Drug Policy and Public Health - ids

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PAPERS
INTERNATIONAL SYMPOSIUM ON DRUG
POLICY AND PUBLIC HEALTH
PAPERS
29 September - 1 October 2014
İSTANBUL
THE FINAL BOOK OF THE INTERNATIONAL SYMPOSIUM
ON DRUG POLICY AND PUBLIC HEALTH
© PUBLISHED BY THE TURKISH GREEN CRESCENT SOCIETY
All rights reserved
The authors are responsible for the content of their published articles
Editors:
Abdülhakim Mermer
Ahmet Zeki Olaş
Savaş Yılmaz
Graphic Design:
Düet Reklam
Correspondence
Türkiye Yeşilay Cemiyeti Genel Merkezi
Sepetçiler Kasrı – Kennedy Cad. No: 3
Sarayburnu, Fatih 34110 İstanbul
+90 (212) 527 16 83
www.yesilay.org.tr [email protected]
4
INTERNATIONAL SYMPOSIUM ON DRUG POLICY AND PUBLIC HEALTH
BOARDS
Organizing
Committee
Scientific Advisory
Committee
Dr. M. Akif Seylan
Prof. Dr. Ayşen Gürcan
Prof. Dr. Nesrin Dilbaz
Dr. İbrahim Topçu
Prof. Dr. Alaattin Duran
Prof. Dr. Osman Hayran
M. Pervin Tuba Durgut
Prof. Dr. Bülent Çaplı
Prof. Dr. Saffet Tüzgen
Assoc. Prof. Yusuf Adıgüzel
Prof. Dr. Cahide Aydın
Prof. Dr. Sabahattin Aydın
Dr. Ahmet Özdinç
Prof. Dr. Cevdet Erdöl
Prof. Dr. Yunus Söylet
Savaş Yılmaz
Prof. Dr. Faruk Aşıcıoğlu
Prof. Dr. Zehra Arıkan
Prof. Dr. Ayşen Gürcan
Prof. Dr. Ferhunde Öktem
Assoc. Prof. Hasan Hüseyin Eker
Prof. Dr. Figen Karadağ
Assoc. Prof. Murat Gültekin
Prof. Dr. Hakan Coşkunol
Assoc. Prof. Cüneyt Evren
Prof. Dr. Halil Ekşi
Assoc. Prof. Mustafa Taşdemir
Prof. Dr. Hasan Bacanlı
Assoc. Prof. Osman Tolga Arıcak
Prof. Dr. Haydar Sur
Assoc. Prof. Osman Vırıt
Prof. Dr. Hayrettin Kara
Assist. Prof. Dr. Perihan Torun
Prof. Dr. Işıl Maral
Assist. Prof. Itır Tarı Cömert
Prof. Dr. İbrahim Cılga
Assist. Prof. Ömer Miraç Yaman
Patrick Pennickx
Prof. Dr. İlhan Yargıç
Dr. Arzu Çiftçi Demirci
Paul Griffiths
Prof. Dr. Kemal Sayar
Dr. Maria Cristina Profili
Sebahattin Kuş
Prof. Dr. Kültegin Ögel
Dr. Gazi Alataş
Prof. Dr. M. Hakan Türkçapar
Dr. Gilberto Gerra
Prof. Dr. Medaim Yanık
Dr. Muhammet Tayyip Kadak
Prof. Dr. Mehmet Akif Karan
Harun Sönmez
Prof. Dr. Musa Tosun
Mehmet Dinç
Prof. Dr. Mücahit Öztürk
Mesud Yılmaz
Prof. Dr. Necdet Ünüvar
Uğur Evcin
Ahmet Zeki Olaş
Dr. Maria Renström
Dr. Sertaç Polat
Dr. Peyman Altan
Dr. Toker Ergüder
Dr. Vladimir Poznyak
Eylül Okay
Gregor Burkhart
Lidija Vugrinec
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CONTENTS
Public Health Perspectives on Drug Policy
6
21-41 Fay Watson, Drug Policy and Public Health
43-52 Gilberto Gerra, Responding to Drug Use Disorders:
The Gap Between Science and Clinical Practice
53-60 Keith Humphreys, Enhancing Addiction Treatment in the Health Care and Criminal
Justice Systems
61-76 Thomas Babor, Drug Policy and Public Health
7
Drug Prevention Strategies
8
81-91
David Foxcroft, Prevention Programs and Effectiveness: Environmental,
Developmental and Informational Approaches
93-104
Arzu Çiftçi Demirci, Alcohol and Drug Abuse in Adolescents
105-116
Enes Efendioğlu, Youth Engagement as a Keystone to Reduce Substance Abuse
117-123
Fatima El Omari, Mediterranean School Survey Project (Medspad) on Alcohol and
Other Drugs: The Moroccan Experience
125-144
Gaetano Di Chiara, Long Term Consequences of Adolescent Cannabis and Ecstasy
Exposure on Dopamine Function and Reward
145-157
Gregor Burkhart, Drug Prevention Approaches in Europe from the Individual to the
Environment
159-177
Marilyn Clark, Exploring the Career Path of Recreational Marijuana Users in Malta: A
Study among Emerging Adults
179-190
Paul Rompani, Drug Prevention on a Global Level
191-199
Peer van der Kreeft, The Unplugged Drug Prevention Program from the EU-Dap
Network
201-210
Savaş Yılmaz, Addiction Training Program of Turkey
211-215
Simona Stankeviciute, Legal and Illegal Drugs: Alcohol as a Gateway Substance to
Using Other Drugs
9
Intervention, Recovery and Rehabilitation
10
219-231
Ambros Uchtenhagen, European Quality Standard in Addiction Treatment and
Rehabilitation
233-242
Boro Goic, Christian Approach to Sustainable Recovery Options
243-255
Bronwyn Jane Myers, Addressing Substance Use within Primary Health Care
Settings in South Africa: Opportunities and Challenges
257-265
Cenk Yancar, Oya Bahadır Yuksel Treatment and Rehabilitation Centre
267-280
Cüneyt Evren, Opioid Maintenance Treatment in Istanbul and Related Outcome
281-294
Elisa Rubini, San Patrignano: A Community for Life. A Model for Drug Rehabilitation,
Recovery and Social Reintegration
295-301
Janusz Sieroslawski, Two Models of Rehabilitation- Therapeutic Community Versus
Community-Based Program
303-308
Jean Kissell, Mohammad Nasib, Wadan Afghanistan: WADAN’s Approach to Drug
Control, 2002-2014
309-316
Jose Angel Prado, Recovery and Rehabilitation in Mexico
317-320
Kültegin Ögel, Individualized Interventions in Addiction Related Problems
321-329
Lars Møller, Treatment in the Criminal Justice System
331-354
Marie Nougier, Best Practice in Harm Reduction Policies and Interventions
355-369
Minerva-Melpomeni Malliori, Designing and Implementing Responsive Drug Policies
under Fiscal Constraints: The Case of Greece
371-376
Muhetaer Ayoufu, Nurmuhammat Amat, Traditional Chinese and Uighur Medicine in
Drug Treatment
377-381
Nesrin Dilbaz, Addiction Health Problem? Treatment Principles
383-392
Nijole Goštautaite-Midttun, Accessibility Challenges in Delivering Addiction Services
to Children in Lithuania
393-402
Peter Sarosi, Advocacy for Harm Reduction: Bridging the Gaps
403-417
Rowdy Yates, Recovery Capital, Addiction Theory and the Development of Recovery
Communities
419-423
Sacide Pehlivan, Genetics of Addiction
425-434
Uğur Elaman, A Point Between 180 Degrees
11
Successes and Challenges
12
439-445
Adrianus (Bob) Keizer, The Role of Monitoring and Evaluation in the Policy Process
447-452
Ali Bertan, Early Warning System in Turkey
453-460
Esbjorn Hornberg, From Beyond 2008 to UNGASS 2016: The Civil Society Tool to
Access the Political Process
461-467
Faruk Aşıcıoğlu, New Strategies of Turkey for Fighting against the New Psychoactive
Substances
469-483
Fay Watson, Drug Policies and Human Rights: EURAD Report
485-503
İlhan Yargıç, Report of the Green Crescent’s Workshshop on Drug Abuse
505-520
Janusz Sieroslawski, Evaluation of Drug Policy-Polish Experiences
521-527
Mustafa Ersoy, Turkish National Strategy on Drug Policy
529-536
Sandy Mteirek, Health, Safety, Justice: Towards Better Laws
537-555
Uğur Evcin, Structure and the Activities of Provincial Drug Coordination Boards in
Turkey
13
Media Awareness Campaigns
14
559-567
Boguslawa Bukowska, Media Campaigns for Preventing Using Psychoactive
Substances and its Evaluation: Example from Central Asia
569-574
Christian Mirre, Media Awareness Campaign & Effective Education on Drugs
575-583
Elias Allara, Are Mass-Media Campaigns Effective in Preventing Use and Intention to
Use Illicit Drugs? A Cochrane Systematic Review and Meta-Analysis
585-590
Richard Ives, Improving Prevention, a critique of drugs prevention media
campaigns
15
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FOREWORD
Growing problem of drug addiction threatens the health and the future generations of the
World. Public institutions and non-governmental organizations have been struggling with
drug addiction through prevention, advocacy, treatment and rehabilitation works in the
World. As the Turkish Green Crescent Society, we hosted an International Symposium on
Drug Policy and Public Health on September 29-October 1, 2014 in İstanbul to provide the
opportunity for the international public health community to share knowledge and best
practices, to evaluate the future of international drug policies as well as to constitute new
frameworks with scientific and evidence based public health approach.
