suicide) poisoning by a broad range of drugs and medicaments - psychoactive and otherwise.

The rationale for using the broad list of drug types had its origin in the difficulty of determining the motivation for drug ingestion. Inappropriate use of prescription or nonprescription drugs constitutes drug abuse, whether a person takes a prescription medication without a prescription or takes a drug for an objective other than that for which it is appropriate.

This study has augmented the basic list of codes by incorporating estimates of deaths from several health problems associated with drug abuse and dependence. Chapter 4 presents the reviews and analyses performed to obtain estimates of attribution factors for tuberculosis, hepatitis B and C, and AIDS for health expenditures. The primary data and references used to calculate the attributable deaths for each of these additional diagnoses are briefly reviewed below. Table 5.4 summarizes data on the number of deaths attributed in this study to drug abuse.

AIDS

In 1992, 33,566 persons died of AIDS (NCHS 1996b). These data are obtained through the national death certificate data. Attribution of AIDS deaths was based on mortality data from national case reports for 1991 submitted to the Centers for Disease Control and Prevention (CDC) surveillance system. This source was chosen because the mortality data provide comprehensive information about AIDS exposure (CDC unpublished data, November 1994). The estimate of 33,566 AIDS deaths incorporates a downward adjustment for the fact that among deaths of AIDS patients, 88 percent were due to AIDS or AIDS-related causes, and the other 12 percent were unrelated (e.g., trauma) (Chu et al. 1993). The most recent year with complete data at the time that these calculations were developed was 1991.

This analysis applied to the reported 33,566 deaths the proportion of deaths within the following exposure categories from the CDC mortality data set (these values were adjusted upward to account for the 5 percent of deaths with no identified exposure category):

• Adults/adolescents who are injecting drug users (about 24 percent of deaths with identified exposure category);
• Adults/adolescents who have heterosexual sex with injecting drug users (about two-thirds of the 6 percent exposed through heterosexual contact);
• Adult/adolescent men who have sex with men and inject drugs (one-half of the 6 percent with dual exposure); and
• Children (under age 13) with a mother who has an infection or is at risk for infection because she is an injecting drug user or has sex with an injecting drug user (more than one-half of the 1 percent who were pediatric AIDS cases).

Out of the 33,566 AIDS deaths in 1992, this study attributes 10,737, or about 32 percent, to intravenous drug abuse. This rate is slightly below the 36-percent AF used for health care expenditures. The difference in these values lies in that the proportion of injecting-drug-user HIV cases has steadily increased since the beginning of the epidemic. The proportion of deaths (this section) actually represents AIDS cases reported several years previously.

Hepatitis B and C

The ICD-9 death certificate data undercount the number of deaths due to hepatitis B and C because they do not make the link between hepatitis and chronic liver disease. As an alternative to the ICD-9 data, the CDC Hepatitis Branch has developed annual death estimates, which take into account the toll of chronic liver disease brought on by hepatitis B and C (CDC 1993c, personal communication). The Branch estimates that there are 4,000 to 5,000 deaths a year from hepatitis B and 8,000 to 10,000 from hepatitis C. For the purposes of this analysis, the midpoint of these CDC-produced ranges is used to estimate that there were 4,500 deaths annually from hepatitis B and 9,000 annually from hepatitis C.

To estimate the numbers of these deaths attributable to intravenous drug use, this study relies on a sentinel risk factor study conducted by the CDC in four representative U.S. counties (Alter et al. 1990a). These studies reported the risk factors for acquiring hepatitis B and C, including parenteral (intravenous) drug use as a factor. Although these data do not link case development to death reports, it is thought that these are the most complete data presently available to estimate the number of hepatitis deaths associated with drug use. This study reported that 20 percent of the hepatitis C cases and 30 percent of the hepatitis B cases were linked to drug use for the range of years studied. This analysis uses these percentages as AF's to calculate the number of deaths attributable to drug use.

