Alabama Drug and Alcohol Statistics - World Forum for Mental Health

Statistical Data on Drugs in Alabama

This comprehensive report presents drug use, overdose, and treatment statistics for Alabama based on multiple data sources spanning from the early 2000s through 2022. The data reveals significant challenges facing the state, including a dramatic rise in fentanyl-related deaths, persistent issues with methamphetamine and prescription opioid misuse, and notable demographic disparities in overdose rates. Alabama has historically had one of the highest opioid prescribing rates in the nation, though this has declined in recent years. The state’s youth and young adult populations show concerning rates of substance use disorders, while treatment access remains limited, particularly in rural areas.

Overdose Deaths and Mortality Rates

Overall Overdose Death Trends

768 annual overdose deaths
1.41% of all deaths are from drug overdose
0.51% annual increase rate over 3-year period
16.3 deaths per 100,000 (earlier period) – 21.26% below national death rate
1.09% of nationwide overdose deaths occur in Alabama
90% increase in overdose deaths from 2018 to 2022
2.5 times increase since 2013

Alabama Overall Overdose Death Statistics
Alabama has experienced a severe escalation in drug overdose deaths over the past decade. The death rate nearly doubled between 2014 and 2022, with the most dramatic increases occurring in recent years.

Overdose Deaths by Year

Year	Total Deaths	Death Rate (per 100,000)	Notable Changes
2010	585	12.2	Below national average (12.9)
2012	—	13.1	—
2014	—	15.4	Baseline for doubling by 2022
2015	—	14.9	—
2016	—	15.4	—
2017	836	17.1	11.1% increase from 2016
2018	—	15.4	—
2020	—	24.6	Nearly doubled from 2012
2021	1,408	—	—
2022	1,492	29	3% lower than US overall; 90% increase since 2018

Geographic Disparities in Overdose Deaths (2022)

Rank	County	Deaths per 100,000
1	Walker County	69.9
2	Jefferson County	57.3
3	Calhoun County	48.4
4	St. Clair County	44.7
5	Cullman County	34.2
6	Morgan County	33.8
7	Lauderdale County	32.3
8	Baldwin County	30.4
9	Etowah County	30.1
10	Mobile County	29.2

Overdose deaths in Alabama show dramatic geographic variation. This disparity highlights the uneven distribution of the crisis and suggests varying levels of drug availability, economic factors, and treatment access.

Opioid-Related Statistics

Deaths and Trends

381 annual opioid overdose deaths
49.2% of all overdose deaths involve opioids (earlier period)
8.3 per 100,000 death rate – 43.2% less than national rate
419 opioid-involved deaths in 2017
8.6 per 100,000 in 2017 (increased from 7.0 in 2016 and 5.7 in 2015)
981 opioid-involved deaths in 2021

Opioids account for approximately half of all overdose deaths in Alabama.

Fentanyl Crisis

Year	Fentanyl Deaths
2006	—
2017	161
2018	121
2022	835

Key Trends

590% rise in fentanyl-related overdose deaths from 2018 to 2022
42.2-fold increase in fentanyl death rates between 2006 and 2022
66% of total overdose deaths in 2022 involved fentanyl and synthetic opioids

Alabama Fentanyl Crisis Statistics

The fentanyl crisis in Alabama has exploded with unprecedented severity. Fentanyl now dominates the overdose landscape, involved in two-thirds of all drug deaths.

Prescription Opioid Trends

Year	Prescriptions per 100 Residents	Notable Facts
2012	143.8	Peak prescribing rate
2013	—	Baseline for 25% decline
2017	107.2	Highest in the nation; 25% decline from 2013
2018	92.8	—
2022	80.4	44% drop from 2012 peak

Additional Prescription Data

Doctors write enough prescriptions for 97.5% of residents to have one (earlier period)
121 prescriptions written per 100 residents in 2016 – more than double the national average
Hydrocodone and oxycodone comprised 68% of pharmaceutical misuse admissions

Alabama’s prescription opioid crisis has shown signs of improvement through policy interventions and prescribing restrictions.