The Symposium was organized by the Turkish Green Crescent Society and has been
supported by the World Health Organization (WHO), the United Nations Office on Drugs and
Crime (UNODC), the Pompidou Group of the Council of Europe, the European Monitoring
Centre for Drugs and Drug Addiction (EMCDDA), the Turkish Ministry of Health, the Turkish
Ministry of Family and Social Policies, the Turkish Ministry of Youth and Sport, the Turkish
Monitoring Center for Drugs and Drug Addiction TUBIM. The President of the Republic of
Turkey H.E. Recep Tayyip Erdogan and respected ministers from Turkey with many national
and international heads of international organizations honored the symposium.
Totally 1270 participants from 65 countries including focal points of Council of Europe and
Organization of Islamic Cooperation (OIC), Country Green Crescent representatives, experts,
university students, teachers and psychologists participated to the symposium.
In three day program, nearly 100 participants presented their papers based on their scientific
works and practices in their own countries. This final book consists of papers presented
at the International Symposium on Drug Policy and Public Health, held in İstanbul. We are
very pleased to publish this study, covering various practices and models to struggle with
drug addiction around the globe. On behalf of the Green Crescent family, I owe authors of
papers, scientific and organizing committee members a debt of gratitude for creating of this
valuable work.
Prof. Dr. M. İhsan Karaman
President of the Turkish Green Crescent Society
17
18
Public Health
Perspectives on
Drug Policy
19
20
Fay Watson*
Secretary General, EURAD (Belgium)
ABSTRACT
In this paper, I have attempted to draw out some of the complexities surrounding the global drug problem as it is today. You will not find
any “quick” fixes to the drug problem here but rather an illustration of how drug policy must be viewed within a much wider context
than it is today. By wider context, I do not mean that we must look at how we jointly co-ordinate our health and justice policies which of
course we must do but by wide, I mean we must see far beyond that, to look at how our international, regional and national economic
and social policies create environments whereby the rural poor in developing countries are tempted or coerced into drug production
and whereby the most vulnerable people in Europe are the most likely to develop drug dependency problems.
* Fay Watson manages EURAD, a European network whose members include drug rehabilitation communities and prevention organisations. Her work focuses on policy, representing the network of both the EU and UN. She is also currently the Vice-Chair of the
EU Civil Society Forum on Drugs.
In the past, she worked in the UK’s first regional tobacco control; successfully managed a stop smoking service and was then
promoted to sub-regional manager for tobacco control in the north of England. During this time she provided performance
management support to stop smoking services as well as developing advocacy campaigns for tobacco control legislation (including
tobacco vending machines and point of sale advertising).
She has a BA (Hons) degree in Human Geography from Lancaster University, a master’s degree in Healthcare Leadership and
Management from Manchester University and is a graduate of the UK’s National Health Service General Management Training
Scheme.
She has co-authored one peer-reviewed article on prostitution and in her current post has authored extensive policy guides on the
topics of cannabis, psychoactive substances and a public health approach to drugs. She is also overseeing the development of two
forthcoming publications on human rights and alternative development.
21
DRUG POLICY AND PUBLIC HEALTH
Drug Policy and Public Health
Introduction
In many international and national political fora, the movement from a justice oriented
drug policy towards a more public health based approach is being discussed. The confirmation that a United Nations General Assembly Special Session (UNGASS) on the Drug
Problem will be held in 2016 has escalated the importance of this discussion as governments across the world consider future approaches to tackling the global drug problem.
Although public health is now increasingly being discussed as an important facet of
drug policy there is still a lot of confusion over what a ‘public health approach’ is. Some
may understand ‘a public health approach’ as a purely clinical health sector approach,
yet such a narrow understanding of public health ignores the need for vital population
level interventions which may help shape wider social norms and prevent the initiation
of drug use and production in the first place.
The WHO defines public health to mean “all organized measures (whether public or
private) to prevent disease, promote health, and prolong life among the population as
a whole” (1). Public health activities aim to provide conditions in which people can be
healthy and focus on entire populations, not on individual patients or diseases. Thus,
public health is concerned with the total system and not only the eradication of a particular disease.
The UK Faculty of Public Health (2) defines public health as “the science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life
through the organised efforts of society.” From this definition, they define an approach
to public health which is:
22
•
Population based
•
Emphasises collective responsibility for health, its protection and disease prevention
•
Recognises the key role of the state, linked to a concern for the underlying socio-economic and wider determinants of health, as well as disease
•
Emphasises partnerships with all those who contribute to the health of the population
The Importance of Social Determinants in a Public Health Approach
There is an increasing understanding that the health of individuals is strongly influenced
or even dictated by the conditions in which people are born, grow, live, work and age.
These factors, which are influenced by the distribution of wealth, power and resources
at global, national and local levels are referred to as social determinants (3) and are demonstrated in Figure 1.
If we look at the drug problem from this perspective, it is not difficult then to empathise
with the struggling farmer from Colombia who turns to illicit drug production in order
to make ‘ends meet’ for his family, or to understand how a young person growing up in a
deprived housing estate in the UK may turn to substance use if they have not succeeded
in the education system and see themselves as having nothing to lose if they indulge in
occasional drug use. With this perspective, we can remove our judgement on the ethical
standards of a drug producer or on people who use drugs and instead learn more about
the reasons their life has turned out in that way and place the burden of repair back
to our governments to address the structural frameworks which have resulted in these
conditions.
Figure 1: The Determinants of Health (4)
23
Framing Drug Production within a Public Health Context
A small number of nations account for the bulk of production of cocoa and opium;
which are both grown in countries characterized by labour and land that have low prices
relative to those in North America and Europe (5). However, many non-drug producing
countries share these factors and many nations are capable of producing illicit drugs
but do not do so, so clearly there are other factors at play. This observation has led some
commentators to note that the comparative advantage of countries such as Bolivia, Peru,
Afghanistan and Myanmar as opposed to other nations which have low labour and land
costs is that the government there may not be able or is reluctant to act aggressively
against growers or early stage refiners (6) but even this explanation may be criticised as
just scratching the surface of why people in specific locations are more likely to become
involved in drug production or trafficking.