Tuberculosis

As described in chapter 4 of this report, it is estimated that drug abuse contributes to 4.5 percent of the tuberculosis cases that occur each year. This figure is applied to the deaths identified through the public-use data set from ICD-9 codes for tuberculosis (010 to 018). Co-infection with HIV does not lead to double counting of dually exposed individuals because both the death certificate ICD-9 system and the AIDS surveillance data from the CDC that this study uses impose a hierarchy of classification that assigns dually infected individuals to HIV/AIDS instead of tuberculosis.

Mortality Costs

The death of a person represents a loss of productive potential, whether in the marketplace (employment) or in the household. This productive potential has a clear economic value. For example, many families buy life insurance to protect against the potential loss of future productive contributions by those contributing to the upkeep of the household through jobs, homemaking responsibilities, or both. In instances of wrongful death, court cases make awards to family members of decedents based at least partially on their expected future earnings as well as the cost of replacing their expected contributions to maintaining the household. The "value of life" is recognized to be more than the replacement of future productive contributions. There are two major methods generally used to estimate the costs of premature mortality: the human capital and the willingness-to-pay approaches, both of which were briefly discussed in chapter 3.

This study applies the human capital approach to the estimation of mortality costs. This is the approach that has been used in most previous cost-of-illness studies (Hodgson and Meiners 1982). The approach to estimation of the cost for an individual is to sum the present discounted value of estimated productivity (market as well as nonmarket) over the person's expected remaining lifetime. Using this approach, a dollar value is assigned to production lost because of premature death.

The table of expected lifetime productivity (market plus nonmarket/household) by age and sex for 1992 was obtained in a personal communication from Dorothy Rice (1997). The formula for these calculations appears in Rice et al. (1990). Because Rice estimated lifetime productivity values for discount rates of 2, 4, and 6 percent, but not 3 percent, this value was interpolated from the values for 2 percent and 4 percent, which were provided by Rice. Analysis of the tables provided by Rice indicated that the interpolation should use the geometric mean, which actually provides a lower estimate of the value than use of the arithmetic mean or "average" provides. These estimates appear in appendix B of this report. Recent research suggests that a 3-percent discount value (as well as other, higher values) should be used in performing cost-benefit studies of health services (Gold et al. 1996).

The calculation of "present discounted value of expected lifetime earnings" for a person of a given age and gender begins with Bureau of Census "life tables." These tables provide average expected additional years of life (which depends on gender and current age) and use data on the average expected value of market (wages plus the value of fringe benefits) plus nonmarket productivity by age and gender. Expected productivity values are generally assumed to grow by 1 percent annually, reflecting expected growth in real labor productivity over time. Summing these values across the expected lifetime yields total expected lifetime productivity. For economic purposes, values in future years are adjusted down (discounted) by an amount related to the number of years in the future and the selected discount rate (equivalent to an interest rate). This adjustment reflects that a dollar today is worth more next year because it can accrue interest in the interim. Accordingly, a future value is reduced when considered in present discounted value terms. The higher the discount rate and the further in the future, the lower the present discounted value of future productivity.

Discussion is warranted on at least two particular issues in application of human capital estimates to alcohol and drug abusers: the discount rate and the expected future course of productivity. It is possible that a person with an alcohol or drug abuse problem may have lower productivity than a member of the general population - indeed, this is examined and supported in the next section of this report. The question is whether such a factor would justify using values lower than those for the general population in estimating future productivity. The rationale for not making such an adjustment or reduction is that if alcohol or drug abuse has caused the initial/current deficit relative to expected productivity, then future deficits will probably also be caused by those problems. Although it is likely that alcohol and drug abusers would have had lower future productivity, this would be caused by and attributable to alcohol and drug abuse, and making the adjustment would omit a material effect and cost that should be counted.