Substance Use Prevalence by Youth (Ages 12-17)

Drug Use Statistics

26,000 (6.99%) used drugs in the last month
16.10% less likely to have used drugs than average American teen
7.2% past-month illicit drug use (2017-2019) – similar to regional (7.5%) and national (8.2%)
5.2% past-month marijuana use (2017-2019) – similar to regional (6.2%) and national (6.8%)
8.33% used alcohol in the last month
8.93% less likely to use alcohol than average American in their age group
7.2% illicit drug use rate, with prescription drug misuse at 5.8%

Specific Substances (Past Year/Month)

Marijuana: 9.68% in the last year; 84.62% of drug users use marijuana
Cocaine: 0.27%
Methamphetamines: 0.27%
Heroin: Up to 0.13% (limited data)
Pain relievers misuse: 4.03%

Substance Use Disorders

2.42% met criteria for Illicit Drug Use Disorder (IDUD) in the last year
1.61% met criteria for Alcohol Use Disorder (AUD) in the last year

First-Time Use (2017-2019 Annual Average)

Alcohol: 6.3% (23,000 youth) – lower than regional (8.7%) and national (9.3%)
Marijuana: 4.0% (15,000 youth) – similar to regional (4.8%) and national (5.2%)
Cigarettes: 3.2% (12,000 youth) – similar to regional (2.7%) and national (2.3%)

Alabama youth show lower rates of substance use compared to national averages, which is a positive indicator. However, the early age of first marijuana use (12.2 years) and the fact that over 26,000 teens used drugs in the last month indicate ongoing prevention needs. Prescription drug misuse at 5.8% is particularly concerning given the dangers of opioids.

Substance Use Prevalence by Young Adults (Ages 18-25)

Drug Use and Disorders

152,000 used drugs in the last month
14.50% less likely to use drugs than average American in same age group
18.94% past-month illicit drug use (2021-2022)
17.61% past-month marijuana use (2021-2022)
28.4% past-year marijuana use (2017-2019) – similar to regional (30.6%), lower than national (35.0%)
2.9% opioid use disorder – higher than Region 4 (1.4%) and national average (1.3%)
8.1% illicit drug use disorder – higher than Region 4 and national average (both 7.2%)
7.88% misuse of prescription pain relievers

Substance Use Disorders (2017-2019)

5.0% marijuana use disorder (25,000 people) – similar to regional (4.6%) and national (5.6%)
1.9% opioid use disorder (10,000 people) – similar to regional (1.3%) and national (1.0%)
7.9% illicit drug use disorder (40,000 people) – similar to regional (6.6%) and national (7.5%)
12.3% substance use disorder (63,000 people) – similar to regional (12.3%) and national (14.7%)
15.23% drug use disorder (2021-2022)
22.27% substance use disorder (2021-2022)

Treatment Statistics (2022)

4.99% received substance use treatment
24.56% classified as needing substance use treatment
80.84% not receiving treatment among those needing it

Young adults in Alabama face elevated rates of substance use disorders compared to older adults and often exceed national averages. The opioid use disorder rate of 2.9% is approximately double the national average, representing a critical public health concern for this age group. The high percentage not receiving treatment (80.84%) indicates significant gaps in service access.

Substance Use Prevalence by Adults (All Ages 12+)

Past-Month Use (2021-2022)

11.02% illicit drug use
8.69% marijuana use
3.19% illicit drug use other than marijuana

Past-Year Use

13.7% marijuana use (561,000 people in 2017-2019) – similar to regional (14.0%), lower than national (16.2%)
1.37% cocaine use
1.40% methamphetamine use
0.43% heroin use (18,000 people in 2017-2019) – similar to regional (0.25%) and national (0.30%)
1.86% hallucinogen use
4.22% prescription pain reliever misuse
4.38% opioid misuse
5.1% prescription pain reliever misuse (209,000 people in 2017-2019) – higher than regional (3.9%) and national (3.7%)

Substance Use Disorders (2021-2022)

14.51% substance use disorder (618,000 people)
8.74% drug use disorder (372,000 people)
3.03% opioid use disorder
2.65% pain reliever use disorder
1.4% marijuana use disorder (56,000 people in 2017-2019) – similar to regional (1.3%) and national (1.6%)
1.0% opioid use disorder (43,000 people in 2017-2019) – similar to regional (0.8%) and national (0.7%)
3.2% illicit drug use disorder (132,000 people in 2017-2019) – similar to regional (2.7%) and national (2.9%)
7.6% substance use disorder (310,000 people in 2017-2019) – similar to regional (6.4%) and national (7.4%)

Treatment Statistics (2022)

5.23% (224,000) received substance use treatment
17.85% (764,000) classified as needing treatment
71.05% not receiving treatment among those needing it

Risk Perceptions

24.96% perceive great risk from smoking marijuana once a month
72.11% perceive great risk from using cocaine once a month
83.70% perceive great risk from trying heroin once or twice

Overall adult substance use in Alabama generally tracks below or similar to national rates, though prescription pain reliever misuse is notably higher than both regional and national averages. The large treatment gap – over 70% of those needing treatment not receiving it – represents a major system failure.