The Executive Director of the United Nation’s Office on Drugs and Crime notes that
“in many regions of the world, transnational organised crime and drug trafficking have
evolved from social and criminal problems into a major threat to international and human security, as well as to public health and development” (7). It is also noted in the
same document how important it is that the drug problem is seen within the wider context of development policies, as organised crime exacerbates income inequality, inhibits
legitimate social and economic policy, deleteriously affects public health, undermines
gender equality as well as promoting violence. This has been backed up by commentators (8) who have linked historical settlement patterns, the distribution of populations
and geographical characteristics such as hard to reach areas to various forms of political
rebellion and who have concluded that in Colombia for instance, it is not coca production which is the driving force of contemporary Colombian violence, rather the more
prominent explanatory factors are underlying economic issues and the way coca has
been eradicated.
The role of income inequality and drug production
Whilst absolute poverty obviously plays a role in crime, in this section we will look at
the role which inequality plays, as this is a topic which may not so far have received the
attention it deserves in the drug policy field.
We take the Latin American region as an example because alongside Sub-Saharan African countries, Latin America is the most unequal region of the world and because countries in Latin America play such a central role in drug production as well as trafficking
activities (9). Such is the scale of drug-related violence in this region that some Central
American countries have been facing some of the highest homicide rates in the world,
often surpassing those of countries in armed conflict (10).
24
Figure 2: Global Income Inequality (The Palma Ratio)
The level of income inequality in Latin American countries is striking when we look at
it in Figure 2. What is shown above is a relatively new measure of income inequality,
known as the Palma Ratio. It is an updated look at how we view income inequalities and
is defined as the ratio of the richest 10% of the population’s share of gross national income (GNI), divided by the poorest 40% of the population’s share (11, 12, 13, 14).
Evidence suggests that individuals in highly unequal societies have incentives to engage
outside legal markets, in crime and in robbery (15) and it is worth noting here that the
narco-terrorist group FARC-EP in Colombia set out originally with an aim to fight for
fair land distribution, an aim which may have appealed to those at the bottom end of the
socio-economic scale. A large scale review even showed that countries with an average
of a 1% increase in the Gini coefficient (another measure of inequality) appear to have
crime rates increased by between 1 and 4% (16). For reference, the most unequal of
the developed countries (Portugal) has a coefficient of below .4 whereas the average for
Latin America is .52. In countries where high inequality is combined with low mobility,
there may be very few options available to escape poverty and despite the fact that in
principle there may be examples (i.e. Chile) where high social mobility is found despite
high income inequalities, broadly speaking high inequality and lack of mobility tend
to move together. If we look back as to the reasons why such inequalities exist, then we
are likely to look back to the colonial era in order to understand how colonial powers
allowed a small group of elites to prosper in terms of land ownership, education and
political power (17, 18).
Nowadays, countries severely afflicted by drug production in Latin America still suffer
from high inequalities in educational levels and these differences in education are now
one of the most important indicators of differences in income in Latin American countries. To complicate matters even further, educational returns for the children of the poor
are lower than for children of the rich. This may be due to lower quality of schooling,
lower availability of assets like land, public infrastructure and credit which may facilitate
25
education as well as unobservable factors, such as differences in nutrition and the ability
for parents to take time to support their children’s educational needs (19).
Researchers who have compared Latin American countries with European countries,
where inequality is at least a policy concern and where inequalities are narrower, have
found that the inequalities can be accounted for by two modern factors: how taxes and
transfers are arranged. The case study of Europe is indeed important because European
countries were able to break away from a history of high inequality during the 20th
century, suggesting that such an event is possible for Latin America. However, economic
projections for OECD countries show that earning inequalities are likely to continue to
rise in the next 50 years as long as technological progress remains skill-based (20). Moreover, redistributive tools of taxes and transfers may become more difficult to implement
in the future due to increasing cross-country mobility of tax bases in the context of rising
trade and investment integration. Such studies recommend implementing a wide range
of policy tools to address inequality such as:
•
Increase equality of opportunities in education (with a special focus on early years education for those from less privileged backgrounds as well as investment in
lifelong learning, due to an increasingly aging population)
•
Adjust tax and welfare system to increase mobility of capital and labour (e.g. by
shifting taxation to immoveable factors such as property and extraction of natural
resources) and reform employment regulations, benefit systems and activation
policies to support workers mobility)
•
Broaden welfare systems that provide insurance against individual shocks and
macroeconomic risks, accompanying them with conditionality to ensure their
sustainability
Responding to the challenges of drug supply
As with reducing drug demand, actions to prevent drug supply and trafficking
activities can also be tackled partially through preventative measures, such as:
26
•
Primary interventions – universal approaches which aim to prevent the drug-related crime before it occurs (i.e. taxation policies, education policies, trade agreements, controlling the sale and transportation of drug precursors)
•
Secondary interventions – approaches which target those most at risk from
drug-related crime or as victims of such crimes (i.e. alternative development
programmes as prevention for those not currently involved in drug production,
crime prevention programmes, targeted employment and training programmes)
•
Tertiary interventions – approaches which focus on those already engaged or affected by drug-related crime (i.e. alternative development opportunities for those
already involved in drug production, judicial interventions, employment and training programmes for individuals)
•
There are countries such as Japan and Norway, as well as other Scandinavian countries where strong welfare systems coincide with low rates of economic
inequality, drug use and crime. Social development tends to be seen as the best
crime prevention policies in Nordic countries and the results speak for themselves
(21, 22).
On a secondary prevention level, the activities of the organisations involved in the production and distribution of drugs must be tackled, in order to reduce the risk of future
drug-related crime. It is possible that if their activities are curtailed, other drug-related
crimes, such as systemic violence and corruption could fall (23). Whilst little evidence
is available on how to reduce the crimes that are committed by criminal organisations
involved in the drug trade, the extensive use of asset removal has been successful in
tackling other criminal markets. For example, in New York, the use of RICO (Racketeer-Influenced and Criminal Organisations Act), reduced the financial viability of organised crime by enabling state agencies to seize assets and to levy steep financial penalties
for repeated criminal activities carried out by the groups. This was accompanied by the
establishment of new regulatory powers which made it much harder for criminal gangs
to own and operate legitimate businesses. These instruments were decisive in the decline
of the Cosa Nostra (24).
Underlying Issues Linked To Drug Trafficking
The precise nature of drug trafficking is not easily explained. Whilst countries such as
Thailand, Argentina and Brazil may act as transhipping countries for Myanmar and Colombia, proximity to a producing country can be extremely important but it may not be
the only factor needing consideration. Mexico is perhaps the region in the world where
geographic destiny is strongest; it is a natural smuggling point to the United States, for
cocaine, heroin, cannabis and methamphetamine. Indirect smuggling routes however
can also be common, with seizures in countries such as Germany sometimes turning out
to have travelled through Scandinavia into Russia and then exited through Poland to get
to their final market.
It is also important to understand how economic, sociological and political factors can
also help facilitate trafficking activity. For example, Nigeria is quite isolated from producer countries and Western consumer markets but yet in spite of this, Nigerian traffickers
have come to play quite a substantial role in both the heroin and cocaine market. Some
have accounted for this through factors such as entrepreneurial spirit, corruption, large
overseas populations, weak civil society, low wages and good commercial transportation
links with the rest of the world (25). The UN notes that the vulnerability of West and
27
East African countries has increased in recent years, with large-scale methamphetamine
emerging in West Africa and with more cocaine and heroin trafficked through these two
sub-regions, there has been an increase in local use of these drugs (26).
Framing Drug Use within a Public Health Context
Some people view drug use as an individual choice, rather than a social phenomenon
which is shaped by individual characteristics such as age, sex and genetics as well as by
wider social norms, laws, socio-economic factors and environmental factors. However,
drug use, just like any other health behaviour is influenced by a much wider set of social,
cultural, environmental, legal and individual factors and not just simply personal choice.
If we consider other public health issues such as the global obesity epidemic, we see how
risk factors on the population level impact on individual behaviour. Obesity is linked to
a high-calorie diet, low physical exercise, physical injury and even genetic vulnerabilities linked to metabolic disorders. One may argue that all these factors are individual;
however they cannot explain why obesity rates are increasing in the population at large.