The appropriate discount rate for human capital estimates is somewhat controversial (Burkhead and Miner 1971). A high discount rate gives a lower present value of expected earnings, and a low discount rate gives a higher present value of expected earnings. There is extensive debate about what rate is appropriate for what kinds of studies. Higher rates (such as 8 to 10 percent) are used when there is more risk or uncertainty associated with a stream of values, while lower discount rates (2 to 4 percent) are used when there is less risk or uncertainty around events. Higher rates give preference to current benefits and consumption, whereas lower discount rates give more emphasis to future consumption and benefits. The major prior alcohol and drug studies have used a value in between - 6 percent - and the primary justification for using this value is to allow comparability with previous estimates. However, lower values, such as 3 percent, are apparently being used in much cost-benefit work for the Office of Management and Budget. This study reports costs using rates of 3, 4, and 6 percent. The more conservative, 6-percent figure (in that it gives lower cost estimates) is used in constructing and reporting the total estimates.

Using a 6-percent discount rate, the costs of alcohol and drug abuse-related deaths in 1992 are estimated to be $45.2 billion. About $30.7 billion of this is attributed to alcohol abuse (see table 5.5), and $14.6 billion is attributed to drug abuse (see table 5.6), or about $290,000 per alcohol-related death and $570,000 per drug-related death. The value per drug death is much higher because much of the alcohol-related mortality occurs at older ages as a result of chronic effects (cirrhosis and neoplasms), whereas virtually all the drug deaths are among young and prime-age adults (drug overdoses, homicide, and AIDS). Estimates are also calculated and reported using 3-percent and 4-percent discount rates. At a 3-percent discount rate, the estimated costs are $45.7 and $21.3 billion, respectively, or $425,000 and $835,000 per death for alcohol and drug abuse.

Much higher costs would result from application of the willingness-to-pay approach. A review of the willingness-to-pay literature found an average value per death across 47 studies of $2.3 million in 1989 dollars (cited in Miller et al. 1995). Adjusted for 3 years of inflation (about 12 percent to $2.55 million per death), this approach would indicate losses of $274 billion for alcohol-related mortality and $65 billion for drug-related deaths. These values are almost 9 and 4.5 times greater, respectively, than the estimates obtained using the human capital approach with a 6-percent discount rate. The application of the willingness-to-pay technique should be given further consideration. It was found that for smoking behaviors, willingness-to-pay values were substantially lower than for other populations and risks. It is worth considering whether the willingness-to-pay to save the lives of alcohol and drug abusers would be different from values for other types of risk and how such values would compare with other willingness-to-pay values.

Table 5.2: Total Number of Deaths and Economic Costs for Premature Mortalities Attributed to Alcohol and Drug Abuse, 1992

Table 5.2: Total Number of Deaths and Economic Costs for Premature Mortalities Attributed to Alcohol and Drug Abuse, 1992

Category	Deaths	Economic Cost (millions of dollars)
Alcohol abuse	107,360	$31,327
Drug abuse	25,493	$14,575
TOTAL	132,853	$45,902

Note: Components may not sum to totals because of rounding. Economic cost is the present discounted value of expected lifetime market plus nonmarket productivity, discounted by 6 percent. Estimates are also presented later in this section for 3-percent and 4-percent discount rates.