Treatment Facility Statistics

Facilities and Capacity

171 active substance abuse centers in Alabama (ranks 38th for treatment affordability)
147 facilities provided substance abuse treatment (2011)
103 facilities: substance abuse treatment only
33 facilities: mix of mental health and substance abuse treatment
4 facilities offer free drug rehab treatment for all clients
83 Certified and Contract entities work with ADMH
11 additional providers certified but not receiving ADMH funding
21 Opioid Replacement Therapy (ORT) clinics statewide
19 public non-profit regional mental health boards (310 boards); 14 provide substance abuse treatment

Annual Patient Volume

14,578 patients serviced annually
13,567 patients in outpatient services annually (93%)
797 patients in residential (non-hospital) services annually (5.5%)
214 clients in hospitals for drug rehab (1.5%)
15,924 clients in treatment (March 31, 2011)

Alabama Annual Patient Volume Statistics

Single-Day Count (March 2019)

14,578 people enrolled (increase from 14,548 in 2015)
63.6% received treatment for drug problem only
9.7% received treatment for alcohol problem only
26.7% received treatment for both drug and alcohol

Alabama has a limited treatment infrastructure, which may contribute to the high percentage of people not receiving needed care. The state’s treatment system is heavily weighted toward outpatient services (93% of patients), which may not be adequate for severe substance use disorders.

Treatment Costs

Outpatient Treatment

Average individual cost: $1,703
Total public spending: $23.1 million (1.0% of U.S. total)

Residential Treatment

Average individual cost: $58,607
Total public spending: $46.71 million (0.9% of U.S. total)

Alabama’s treatment costs are moderate compared to other states. However, the high cost of residential treatment ($58,607 per patient) may be prohibitive for many residents, potentially driving them to less intensive outpatient care.

Medication-Assisted Treatment (MAT)

Methadone and Buprenorphine (Single-Day Counts)

7,093 people receiving methadone in March 2019 (decrease from 7,639 in 2015)
1,274 people receiving buprenorphine in March 2019 (increase from 787 in 2015)

Opioid Treatment Program Enrollments

6,132 in 2016
7,441 in 2017 (21.3% increase)

ADMH Treatment (2018)

4,546 individuals treated for heroin addiction
7,082 treated for other opiates and synthetics
These represent approximately 66% of patients receiving SUD treatment (34% treated elsewhere)

Alabama has shown mixed trends in MAT utilization, with methadone use declining while buprenorphine use increased substantially.

Treatment Admission Trends by Substance

2010 Data

6,945 marijuana admissions
2,108 smoked cocaine
842 other-route cocaine
4,755 treated for both alcohol and drugs
9,810 treated for drugs only
1,359 treated for alcohol only

2011 Data

Approximately 90.3% of those using illicit drugs did NOT receive treatment
99,000 individuals aged 12+ were dependent on or abused illicit drugs

Alabama Department of Corrections (December 2014)

2,733 inmates completed drug treatment programs
2,059 in aftercare programs

Treatment admissions reveal shifting patterns in Alabama’s drug crisis. The decline in smoked cocaine admissions among males and corresponding increase among females may reflect changing demographic patterns of use. Similar gender shifts are seen across multiple substances, suggesting evolving risk profiles.

Emergency Response Statistics

Emergency Department Visits

11,081 overdose-related ED visits in 2018 (2,180 involving opioids)
50%+ of all ER visits statewide accounted for by overdoses

Emergency Response

20,353 overdose-related 911 runs in 2018 (4,373 involving opioids)
4,669 emergency calls about possible overdoses (first half of 2022)

Treatment Enrollment (March 2022)

Nearly 12,000 people receiving SUD treatment

The volume of emergency responses to overdoses demonstrates the acute strain on emergency services. The first half of 2022 saw 4,669 emergency calls for possible overdoses, indicating the crisis continues unabated.