To tackle the obesity epidemic, medical interventions such as bariatric surgery may be
vital to help individuals who suffer from severe obesity and who are at risk of developing
related complications such as diabetes but these sort of interventions do little to address
the wider factors which help to create the obesity epidemic in the first instance.
28
Priority Area
Determinant/ Risk Factor of Drug Use
Child Abuse
Systems and infrastructure to
support health child, youth and
adult development throughout the
life course (i.e. support for raising
families, structures for youth
development, support for adolescents and adults in achieving
success in education)
Extended periods of adolescence
linked to fewer responsibilities, more
time spent with peers and less certainty about the future
Safety nets for those who begin on
a negative pathway (i.e. the provision of options for youth who are
struggling at school)
Genetic predisposition
Assistance during challenging
transitions, particularly for vulnerable groups (i.e. assistance for
those exiting prison and support
for drug-dependent pregnant
women)
Stress
Resilience (protective factor)
Self-regulation (protective factor)
Human relationships and attachment
(positive relationships as a protective
factor)
Human Development
Exposed to drug use as a foetus
Behavioural problems (in childhood
and adolescence)
Exposure to drugs and drug-using
social contexts during adolescence
Poverty
Unemployment
Wealth inequalities
Social and Cultural
Environment
Potential Interventions
Impact of individualistic society
(reduced social cohesion and social
support)
Drug-specific norms (mass media,
trends in youth culture, laws and the
implementation of laws)
Employment programmes, taxation policies and education policies
Address marginalisation and
exclusion
Evidence based community building programmes to be prioritised
for disadvantaged communities
Interventions targeted at different
points along the casual chain of
poverty and disadvantage
Targeted programmes to reduce
the risk of intergenerational transmission of drug problems
Housing quality (linked to self-identity and depression)
Overcrowding (linked to depression,
stress and a reduction in childhood
academic achievement)
Physical environment
Inadequate public transport and increased dependency on car ownership
(leads to less walking, less public
interaction, reduced social contact)
Consider drug use in urban, housing, transport and environmental
planning strategies and programmes
Lack of public spaces where young
people can socialise in the presence
of adults (increased exposure to drug
markets, reduced social control and
reduction in adult role models)
Figure 3: The Social Determinants of Drug Use (27)
29
As Figure 3 demonstrates, no single risk factor predicts drug use or problematic drug
use. It is also important to note that whilst up to 25% of the adult population may have
experimented with substances like cannabis and 5% of young people in Europe may
have experimented with new psychoactive substances, far fewer progress to regular drug
use or dependence. In this regard, we should also keep in mind that the risk factors for
experimental use, continued use and dependence differ.
Rather than one factor predicting use and different types of use, it is probably more the
balance of the number of negative risk factors relative to the number of protective factors which actually predicts where and with whom drug use will occur and the extent to
which this may progress from experimental to dependent use.
Why We Need Approaches to Target the Whole Population
Measures to reduce harmful health behaviours are sometimes described as an infringement of individual liberty and an obstacle to individual choice. While these are legitimate concerns, the lessons of public health show us that individual choice and freedoms are
constrained by a number of structural factors and we have seen this both when looking
at drug supply and at drug use. Furthermore, health behaviour choices tend to follow
patterns – hence they are not merely a result of individual choice, but influenced by environmental, cultural and economic factors and the resulting harms are often influenced
by the unequal distribution of resources, risk and protective factors.
If we consider other public health issues such as the global obesity epidemic, we see how
risk factors on the population level impact on individual behaviour. Obesity is linked to
a high-calorie diet, low physical exercise, physical injury and even genetic vulnerabilities
linked to metabolic disorders. One may argue that all these factors are individual, but
while individual factors can explain individual cases of obesity, they cannot explain why
obesity rates are increasing in the population at large. Interventions aimed at high-risk
groups or individuals, such as medication and surgery may be an important help to individuals who suffer from obesity however, they do little to reduce the rates of obesity in
the population. A public health approach to obesity would therefore need to address the
structural factors that shape individual behaviour. Furthermore, key interventions may
not involve the health sector at all, but may include e.g. transportation, legislation, urban
planning, taxation, agriculture and food policy.
Likewise, in the drugs field, there is evidence to suggest that universal measures such
as pricing, accessibility and availability impact on consumption. High prices are known
to deter consumption (28), with estimates that a 10% reduction in the price of cocaine,
for example due to legalisation, would lead to an increase of around 8% in the number
of users and a 3% increase in the frequency of use (29). This is consistent with other
substance use fields, for example, over 100 studies have demonstrated the impact of price increases on cigarette smoking (30), with many concluding that a 10% rise in price,
30
leads to a reduction of smoking between 2.5% - 5% (31). This fall is made up of both
reductions in the number of cigarettes smoked and by a fall in the number of people who
smoke. The author of the previous studies also found that young people are up to 3 times
more sensitive to price increases than adults (32). This finding is very relevant for drugs,
as use is often concentrated among younger age groups. Similarly, a meta-analysis of 112
studies of alcohol pricing found a highly significant relationship between alcohol price
and consumption, even for heavy drinkers (33).
In relation to the controversial area of drug enforcement, there is evidence which is
clearly consistent with the hypothesis that enforcement leads to higher prices (34) and
that currently controlled substances are substantially more expensive, as well as being
less available, than they would be in a legalized market (35). Recently, a ban on the production, importation, exportation, advertising, sale, possession or manufacture of new
psychoactive substances was introduced in Portugal and since then, has been hailed as
a success due to its immediate reduction in drug-related hospital admissions, with the
Head of SICAD, Joao Gouloa noting that the new legislation “led to a decrease in hospitalisations from the moment it was introduced” when speaking at a conference on psychoactive substances in May 2013. However, it is also fair to show that similar legislation
exists in countries where psychoactive use still remains very high. This can be seen in
Ireland and some reasons for this are linked to the time delay before the legislation was
introduced, meaning that there was significant time for user groups to become established. It could also be true that many of the social determinants of drug use which were
listed in Figure 3 are more prevalent in Irish society, than say Portuguese society.
Why We Need Approaches To Target Risk Groups
Targeting typically involves the development of a single intervention approach for a defined population subgroup that takes into account characteristics shared by the subgroup’s
members. These subgroups may be very small and quite specifically defined, such as
African-American women aged 50–65 belonging to a particular neighbourhood health
centre. Targeting is essentially based upon the advertising principle of market segmentation, which aims to find the right kinds of consumers for a particular product or service
(36).
This approach is now commonly used in public health. For example, Iceland, noticing a
general upward trend in adolescent substance use during the 1990s in Western Europe as
well as in its own population (37) developed local partnerships that worked assiduously to strengthen school and community-level protective factors for young people. They
carried out local level intervention activities alongside community youth organisations
and schools, which focused on building relationships between the young people and
the adults in the local community. They also attempted to improve access for all young
people to healthy activities by providing them with free sports membership and access
31
to youth club facilities. As these activities were rolled out to all young people, rather
than specific individuals, many of the components of this initiative would be classed as
a targeted programme (which is also sometimes referred to as a selective programme).
The efforts in Iceland are believed to have contributed significantly to the 60% decline
in the experimentation and use of alcohol, tobacco and cannabis which followed the
decade later (38).
Now, whilst Iceland certainly made impressive progress through its targeted youth programme, it is also important to make note of the macro level policies which were also in
place during that time. For example, Iceland operates a state monopoly on alcohol and
tobacco which restricts the accessibility, availability and marketing of the products. Also,
like many other Nordic countries, Iceland operates a high level of taxation for alcohol
products (39). The impact of price on alcohol consumption and related harm has been
studied more extensively than any other potential alcohol policy measure (40), with the
result being that when all other factors remain unchanged, an increase in alcohol prices
usually leads to a decrease in alcohol consumption. Therefore, Iceland’s targeted youth
prevention programme was coupled with an already existing extensive and comprehensive alcohol policy, which also had the aim of reducing consumption.
This example shows us that even in the presence of fairly comprehensive universal measures which aim to reduce substance use; there was still room for significant improvements through targeted programmes. Studies carried out in other parts of the world
suggest why the Iceland targeted approach to young people may have been successful.