Table 5.3: Number of Deaths Attributable to Alcohol Abuse, 1992

Table 5.3: Number of Deaths Attributable to Alcohol Abuse, 1992

Cause	ICD-9 Code	Percent Attributed This Study	Percent Attributed Rice et al. (1990)	Estimate This Study, 1992 Data	Estimate Rice et al. (1990), 1985 Data
DIRECT PRIMARY CAUSES
Alcoholic psychoses	291.0	100	100	384	368
Alcohol dependence syndrome	303.0	100	100	5,217	4,188
Nondependent abuse of alcohol	305.0	100	100	788	750
Alcoholic polyneuropathy	357.5	100	100	4	2
Alcoholic cardiomyopathy	425.5	100	100	878	767
Alcoholic gastritis	535.3	100	100	90	61
Alcoholic cirrhosis	571.0-571.3	100	100	11,868	11,288
Excessive blood level of alcohol	790.3	100	100	34	12
Accidental poisoning - alcohol	E860.0-E860.1	100	100	179	175
Subtotal				19,442	17,611
DIRECT SECONDARY CAUSES
Respiratory tuberculosis	011-012	25	25	329	342
Malignant neoplasm of lip, cavity, and pharynx	140-149	50 (men) 40 (women)	47	3,741	3,896
Malignant neoplasm - esophagus	150	75	75	7,665	6,460
Malignant neoplasm - stomach	151	20	20	2,700	2,790
Malignant neoplasm of liver and interhepatic bile ducts	155	15	15	1,411	1,021
Malignant neoplasm of larynx	161	50 (men) 40 (women)	49	1,894	1,716
Diabetes mellitus	250	5	5	2,423	1,848
Essential hypertension	401	8	0	416	0
Cerebrovascular disease	430-438	7	0	9,985	0
Pneumonia and influenza	480-487	5	5	3,693	3,378
Diseases of esophagus, stomach, and duodenum	530-537 (not 535.3)	10	10	892	943
Chronic hepatitis	571.4	50	0	349	0
Cirrhosis of liver w/out alcohol	571.51	50	50	5,654	6,667
Biliary cirrhosis	571.6	0	50	0	(w/571.5)
Other chronic nonalcoholic liver damage	571.8	50	0	199	0
Unspec. chronic liver disease without mention of alcohol	571.9	50	0	118	0
Portal hypertension	572.3	50	0	67	0
Acute pancreatitis	577.0	42	41	907	917
Chronic pancreatitis	577.1	60	67	126	159
Subtotal				42,569	30,137
INJURIES AND ADVERSE EFFECTS INDIRECTLY ATTRIBUTED TO ALCOHOL
Motor vehicle accidents	E810-E825	42	51	17,196	23,190
Pedal cycle, other road accidents	E826, E8292	20	20	45	76
Water transport accidents	E830-E838	20	35	167	388
Air and space transport accidents	E840-E845	16	10	175	143
Accidental falls	E880-E888	35	41	4,372	4,919
Accidents caused by fire/flames	E890-E899	45	42	1,831	2,067
Accidental drowning, submersion	E910	38	30	1,339	1,851
Suicide and self-inflicted injury	E950-E959	28	13	8,476	3,828
Homicide and injury purposely inflicted by other persons (Rice et al. [1990]: 960-8)	E960-E969	46	42	11,609	8,329
Other injuries and adverse effects (Rice et al. [1990] used different coding)	E901, E911 E917, E918 E919, E920 E922, E980	25	11	139	2,229
Subtotal				45,349	47,020
TOTAL				107,360	94,768

Sources: Analysis by The Lewin Group based on data from the National Institute on Alcohol Abuse and Alcoholism (1993), Stinson et al. (1993), National Center for Health Statistics (1996b), and Rice et al. (1990).
Note: Components may not sum to totals because of rounding.
¹Rice et al. (1990) included 571.6 in this category. 
²Rice et al. (1990) included E825 in this category.