Related Health Impacts

HIV/AIDS and Injection Drug Use

New HIV Cases (2016)

533 total new HIV cases
Males: 5.6% attributed to IDU or male-to-male contact + IDU
Females: 7.9% attributed to IDU

Alabama New HIV Cases Statistics

Persons Living with HIV (2015)

12,316 persons with diagnosed HIV infection (302 per 100,000)
Males: 12.6% attributed to IDU or male-to-male contact + IDU
Females: 15% attributed to IDU
13,124 total HIV/AIDS cases attributed to intravenous drug use

Injection drug use contributes significantly to Alabama’s HIV/AIDS burden, with over 13,000 existing cases attributed to IDU. The relatively low percentage of new cases from IDU compared to the large existing population suggests either that IDU-related transmission has decreased or that these represent long-term survivors.

Hepatitis C

32 new acute HCV cases in 2016 (0.7 per 100,000)
Estimated 31,300 persons living with Hepatitis C (2013-2016 average)
Rate: 840 cases per 100,000
30,700 cases attributed to intravenous drug use

Alabama faces a substantial hepatitis C burden, with over 31,000 people living with the disease. The relatively low number of acute cases (32) compared to the total population suggests most current cases are chronic infections from past injection drug use.

2009 Alabama Drug Court Statistics

41 total specialty courts
3 domestic violence courts
6 juvenile drug courts

Alabama has developed a network of specialty courts to address substance use disorders in the criminal justice system. The 41 specialty courts represent an effort to divert individuals to treatment rather than incarceration, though coverage may still be inadequate given the scope of the problem.

Education and Prevention: School-Based Data (PRIDE Survey)

Average age of first marijuana use: 12.2 years
44.3% of students report teachers seldom or never talk about tobacco, alcohol, and marijuana problems
33.6% report teachers seldom or never discuss these problems (second mention, possibly different survey year)
10% of high school students bought or sold drugs at school
17.8% bought or sold drugs while not at school

Alabama Drug Education and Prevention Statistics

The PRIDE Survey reveals concerning gaps in drug education and early initiation of use. The fact that 44.3% of students report their teachers seldom or never discuss substance use problems indicates missed prevention opportunities. The high rates of drug sales at school (10%) and off-campus (17.8%) point to ready availability.

Final Words

Alabama faces a severe and escalating drug overdose crisis driven primarily by fentanyl, which caused 835 deaths in 2022 and now accounts for 66% of all overdose deaths. Despite a 44% reduction in prescription opioid dispensing since 2012, overall overdose deaths have increased 90% since 2018, with significant geographic disparities ranging from 11.6 to 69.9 deaths per 100,000 across counties. The most critical gap is in treatment access, with over 71% of people needing substance use treatment not receiving it, compounded by 41% fewer facilities in rural areas where death rates are 22% higher. Young adults aged 18-25 face particularly elevated risks, with opioid use disorder rates double the national average and over 80% not receiving needed treatment.

Statistical Data on Alcohol in Alabama

This comprehensive report presents alcohol use, abuse, and related mortality statistics for Alabama based on multiple data sources. The data reveals that while Alabama has lower rates of excessive drinking compared to national averages, alcohol abuse remains a significant public health concern. The state has the third-highest rate of under-21 alcohol-related deaths in the nation and ranks 7th nationally for excessive drinking. Alabama experiences over 2,200 annual deaths attributable to excessive alcohol use, with significant impacts on traffic safety, healthcare costs, and productivity. Binge drinking patterns, particularly among young adults and 12th graders, present ongoing challenges despite rates that are generally lower than national averages.

Alcohol-Related Deaths and Mortality

Overall Alcohol Death Trends

2,208 annual deaths attributable to excessive alcohol use
3.9% of alcohol-related deaths are people under age 21
71.5% of deaths are male
79.9% of deaths are adults aged 35 years and older
3.94% of deaths are under age 21
Alabama has the third-highest rate of under-21 deaths related to excessive alcohol use in the nation

Alabama Alcohol-Related Deaths and Mortality Statistics

Death Rate Statistics

5.65 deaths per 10,000 adults (or 1 death per 2,275 people aged 18+)
5-year average annual rate increased by 44.8% from 2015 to 2019

Types of Deaths

49.8% of deaths are from chronic causes (such as Alcohol Use Disorder)
50.2% of deaths are from acute causes

Years of Potential Life Lost

CDC estimates 59,606 years of potential life lost to excessive alcohol use annually

Alabama experiences a substantial burden from alcohol-related deaths, with over 2,200 deaths annually. The 44.8% increase in the death rate from 2015 to 2019 indicates a worsening crisis. Males account for nearly three-quarters of deaths, and the majority of deaths occur in adults 35 and older, suggesting long-term consequences of chronic alcohol use.