Results from the Minnesota Twin Family Study of over 1,000 twins, for instance, found
that peer deviance and parent-child problems were dominant environmental factors related to first time drug use (41).
Why We Need Tailored Approaches For At Risk Individuals
Vulnerability to develop a drug addiction is influenced by a combination of genetic as
well as environmental factors. Typically universal, and to some extent targeted, programmes are focused on adapting the environmental context where health and lifestyle
behaviours take place and are not focused on addressing for example, genetic factors.
Although behaviour genetic studies have suggested that early substance use is primarily
environmentally mediated, some researchers estimate heritability of this drug use to develop into addictive disease to be anywhere in the range of 30 – 60% (42). For instance,
character traits such as impulsivity, risk taking behaviour and novelty seeking which
may be correlated to serotonin and dopamine functioning are often part of a constellation of traits observed in individuals with a propensity towards drug use. A recent
study carried out at the University of Cambridge concluded that some people are more
likely than others to be vulnerable to addiction to drugs, due to specific abnormalities in
the brains which are present during childhood. Interestingly, the study found the same
32
abnormalities in the siblings of non-addicts, which led the researcher to conclude that
whilst some people’s brains may be more wired up for addictive behaviour, people can
also “overcome this predisposition to remain free of drugs” (43). The study concludes
with the assumption that the non-dependent siblings have benefited from some resilience or protective factors to offset the risks they shared with their dependent siblings but
that it was not clear from this study, what those particular protective factors were (44).
Other studies have shown that for many people who become addicted to drug use, the
drug use tends not to occur as an isolated behaviour. Four psychiatric conditions (depression, anxiety, antisocial personality disorder and attention deficit-hyperactivity disorder) are commonly present in addiction to opiates as well as to alcohol (45). Epidemiological studies have found that 20-50% of people with stimulant addiction have
depressive and/or anxiety disorders, with attention deficit disorder in either childhood
or adulthood being especially common (46). Although the role of genetics in addiction
remains somewhat controversial, the presence of particular character traits or disorders can certainly affect one’s vulnerability to or severity of addiction. Clearly, whilst
environmental factors may have more of an impact on first time drug use; individual
characteristics, particularly in the presence of a lack of protective factors appear to make
dependency more likely.
Targeted interventions which have been shown to be beneficial or likely to be beneficial
for those with drug problems include (but are not limited to):
•
Buprenorphine maintenance therapy, when compared to placebo (47)
•
Case management for reducing drug use (48)
•
Opioid assisted withdrawal with buprenorphine (49)
•
Combination of opioid substitution treatment (OST) and needle and syringe programmes (NSP) to reduce HIV or HCV incidence (50)
•
Continuity of treatment from prison to community to reduce mortality (51)
•
Residential rehabilitation to improve employment performance (52)
•
Drug court programmes on employment-related outcomes (53)
•
Motivated stepped care to promote employment (54)
•
Customised employment support (55)
•
Vocational training as a component of a comprehensive package to promote stable
employment (56)
However, not all harms are related to dependent drug users alone. Therefore, a more
comprehensive framework which addresses the risks of regular as well as occasional
drug use and those affected by drug use is needed. For example, occasional users may be
33
perpetrators of drug-related traffic accidents (57), whilst non-users may be the victims
of drug related crimes (58), be the child of drug dependent parents (59) or have caring
responsibilities towards others with drug dependency (60) and there is a need for appropriate interventions to be developed for these groups also.
Global Recommendations
•
The UNGASS 2016 should be used as an opportunity by Member States and UNODC to link the global drug problem to wider social and economic problems.
•
The WHO should lead on the development of a public health framework on drug
policy.
•
The UN as well as the WHO should take a leading role in advocating for the social
determinants of drug supply and demand to be incorporated into the sustainable
development goals which follow the Millennium Development Goals after 2015.
•
The UNODC should carry out a review of how current International Trade Agreements and Regional Trade Agreements hinder socio-economic development in
drug-producing countries.
•
Authorities developing aid agreements with drug producing countries should ensure that aid is specifically structured to support social and economic development, equality, mobility and human rights (particularly of the rural poor who may
be at risk of entering the drug trade).
•
The UN should continue to facilitate international collaboration on drug control
issues (including issues such as controlling drug precursors, cross-border trafficking and asset removal).
•
The UN should develop clear guidance in relation to what constitutes disproportionate sentencing, including the use of the death penalty.
•
The UNODC and Member States should ensure that alternative development
programmes are coupled with interventions and measures which seek to alleviate
internal wealth inequalities and improve the livelihoods and prospects of small
farmer households.
•
Member States should work together to develop resolutions at the UN Commission of Narcotic Drugs to the social determinants of drug production, trafficking
and use.
•
Member States should work together to develop resolutions at the UN Commission of Narcotic Drugs to on further investigate the role inequality plays in both the
production and use of illicit drugs.
•
The UN and Member States should seek to develop a platform for proportionate
34
sentencing for those paid, coerced or tricked into transporting drugs across international borders as drug mules, and who have no further connection to the wider
drug trade market.
•
The UN, the EU and Member States should seek to collaborate on the development
of asset removal systems which target global organised criminal networks.
Recommendations for the EU
•
The European Commission should assess how EU regional trade and development policies impact drug production and use (for example, assessing the impact
that structures such as CAP have on agricultural markets outside the EU and the
unintended impact these programmes may have on drug production).
•
The Commission’s working structure and commitments in the area of drugs should
reflect the spirit of the WHO Alma Ata and Rio Political Declaration by furthering
co-operation between DG Justice and DG Sanco on drug issues (including the execution of joint projects, a wider reflection of social issues within future EU Drug
Strategies and more joined up working on alcohol, tobacco and drug use, as well as
mental health issues and inequalities).
•
The European Commission should continue to develop cross border partnerships
with transit countries and potential EU candidate countries with a focus on strengthening information-sharing.
•
The European Commission should continue to work closely with Member States
to promote a European stance within United Nations meetings on clear violations
of human rights perpetrated in the name of drug control.
•
The EMCDDA should include in its future work plan publications on drug supply
areas, notably drug related crime and markets.
•
The European Commission should continue to develop effective means of controlling the sale and transport of drug precursors and new psychoactive substances.
•
The European Commission should publish evaluations of any aid or development
programmes it funds which influence drug producing countries.
35
Recommendations for National Governments
•
Adjust tax and welfare systems to increase mobility of capital and labour supply.
•
Broaden welfare systems to provide insurance against individual shocks and macroeconomic risks.
•
Introduce adequate measures which reduce the use and harms caused by drug use,
as well as measures which increase the age of initiation of drug use.
•
Research, fund and implement programmes which address the risk factors linked
to drug use (such as programmes to support child and adult development through
the life course, evidence-based programmes for at risk youth during challenging
transitions such as assistance for those existing prison and programmes to support
drug dependent women).
•
Ensure all levels of interventions are evidence based or subject to thorough evaluation.
•
Develop programmes which ensure equality of opportunity in the education system for young people as well as opportunities for life-long learning for adults.
•
Introduce proactive timely legislation to tackle the trade and sale of drug precursors which restrict the opportunities for diversion from the licit to the illicit market.
•
Facilitate alternative development, educational and mobility opportunities for rural poor in drug producing countries and in countries at risk of drug production.
•
Develop effective legislation to seize assets of those involved with transnational or
national organised criminal activities.
•
Develop and implement effective alternatives to incarceration for drug addicted
offenders which improve health outcomes and lower recidivism rates.
•
Governments should consider implementing new procedures that will avoid people with drug and alcohol dependency from entering into prison, sending them
instead directly to treatment if they consent.
•
Deliver a package of targeted interventions to at risk individuals.
36
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41
42
Gilberto Gerra*
Chief of Drug Prevention and Health Branch, UNODC
ABSTRACT
The article will focus on the new approach adopted by the international community (Commission on Narcotic Drugs) in dealing with drug
problem. Member States are more and more recognizing the need of a balanced approach equally based on law enforcement, intervention and prevention treatment and rehabilitation measures. The health oriented strategy is progressively replacing the repressive
and punitive attitude. Substance use disorders are recognized not as criminal or moral issues but as health problems that should be
considered by the public health care system without any discrimination respect to the other diseases.