Table 5.4: Number of Deaths Attributable to Drug Abuse, 1992

Table 5.4: Number of Deaths Attributable to Drug Abuse, 1992

Cause	ICD-9 Code	Estimate This Study, 1992 Data	Estimate Rice et al. (1990), 1985 Data
Drug psychoses	292	13	11
Drug dependence	304	309	1,165
Nondependent abuse of drugs	305.2-305.9	777	524
Polyneuropathy due to drugs	357.0	0	0
Newborn affected by maternal transmission of narcotics and hallucinogens via placenta or breast milk	760.72,   760.73	NA	0
Drug withdrawal syndrome in newborn	779.5	6	1
Accidental poisoning by drugs, medicaments, and biologicals	E850-858 (Rice et al. [1990] includes 859)	5,951	3,552
Agricultural and horticultural chemical and pharmaceutical preparations other than plant foods and fertilizers	E863	18	0
Heroin, methadone, other opiates and related narcotics, and other drugs causing adverse effects in therapeutic use	E935.0-E935.2, E937-E940	27	33
Injury undetermined whether accidentally or purposely inflicted from poisoning by drugs, medicaments, and other	E980	1,464	832
Homicide and injury purposely inflicted by other persons (age > 15)	E960-E969	2,514	0
Tuberculosis	010-018	77	0
Hepatitis C	various	900	0
Hepatitis B	various	2,700	0
AIDS	various	10,737	1,336
TOTAL		25,493	7,454

Sources: Attribution factors: Gottshalk et al. (1977); analysis by The Lewin Group.
Note: The 760.7 diagnosis contains several factors in addition to narcotic and hallucinogen drugs. There were 69 deaths under this diagnosis in 1992, but the five-digit cause of death values were not available. Number of deaths derived from the National Center for Health Statistics (1996b) (mortality by cause for 1992).

Table 5.5: Economic Cost of Mortalities Due to Alcohol Abuse, for Various Discount Rates, 1992

Table 5.5: Economic Cost of Mortalities Due to Alcohol Abuse, for Various Discount Rates, 1992

Causes of Death, by ICD-9 Code		Total Deaths	Attributed to Alcohol Abuse			Discounted Economic Effects (millions of dollars)
Cause	ICD-9 Code		Percent	Age	Number	3%	4%	6%
Direct Primary Causes
Alcoholic psychoses	291	384	100	> 0	384	113.9	103.8	88.3
Alcohol dependence syndrome	303	5,217	100	> 0	5,217	2,215.9	2,012.3	1,701.1
Nondependent abuse of alcohol	305.0	788	100	> 0	788	504.4	445.8	360.7
Alcoholic polyneuropathy	357.5	4	100	> 0	4	1.0	1.0	0.9
Alcoholic cardiomyopathy	425.5	878	100	> 0	878	329.0	299.7	254.7
Alcoholic gastritis	535.3	90	100	> 0	90	42.1	38.0	31.9
Alcoholic cirrhosis	571.0-571.3	11,868	100	> 0	11,868	4,664.2	4,246.7	3,604.9
