The changing landscape of substance use disorders over 30 years: insights on US state disparities and policy from the global burden of disease study

Abstract Background Substance use disorders (SUDs) remain a major source of preventable morbidity and mortality in the United States. This study described trends in the burden of SUDs from 1990 to 2019 by substance, sex, and age, and examined whether state-level policy environments and behavioral health budgets differed across states with the highest and lowest SUD-related disability-adjusted life years (DALYs). Methods We conducted a descriptive epidemiologic study using Global Burden of Disease Study 2019 estimates for alcohol, opioid, cocaine, amphetamine, cannabis, and other drug use disorders in the United States. DALYs were the primary outcome and were examined by sex, age, substance, and year. To contextualize state-level disparities, we descriptively summarized behavioral health budget allocations and selected policy domains in states with the three highest and three lowest DALY rates for drug use disorders and alcohol use disorders. Results From 1990 to 2019, prevalent SUD cases in the United States increased from 12.6 million to 19.5 million, and the age-standardized DALY rate for SUDs rose from 725.5 to 2,274.4 per 100,000 population. Opioid use disorders showed the largest increases in both prevalence (618.5%) and DALY rates (643.7%), becoming the leading contributor to SUD-related burden. Cocaine and amphetamine use disorders showed smaller increases in prevalence but larger increases in DALY rates, whereas alcohol use disorder changed modestly and cannabis-related DALY rates remained unchanged. In 2019, the age-standardized DALY rate for SUDs was higher among males than females (2,486.8 vs. 1,722.6 per 100,000 population). Opioid-related DALYs peaked in early adulthood, whereas alcohol-related DALYs peaked in midlife. Substantial geographic variation was observed: drug-related DALY rates were highest in West Virginia, Kentucky, and Ohio and lowest in Nebraska, South Dakota, and North Dakota, while alcohol-related DALY rates were highest in New Mexico, Alaska, and the District of Columbia and lowest in New Jersey, Maryland, and Texas. States with lower burden generally reflected more prevention-oriented and coordinated policy environments, although the presence of policy alone did not consistently correspond to lower burden. Conclusions The burden of SUDs in the United States increased substantially over three decades, driven primarily by opioids and with marked variation across sex, age, and geography. Descriptive comparisons suggest that policy context and behavioral health investment may help shape state-level differences, but implementation, treatment access, and broader structural conditions also matter. Coordinated, equitable, and adequately resourced prevention, treatment, and harm-reduction strategies are needed to reduce persistent disparities in SUD-related outcomes.