Science-based policies are taking into consideration that often use of drugs and substance use disorders are associated with a long
history of adverse experiences starting with early childhood difficulties. This constitutes a pathogenetic pathway underlying the vulnerability for substance abuse. In addition, in most of low income countries substance use disorders are related to very problematic
environmental conditions such as coping with extreme poverty, hunger, violence, displacement and work overload.
International community recognizes that there is very little “recreational” dimension in the use of drugs and prevention programme
should target the problematic trajectory driving children and adolescence at risks. Accordingly, treatment facilities should be made
available and accessible for basic low threshold intervention to reach the most marginalized and compromised users.
* Dr. Gilberto Gerra, born on 24 May 1956, Parma-Italy. Medical Doctor degree at the University of Parma in 1981. Specialist in Internal
Medicine, 1986. Specialist in Endocrinology, 1989.
Professor at numerous universities in Italy, on Neurology and Addiction Medicine. Consultant to the ministries (Ministry of Health,
Ministry of Interior, and Ministry of Social Affairs) in the field of substance use disorders treatment in Italy.
1993-2002 Director of the Addiction Research Centre of Parma
1995-2002 Director of the Drug Addiction Treatment Centre in Parma
2003-2006 Director of the National Observatory on Drugs, at the Prime Minister Office, Rome, Italy
2004-2007 Member of International Narcotics Control Board (INCB) at the United Nations, Vienna
2007- Present Chief of Drug Prevention and Health Branch, Division for Operations, United Nations Office on Drugs and Crime, Vienna.
He is the author and/or co-author of many articles in the field of psychobiology of substance abuse, psychoneuroendocrinology and
clinical pharmacology (120 articles on scientific peer reviewed journals).
· Member of the College on Problem of Drug Dependence (CPDD)
· Member of the International Society of Psychoneuroendocrinology (ISPNE)
· Referee of many scientific journals in the field of addiction and clinical pharmacology.
43
RESPONDING TO DRUG USE DISORDERS: THE GAP BETWEEN SCIENCE AND CLINICAL PRACTICE
Responding to Drug Use Disorders - The Gap
between Science and Clinical Practice
Drug abuse remains one of the most challenging global problems. Only a small proportion of the millions of people worldwide who are impacted to various degrees by drug
use receive treatment in a given year. The stigma of drug abuse and the political and
financial barriers encountered at all levels impede efforts to increase availability and accessibility of treatment. The care of patients with drug use disorders is characterized by
a high degree of variability in the application of treatment methodologies across the globe. In addition, the field of addiction medicine has always been plagued by approaches
that have not been based on evidence beyond anecdotal reports, ideologies, and belief
systems. In many instances the application of interventions occurs without reference to
their appropriateness or efficacy for certain groups of patients, and some of the practices
are in contradiction with the human rights standards.
There is an obvious need for more scientific data on the efficacy of specific treatments
and their short- and long-term outcomes, as well as on the relationship between clinical,
demographic and cultural characteristics of patients with drug use disorders and their
responses to particular treatment modalities. These difficulties are greatly complicated
by the fact that patients often have limited ability to comply with treatment regiments,
a high incidence of relapse, and high level of other additional psychiatric, psychological
and medical problems.
This global situation has major implications for prevention and treatment of drug use
disorders and for public health in general, which primarily reflects on the quantity and
quality of care provided by various organizations. Services for drug dependent clients
developed in response to many factors: poor care in state hospitals and private facilities,
discrimination and prejudice in general health care settings, the expense of providing
care in private services, and the need to rapidly expand the countries’ capacity to provide
treatment. One of the major challenges in providing effective treatment interventions is
the widening gap between knowledge gained from basic scientific and treatment research, and its actual implementation (or lack of such) in the real clinical practice. This is
accompanied by growing isolation of the clinical-provider communities from the research communities. Within this context it is clearly critical to make every possible effort
to facilitate new strategies for partnership and increasing synergy among those working
in a variety of treatment settings and the world scientific community.
The evidence for the gap begins with different perspectives and priorities among researchers, treatment providers, and policymakers. Admittedly, the treatment of drug use di44
sorders is a relatively new field with abundant anecdotal material being the major source
of information until only 20-25 years ago. However, in the last two decades both at the
biological/biochemical level and in the behavioral sciences there have been important
studies that demonstrate the value of research when applied to practice.
Researchers perceive that many science-developed innovations have improved the treatment of drug use disorders. For example, methadone maintenance treatment began as a
research effort (3), relapse-prevention techniques were honed by research investigations
(14), the processes of behavioral change was studied in depth (21), motivational enhancement techniques (15). Significant advances have been made in behavioral treatment of
drug abusers (26). Studies have found that treatment intensity and systematic follow-up
improve treatment outcomes (9, 13, 20, 25). Researchers believe that treatment outcomes would be significantly improved if these, and other research findings, were fully
utilized in treatment.
Treatment providers have a different perspective. Faced with the challenges of providing
services on a daily basis, providers are often frustrated by what they see as the failure of
research to provide them with answers to their important questions. Many of their most
important questions are in policy- and budget-related areas that, at least until recently,
have not been carefully researched. They perceive that current policy, including funding,
provides little incentive for treatment programs to implement new research findings.
Those who define and implement policies have a third perspective. They do not find research literature easily accessible, neither easily understandable. They point to the oversupply of often contradictory information at all levels, too little of which supports the
cost-effectiveness of the programs they fund and administer. Frustrated by the time lag
and the flood of printed materials, policymakers tend to rely on familiar sources to select
and summarize the information relevant to them as the issue emerges.
The client’s perspective is often overlooked. There is no literature pushing new research
findings to the actual clients, as there is for other chronic conditions. Clients generally
face long waiting lists, and have fewer options in selecting drug treatment programs
than in other areas of medical care. There is little structure for clients’ input in treatment
development. The stigma and denial attached to drug use disorders further inhibit their
actions. The situation is even worse when we think about any application of science to
highly marginalized groups, such as street drug users, who are not involved in any kind
of meaningful rehabilitative operations, or drug dependent individuals in prisons.
Numerous impediments make it difficult for program managers and clinical staff to sift
through the research literature, critique it effectively, and select findings to implement in
their setting. Key among these are the complex and specific language, often requiring a
trained researcher to translate the findings to the practitioners.
It may sound surprising, but even among health professionals there is a lot of variability
45
in their fundamental understanding of both the nature of drug use disorders, and evidence-based approaches to treatment – something totally unacceptable in any area of
physical medicine, yet it is very common in addiction medicine. Such variety of views
and opinions is almost always ideology and “habit’’ driven rather than coming from different interpretations of the science.
A significant number of research findings coming from well-controlled and reliable
studies are clearly underutilized in various components of the treatment system. They
include neuropharmacology, genetic and epigenetic research, pharmacotherapy and
psychosocial interventions, as well as service delivery approaches. Methadone maintenance for treatment of opiate dependence provides an example of the difficulty implementing established findings and knowledge in the field. The studies and clinical trials
have consistently shown that methadone maintenance treatment is effective only when
methadone is given in adequate doses (3, 5) and accompanied by an adequate psychological support (16). Despite these research findings many treatment programs continue
using inadequate methadone doses (6, 8). Ambivalent attitudes in treatment providers
concerning the use of medication in the treatment of drug use disorders may also be a
contributing factor. Another example of this gap between research and practice is the
underuse of naltrexone, an opiate-antagonist which has long been shown to be effective
in preventing relapse in highly motivated opioid dependent patients (4).
Another example of an established research finding that has not been adopted widely
in clinical practice is the integration of contingency management strategies in community-based treatment settings. The knowledge that positive reinforcement can increase
desired behaviors has been empirically demonstrated in both laboratory and clinical
settings a long time ago (12, 24). Despite this, the use of positive reinforcement has not
been widely implemented in treatment settings. Again, the barriers are multiple, including lack of information concerning the efficacy of these strategies as well as implementation difficulties due to existing policies.