Excessive blood level of alcohol	790.3	34	100	> 0	34	31.2	27.0	21.2
Accidental poisoning by alcohol	E860.0, E860.1	179	100	> 0	179	128.1	113.0	91.1
Direct Secondary Causes
Tuberculosis	011-012	1,315	25	>35	329	905.8	811.0	670.1
Malignant neoplasm of lip, oral cavity, and pharynx	140-149	8,107	50 (men) 40 (women)	>35	3,741	632.6	589.1	519.1
Malignant neoplasm of esophagus	150	10,239	75	>35	7,665	1,073.3	1,005.0	893.8
Malignant neoplasm of stomach	151	13,630	20	>35	2,700	316.6	294.6	259.3
Malignant neoplasm of liver and interhepatic bile ducts	155	9,555	15	>35	1,411	178.8	166.4	146.5
Malignant neoplasm of larynx	161	3,114	50 (men) 40 (women)	>35	1,894	284.8	266.5	236.7
Diabetes mellitus	250	50,067	5	>35	2,423	255.3	237.3	208.6
Essential hypertension	401	5,232	8	>35	416	33.7	31.5	27.8
Cerebrovascular disease	430-438	143,769	7	>35	9,985	586.3	546.4	482.5
Pneumonia and influenza	480-487	75,719	5	>35	3,693	181.8	168.9	148.5
Diseases of esophagus, stomach, and duodenum	530-537 (excl. 535.3)	9,088	10	>35	892	67.6	62.8	55.2
Chronic hepatitis	571.4	729	50	>35	349	65.9	60.8	52.6
Cirrhosis of liver without mention of alcohol	571.5	11,506	50	>35	5,654	1,145.2	1,058.0	920.0
Other chronic nonalcoholic liver damage	571.8	482	50	>35	199	94.8	86.2	73.0
Unspecified chronic liver disease without mention of alcohol	571.9	244	50	>35	118	23.4	21.5	18.6
Portal hypertension	572.3	144	50	>35	67	12.0	11.2	9.9
Acute pancreatitis	577.0	2,317	42	>35	907	170.5	156.6	134.8
Chronic pancreatitis	577.1	222	60	>35	126	33.9	31.0	26.6
Injuries and adverse effects indirectly attributable to alcohol
Motor vehicle traffic and nontraffic accidents	E810-E825	40,982	42	> 0	17,196	12,685.1	10,692.3	8,023.1
Pedal cycle and other road vehicle accidents	E826, E829	223	20	> 0	45	28.6	24.1	18.2
Water transport accidents	E830-E838	837	20	> 0	167	133.1	113.9	87.6
Air and space transport accidents	E840-E845	1,094	16	> 0	175	129.9	113.6	90.3
Accidental falls	E880-E888	12,646	35	>15	4,372	664.8	591.6	485.1
Accidents caused by fires and flames	E890-E899	3,958	45	> 0	1,831	994.5	806.1	572.4
Accidental drowning and submersion	E910	3,524	38	> 0	1,339	1,068.2	869.0	617.1
Suicide and self-inflicted injury	E950-E959	30,484	28	>15	8,476	5,533.4	4,801.1	3,771.6
Homicide and injury purposely inflicted by other persons	E960-E969	25,144	46	>15	11,609	10,342.2	8,746.8	6,589.3
Other injuries and adverse effects	E901, E911, E917, E918, E919, E920, E922, E980	558	25	>15	139	45.8	40.8	33.5
Total		483,490			107,360	45,717.7	39,691.5	31,326.6