Alcohol Use Prevalence by Youth (Ages 12-17)

Past-Month Alcohol Use

8.4% (31,000 youth) in 2017-2019 – similar to regional (9.2%) and national (9.4%)
5.72% (23,000) past-month use in 2021-2022
8.08% used alcohol in previous month (2015-2016 data)
5.7% reported drinking in past month (the year is not specified) – Alabama ranks 3rd nationally

Binge Drinking

3.10% (12,000) youth engaged in binge drinking in past month (2021-2022)

Alcohol Use Disorder

3.13% (12,000) met criteria for AUD in past year (2021-2022)
1.67% affected by AUD (2015-2016)

Trend Data – Past-Month Use

Period	Alabama	U.S.
2016-2017	4.4%	5.1%
2017-2018	4.8%	5.0%
2018-2019	4.3%	4.8%
2021	3.4%	3.8%

Alabama youth show relatively low rates of alcohol use compared to national averages, which is encouraging.

Alcohol Use Prevalence by Young Adults (Ages 18-25)

Past-Month Alcohol Use

40.59% in 2021-2022 (214,000 young adults)
50.76% used alcohol in previous month (2015-2016 data)

Binge Drinking

26.3% in 2017-2019 (134,000 young adults) – lower than regional (30.1%) and national (35.4%)
24.40% in 2021-2022 (128,000 young adults)
31.5% in 2016-2017
29.6% in 2017-2018
28.0% in 2018-2019
23.4% in 2021

Binge Drinking Trend Data

Period	Alabama	U.S.
2016-2017	31.5%	37.6%
2017-2018	29.6%	35.9%
2018-2019	28.0%	34.6%
2021	23.4%	29.2%

Young adults show the highest rates of alcohol use and binge drinking of any age group, though Alabama rates remain below national averages. The decrease in AUD from earlier periods (9.08% to 7.5%) is a positive trend.

Alcohol Use Disorder

7.5% in 2017-2019 (38,000 young adults) – similar to regional (7.8%) and national (9.8%)
14.20% met criteria for AUD in 2021-2022 (75,000 young adults)
9.08% affected by AUD (2015-2016)

Alcohol Use Prevalence by Adults (Ages 26+)

Past-Month Alcohol Use

43.70% in 2021-2022 (1,460,000 adults)

Binge Drinking

19.70% in 2021-2022 (658,000 adults)
21.8% in 2016-2017
24.0% in 2017-2018
25.4% in 2018-2019
20.0% in 2021

Binge Drinking Trend Data

Period	Alabama	U.S.
2016-2017	21.8%	24.5%
2017-2018	24.0%	25.0%
2018-2019	25.4%	24.8%
2021	20.0%	22.4%

Adult alcohol use and binge drinking rates show an increasing trend from 2016-2019, which is concerning given that this age group comprises the largest population segment.

Alcohol Use Disorder

8.83% in 2021-2022 (295,000 adults)

High School Students (12th Graders) – PRIDE Survey Data

Alcohol Use Patterns

40% use alcohol on a monthly basis
37.7% have had 5 or more drinks within a few hours (binge drinking)
Monthly alcohol use in Tuscaloosa is higher than the national average
Average age of first alcohol use: 11.3 years

Drinking and Driving

20.5% have driven a car after drinking alcohol in the past 30 days
30.2% have ridden in a car with someone who has been drinking alcohol in the past 30 days

Access and Social Context

56.5% use alcohol at their own home or a friend’s home
63.6% say alcohol is fairly or very easy to get
75.3% feel their friends believe using alcohol is only a little wrong or not at all wrong

The PRIDE Survey reveals extremely concerning patterns among Alabama 12th graders, with 40% using alcohol monthly and over one-third engaging in binge drinking. The average age of first use combined with easy access and low perceived risk from peers creates a perfect storm for underage drinking.