Another good and recent example of the discrepancy between the new genetic and epigenetic research and current practices in prevention and treatment: It is well established
by now, that adverse childhood experiences are not just behavioral risk factor for many
problems, but they have direct impact on our genetic makeup. Genes and experience
are interdependent. Genes are merely chemicals and without “experience”, with no context, no environmental signals to guide their activation or deactivation, create nothing,
as well as “experiences” without a genomic matrix cannot create, regulate or replicate
life in any form either. While experience may alter the behavior of an adult, experience
literally provides the organizing framework for an infant and child. In the developing
brain, undifferentiated neural systems are critically dependent upon sets of environmental and micro-environmental cues (e.g., neurotransmitters, cellular adhesion molecules,
neurohormones, amino acids, ions) in order for them to appropriately organize from
46
their undifferentiated, immature forms. Lack, or disruption, of these critical cues can
alter the neurodevelopmental processes of neurogenesis, migration, differentiation, synaptogenesis, all of which can contribute to disorganization and diminished functional
capabilities in the specific neural system. Childhood adverse experiences – loss, threat,
neglect, abuse, injury, overprotection, disorganized attachment, can cause disruptions of
neurodevelopment. Epidemiological and clinical data show frequent associations between adverse childhood experiences (ACEs) and drug use disorders particularly in adolescents. Some genotype variables regulating basal plasma levels of cortisol and ACTH and
its environment interactions have been associated with an increased risk for early onset
substance abuse. Such relationship has been found important when associated with the
polymorphism of the gene encoding the 5-HTT transporter, both in homozygote and
heterozygote individuals. Similar findings have been reported in case of childhood abuse
or neglect, but also in case of “over-protecting” parents.
The processes of gene activation, repression of already active ones, inhibiting translation
and transcription, are not only DNA-related, but can also come from the environment.
The word ‘epigenetic’ refers to a heritable phenotype not coded by DNA itself but by a
cellular process ‘above the genome’. Epigenetic studies show that genetic information
within DNA is also influenced by physiological and pathological factors from the environment during embryonic, post-natal development, and also in adulthood. They may
include the quality and type of nutrition, stress, emotional state, upbringing, and education. The notion that DNA is the sole regulator and controller of biological function and
hereditability has been superseded by the acknowledgement that the environment can
play similar roles in regulation of protein synthesis. It has also been seen that epigenetic
changes mediated by substances have shown special resistance to treatment by conventional therapies where individuals are vulnerable to relapse. Altered gene expression has
been observed in neurons of the brain’s reward, motivation and pleasure center. These
changes are maintained for many months of abstinence from substances. All of these
recent genetic and epigenetic findings have serious practical implications, particularly
in the delivery of evidence-based prevention strategies. It is conceivable that an effective
prevention approach can reduce the likelihood of the onset of drug use even in adolescents with some genetic vulnerabilities.
Another important area of discrepancies between scientific findings and their practical implementation is services delivery approaches. Evaluation of the effectiveness of
service delivery methods have identified important variables in determining outcomes,
including patients factors at treatment, duration and intensity of treatment, and service
delivery methods and their determination (17). Outcome studies of a wide variety of
programs and service delivery methods demonstrate, when keeping patient characteristics, treatment intensity, and duration constant, some programs have much more success
than others.
47
Some problems in closing the gap
Despite the potential benefits, many barriers exist to the successful dissemination and
adoption of these evidence-based practical guidelines within the drug abuse treatment
community. An often reason for this is the heterogeneity in the background, training,
and clinical perspectives of within the drug treatment field. Another reason is the fact
that most of the practice guidelines are not culturally specific and sensitive to different
countries.
The most typical difficulties are:
Organizational difficulties
In different countries various governmental structures and agencies carry responsibilities for activities related to the drug problem. Most commonly these are Ministries of
Health, Ministries of Social Affairs, and Ministries of Interior. These are not just different
organizations and structures. Most importantly these are different cultures and perceptions of the drug problem. Consequently, they look at the problem from a specific angle,
that is not necessarily consistent with the scientific view of drug use disorders as health
conditions that affect the brain and behavior. Additionally, these structures have various
degrees of appreciation and acceptance of the science as a valuable decision-making
resource, which may adversely impede implementation of the best practices fundamentally based on evidence rather than political or governmental mandates.
Financial problems
Drug treatment organizations are supported primarily by public funds. Resources constraints limit to type and range of services the organization can provide, and it often lacks
the financial and human resources to participate, or even read and understand research.
Even the introduction of new treatment modalities with a significant scientific basis
may be impossible for many treatment providers without significant external financial
support. Implementing new treatment methods generally require academically trained
people who are not a part of current staff, which is another financial barrier (26). Treatment organizations are often unable to afford the additional professional time to implement new treatment (18). Even those with enough resources may be reluctant to spend
the amounts required.
Problems relevant to training
Even when studies document that a treatment can be successfully implemented in a clinical setting, the challenge of the final stage of transfer to treatment programs is: additional training for staff in delivering the new treatment; changing the attitudes of the providers; and providing evidence that the new treatment is effective to the unique culture
48
or local situation. Each of these components of training poses problems. Training must
be planned, systematic, and protective of the fidelity of the treatment. Researchers who
establish treatment effectiveness are often not able to translate the intervention from the
perspective of training for daily activities. With the right skills and resources, researchers
can provide the requisite training, anticipate the difficulties, and assist in the process of
changing the practices. Further, shared technology transfer can encourage providers to
“own” the research. If this transfer of capacity building does not happen the prospects are
poor for sustaining the intervention after the researchers are gone (1). Few incentives
exist for researchers to participate in the final processes necessary for a successful adoption. Researchers may not only not have the skills, they may be unwilling to engage in
on-site training and mentoring of providers as they implement new treatment. Basically,
dissemination activities count far less than scientific publications for academic development and promotion.
Another very substantial reason for the gap between research and practice is how little
research occurs due to the stigma of working in the drug use field. The major difference
is the public’s perception of chronic diseases, such as hypertension, diabetes and asthma
as clearly medical conditions, where drug use disorder is most often viewed as a social
problem or character deficit. There is no serious argument against supporting health
care systems for diabetes or asthma, but there is still much public debate regarding support for treatment of drug use disorders (19).
What can be done?
Certain strategies have already been developed and studied to facilitate an integration of
research, treatment and policy. Several models of technology transfer have been found
to be effective (2), providing not only information dissemination, but also knowledge
utilization.
In general, successful adoption of research findings in treatment organizations requires
a number of organizational changes, particularly relevant to the organizational culture,
i.e. the historical pattern of behaviors developed by them early in their development to
solve both work-related problems and their perception of the nature of drug use disorders (7, 23).
Another promising strategy is the development of practice guidelines, which help close
the gap among different segments of the drug treatment field. These guidelines provide a
framework for choosing among treatment options and make specific recommendations
regarding treatment approaches wherever possible, based on the strength of available
research findings as well as perceived degree of consensus among different practitioners
(11, 22). Consensus conference mechanism and the evidence-based reviews might begin
to close the gap, as well as to enhance the potential for broader use of these treatment
guidelines (10).
49
As mentioned, while there are numerous barriers, which must be addressed, there are
models of bridging the gap between science and practice, which have been found promising. A combination of these methods seems to be an important pursuit, and the choice
how to combine different models in unique environments should be based on a variety
of medical, psychological, social and cultural considerations.
In the environment today, the world communities face an increase in drug use, an exploding epidemic of HIV and AIDS, an increase in tuberculosis, hepatitis, and other infectious diseases, an increase in comorbid psychological and psychiatric problems. Treatment organizations are challenged to meet demand in this environment, with dwindling
resources and uncertainty about the future. On the other hand, the entire scientific world has an obligation not only to discover with research, but also to make sure such discoveries have been brought to and understood by the practitioners. The shared ultimate
goal is to reduce individual and societal costs of addiction. To achieve this goal both
researchers and practitioners must have new tools, new skills, new incentives, and work
toward new partnership.