Sources: Alcohol attributable factors: National Institute on Alcohol Abuse and Alcoholism (1993) and Stinson et al. (1993); number of deaths: National Center for Health Statistics (1996b); NCHS Public Use ICD-9 Data Tape (age and gender distribution for deaths by ICD code for 1991); economic costs: Rice (1997), personal communication. Present discounted values for the 3-percent discount rate were estimated by interpolation of values for 2- and 4-percent discount rates.
Note: Components may not sum to totals because of rounding.

Table 5.6: Economic Cost of Mortalities Due to Drug Abuse, for Various Discount Rates, 1992

Table 5.6: Economic Cost of Mortalities Due to Drug Abuse, for Various Discount Rates, 1992

Causes of Death, by ICD-9 Code	ICD-9 Code	Total Deaths	Attributed to Drug Abuse		Discounted Economic Impact (millions of dollars)
Cause			Percent	Number	3%	4%	6%
Direct Primary Causes
Drug psychoses	292	13	100	13	6.7	5.9	4.7
Drug dependence	304	309	100	309	255.1	224.8	180.8
Nondependent abuse of drugs	305.2-305.9	777	100	777	618.8	544.6	437.1
Drug withdrawal syndrome in newborn	779.5	6	100	6	4.3	2.9	1.5
Accidental overdose of psychoactive drugs
Opiates and related narcotics	E850.0	1,279	100	1,279	1,130.9	992.5	792.4
Aromatic analgesics, not elsewhere classified	E850.2	69	100	69	36.7	32.2	25.9
Other non-narcotic analgesics	E850.7	0	100	0	0.0	0.0	0.0
Other	E850.8	167	100	167	151.7	132.6	105.2
Unspecified analgesics and antipyretics	E850.9	2	100	2	1.9	1.7	1.4
Barbiturates	E851	21	100	21	13.3	11.6	9.3
Other sedatives and hypnotics	E852	11	100	11	7.6	6.6	5.3
Tranquilizers	E853	65	100	65	39.6	34.9	28.1
Other psychotropic agents (incl. antidepressants)	E854	269	100	269	197.7	171.4	134.6
Other drugs acting on the central and autonomic nervous system	E855	1,113	100	1,113	1,009.4	877.3	689.6
Agricultural and horticultural chemical and pharmaceutical preparations other than plant foods and fertilizers	E863	18	100	18	9.9	8.4	6.3
Accidental Overdose of Drugs and Medicaments
Salicylates	E850.1	56	100	56	23.5	20.5	16.3
Pyrazole derivatives	E850.3	2	100	1	0.9	0.9	0.8
Antirheumatics	E850.4	3	100	2	1.8	1.5	1.2
Other non-narcotic analgesics	E850.5	79	100	79	60.8	53.5	42.9
Accidental poisoning by antibiotics	E856	55	100	55	15.3	13.3	10.6
Accidental poisoning by other anti-infectives	E857	5	100	5	3.1	2.7	2.2
Hormones and synthetic substitutes	E858.0	18	100	18	5.7	5.1	4.2
Primarily systemic agents	E858.1	44	100	44	21.3	18.2	14.0
Agents primarily affecting blood constituents	E858.2	33	100	33	13.0	9.9	6.4
Agents primarily affecting cardiovascular system	E858.3	218	100	218	16.8	14.9	12.2
Agents primarily affecting gastrointestinal system	E858.4	3	100	3	1.0	0.9	0.8
Water mineral and uric acid metabolism drugs	E858.5	75	100	75	13.6	11.8	9.4
Agents primarily acting on the smooth and skeletal muscles and respiratory system	E858.6	8	100	8	3.7	3.1	2.4
Agents primarily affecting skin and mucous membrane, ophthalmological, otorhinolaryngological, dental drugs	E858.7	7	100	7	1.0	1.0	0.9
Other specified drugs	E858.8	1,328	100	1,328	1,133.0	993.6	792.5
Unspecified drug	E858.9	1,021	100	1,021	855.1	749.6	597.3
Heroin, methadone, other opiates and related narcotics, and other drugs causing adverse effects in therapeutic use	E935.0-E935.2 E937-E940	27	100	27	5.4	4.8	3.9
Injury Undetermined Whether Accidental or Purposely Inflicted
Analgesics, antipyretics, and antirheumatics	E980.0	491	100	491	404.7	355.0	283.4
Barbiturates	E980.1	13	100	13	9.3	8.1	6.5
Other sedatives and hypnotics	E980.2	8	100	8	6.0	5.3	4.2
Tranquilizers and other psychotropic agents	E980.3	159	100	159	109.9	96.5	77.3
Other specified drugs and medicinal substances	E980.4	478	100	478	405.1	352.9	278.6
Unspecified drug or medicinal substance	E980.5	252	100	252	201.0	176.6	141.3
Other and unspecified solid and liquid substances	E980.9	63	100	63	45.1	39.4	31.3
Homicide and injury purposely inflicted by other persons	E960-E969	25,144	10	2,514	2,239.2	1,893.7	1,426.6
Other Causes
Tuberculosis	010-018	1,705	4.5	77	21.2	19.0	15.7
Hepatitis C	See discussion	4,500	20	900	819.4	698.2	532.0
Hepatitis B	See discussion	9,000	30	2,700	2,438.3	2,077.9	1,583.9
AIDS	See discussion	33,566	32	10,737	8,958.2	7,849.1	6,254.3
Total				25,493	21,316.3	18,524.6	14,574.9

Sources: Attribution factors: Gottshalk et al. (1977); analysis by The Lewin Group, Chu et al (1993), Alter et al. (1990a); number of deaths: National Center for Health Statistics (1996b); NCHS Public Use ICD-9 Data Tape (age and gender distribution for deaths by ICD code for 1991); economic costs: Rice (1997), personal communication. Present discounted values for 3 percent were estimated based on values for 2 percent and 4 percent, respectively.
Notes: Components may not sum to totals because of rounding.