Geographic Variations: County-Level Excessive Drinking

Baldwin County: 19% (highest in state, above national average)
Cherokee County: 18%
Several other counties: 17%
State average: 16%
National average: 19%

Baldwin County leads the state in excessive drinking at 19%, exceeding both the state average and the national average. This suggests significant geographic variation in drinking patterns, with coastal and certain other counties showing higher rates.

Alcohol Treatment Statistics

Alcohol admissions are the second most common substance abuse treatment admissions
4,635 people admitted for primary alcohol treatment in 2010
2,746 people admitted for alcohol abuse with a secondary substance in 2010
7,381 total alcohol-related treatment admissions in 2010
62% of alcohol-related treatment admissions are male (compared to 54% nationally)

Alcohol is the second most common reason for substance abuse treatment admissions in Alabama. The 62% male admission rate is notably higher than the national average of 54%, suggesting gender-specific patterns in alcohol abuse severity or treatment-seeking behavior in Alabama.

Alcohol-Impaired Driving and Traffic Safety

Overall Statistics

25% of drivers killed in fatal crashes had BAC of .08 or higher in 2020
30% of fatal crashes in 2020 involved alcohol-impaired driving (144 out of 476 crashes)
25.9% of fatal car accidents involve alcohol (17th lowest nationally, U.S. rate: 26.6%)
31% decrease in alcohol-involved crashes from 2012 to 2022

Alabama Alcohol-Impaired Driving and Safety Statistics

Fatal Crashes by Time of Day (2020)

Time Period	Total Fatal Crashes	Alcohol-Impaired	% Alcohol-Impaired
Midnight – 2:59 AM	75	37	50%
3:00 – 5:59 AM	52	16	32%
6:00 – 8:59 AM	37	3	9%
9:00 – 11:59 AM	33	3	10%
Noon – 2:59 PM	69	13	18%
3:00 – 5:59 PM	62	19	30%
6:00 – 8:59 PM	76	25	32%
9:00 – 11:59 PM	72	28	38%
Total	476	144	30%

Peak Risk Times

50% of fatal crashes from midnight to 3 AM involved alcohol
43% of fatal crashes from 6 PM to 9 PM involved alcohol

Alcohol-impaired driving accounts for 30% of fatal crashes in Alabama, with the highest risk during late night and evening hours. The 50% impairment rate for crashes between midnight and 3 AM demonstrates the extreme danger of nighttime drinking and driving.

Economic Impact

Alabama taxpayers spent $3.724 billion in 2010 as a result of excessive alcohol use
Adjusted for inflation: equivalent to $5.028 billion in 2022 dollars
Cost per drink: $3.06

The economic burden of excessive alcohol use in Alabama is staggering, costing over $5 billion annually when adjusted for inflation. This translates to $3.06 per alcoholic drink consumed, representing costs from healthcare, lost productivity, criminal justice, and other alcohol-related harms.

Final Words

Alabama presents a paradoxical alcohol profile: while overall consumption rates are among the lowest in the nation (ranking 48th out of 50 states), the state faces the third-highest rate of under-21 alcohol-related deaths and has seen a 44.8% increase in alcohol death rates from 2015 to 2019. The most concerning patterns emerge among youth and young adults, with 40% of 12th graders using alcohol monthly, an average first-use age of 11.3 years, and over one-fifth of 12th graders driving after drinking. Despite lower binge drinking rates compared to national averages, alcohol-impaired driving accounts for 30% of fatal crashes, with half of all late-night crashes involving impairment, and the annual economic burden exceeds $5 billion.

Conclusion

In general, Alabama faces a severe dual substance abuse crisis with fentanyl driving 66% of the 1,492 drug overdose deaths in 2022 and over 2,200 annual alcohol-related deaths, both increasing dramatically in recent years (90% rise in overdoses since 2018; 44.8% rise in alcohol deaths from 2015-2019). Young adults aged 18-25 are critically vulnerable with opioid use disorder rates double the national average, while youth begin using substances at ages 11-12, and 40% of 12th graders use alcohol monthly. The crisis is compounded by massive treatment gaps—over 71% of those needing help don’t receive it—extreme geographic disparities (overdose rates varying six-fold across counties), and annual costs exceeding $5 billion for alcohol alone.