50
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C.P., 1996. Evaluating the effectiveness of addiction treatment: Reasonable expectations,
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21. Prochaska, J.O., DiClemente, C.C. 1986. Toward a comprehensive model of change. In:
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22. Rogers, E.M., 1995. Lessons for guidelines from the diffusion of innovations. Joint Commission Journal on Quality Improvement 21 (7), 324-328).
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24. Silverman, K., Higgins, S.T., Brooner, R.K., Montoya, I.D., Cone, E.I., Shuster, C.R., Preston, K.L. 1996. Sustained cocaine abstinence in methadone maintenance patients through
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York: Raven. Pp. 1807-1819.
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Keith Humphreys*
Veterans Affairs and Stanford University Medical Centers,
Palo Alto, California U
ABSTRACT
Regardless of how restrictive the supply of psychoactive drugs, at least some individuals in all societies develop addictions. This paper
examines evidence on how such individuals can be helped, and, how the damage they do to others can be restrained. The informal care
system, which comprises self-help groups and other voluntary associations, can lead many addicted individuals to recovery without
the need of professional intervention. However, treatment will be required for individuals who either present voluntarily to health care
providers or commit crimes that result in them receiving intervention in the criminal justice system. In both settings, the rights of
individuals and the quality of care should be ensured. At the same time, different approaches can and should be employed that fit in
each context. Prisons for example can easily provide residential care that may be less available in the health care system. Contingency
management programs with swift, certain and fair sanctions can be employed in the criminal justice system, but do not fit well within
traditional health care. The scientific evidence indicates that a wide range of informal and formal interventions can help addicted
individuals; the public policy challenge is coordinating these services for maximal population health impact.
Keywords: Addiction, Substance Use Disorder Treatment, Self-Help Groups, Prisons
* Keith Humphreys, Ph.D., Professor of Psychiatry at Stanford University School of Medicine and Career Research Scientist in the U.S.
Department of Veterans Affairs, has for over 20 years researched and advocated for treatments and self-help programs for addiction
and related disorders. In addition to his scientific projects, he is actively involved in teaching addiction treatment methods to medical
students, psychiatric residents, and clinical psychology interns. His widely-cited book, Circles of Recovery: Self-Help Organizations for
Addictions reviews over 500 studies on the effects of self-help groups in 20 nations.
Professor Humphreys has been extensively involved in public policy, having served as a member of the White House Commission on
Drug Free Communities, the Veterans Affairs National Mental Health Task Force, and the National Advisory Council of the Substance
Abuse and Mental Health Services Administration. From 2009-2010 he spent a sabbatical year as Senior Policy Advisor at the White
House Office of National Drug Control Policy. He holds an honorary Professorship of Psychiatry at Kings’ College, London and has testified on multiple occasions in the UK Parliament. His latest books, co-authored with colleagues at the Institute of Psychiatry, are The
Treatment of Drinking Problems and Drug Policy and the Public Good.
53
ENHANCING ADDICTION TREATMENT IN THE HEALTH CARE AND CRIMINAL JUSTICE SYSTEMS
Enhancing Addiction Treatment in the
Healthcare and Criminal Justice Systems
Substance use disorders have a causal or facilitating role in a broad range of public health
and safety problems, including accidental poisonings (aka “overdose”), infectious disease transmission, non-communicable diseases (e.g., cardiovascular disease and many
cancers), violent and non-violent crime and automotive and workplace accidents (1). As
a result, a large number of individuals with substance use disorders come into contact
with the healthcare (usually voluntarily) and criminal justice systems (usually involuntarily) each year, in which they are provided interventions designed to reduce or eliminate
their substance use. This paper describes the content, nature and impact of such interventions.
Services for Individuals with Less Severe Substance Use Disorders
Understanding the range and likely impact of services for substance use disorders requires an appreciation of the diversity of alcohol and other drug problems. For many people, “substance use disorder” conjures up an image of severely addicted multi-problem
person in a detoxification ward or jail cell. That represents one type of person with a
substance use disorder, but the reality is that these disorders exist on a continuum of severity. For example, in the United States, the roughly 2 million people a year who receive
specialty services in a designated addiction treatment program tend to have severe substance use disorders. However, many more millions have substance use disorders that are
either of low diagnostic severity or are even sub-diagnostic, but which impair their own
health and safety or those of people around them. Because this group is so large, it does
more damage to public health and safety collectively than the smaller number of people
with highly severe substance use disorders (2). Yet this population is unlikely to access
or be directed to addiction treatment services, which are generally targeted at persons
with more severe problems.
For this reason, researchers and clinicians have developed low intensity services for individuals with significant but less severe substance use disorders. Typically these services
are described as “screening and brief intervention services” and can be conducted in a
range of settings, including primary care practices, hospital emergency services, schools
and jails. They are generally not administered by an addiction specialist nor are they
expected to alter the course of severe substance use disorders.
Screening for substance use disorders can be conducted with one of several easy-to-use,
validated instruments that are available free of charge in multiple languages from the
World Health Organization (see http://www.who.int/substance_abuse/activities/assist/
54
en/). The most widely used are the AUDIT, which address alcohol use disorders and the
ASSIST, which covers the full range of substances. In any given setting, screening will
identify individuals who have highly severe problems and require extensive treatment.
However, it will also identify a population with less severe problems for whom a brief
intervention can be effective.
The content of brief interventions typically comprises non-judgmental health information provision, advice to reduce use, and motivational support for change. The length
of time involved can be anywhere from 5-30 minutes, and in some settings a “booster
session” may be employed at a later date. For alcohol use disorders, randomized clinical
trials have shown that brief intervention typically reduces problematic alcohol use and
its consequences. For other drugs, the evidence has been more mixed. In developing
countries (e.g., Brazil, South Africa) drug use reductions have been evident but in the
developed world, the results have been less consistent. A German study yielded positive results for reducing misuse of prescription drugs, but in the United States negative
studies outnumbered positive studies, indicating perhaps that the characteristics of the
drug using population in the U.S. are different and may require a different type of service
in order to improve (3).
Interventions for Individuals with More Severe Substance Use Disorders
Mutual Help Organizations
Turning to the population of individuals with severe substance use disorders who will
not benefit from a brief intervention, there are multiple care options. The scope of this
paper is restricted to those that are directed at reducing or eliminating the individual’s
substance use. Other options, for example distribution of the opioid overdose rescue
drug naloxone, are discussed at length in the book Drug Policy and the Public Good (1),
to which the author of the present paper contributed.
The most widely accessed interventions for substance use disorders in most countries
are peer-led mutual help organizations such as Narcotics Anonymous (worldwide),
Danshukai (Japan) and The Links (Sweden and Denmark). Unlike professional services,
these organizations are informal and view personal experience of substance use disorder
as the primary credential for having knowledge in how to help others recover (4). Some
of these programs operate from a defined philosophy such as the “12-step” approach,
whereas others have a less formalized conceptual approach. Some are affiliated with religious organizations, others have a spiritual orientation but are not religious, and still
others have no spiritual or religious content or affiliation. Most meet in groups or in
other informal social networks, but some have residential structures as well.
The randomized clinical trials that have been conducted on mutual help organizations
have yielded positive results. For example, Jason and colleagues (5) conducted a trial of
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150 discharged inpatients who were randomly assigned either to live in a peer-managed
Oxford House or receive care as usual. The sample was 77% African-American and 62%
female; most had long histories both of drug problems and criminal justice involvement.
Follow-ups were conducted every 6 months for 2 years, with an impressive 90% follow
up rate.
Outcomes were markedly superior in the Oxford House condition. Abstinence rates
were about double those of individuals in treatment as usual, and employment rates
were about 50% higher. Just as importantly, the rate of returning to prison was 2/3 lower
in the Oxford House condition.
Another important trial was conducted by Timko and colleagues (6), who randomized
substance use disorder outpatients to an intervention that encouraged participation at
the 12-step mutual help organizations Narcotics Anonymous, Cocaine Anonymous and
Alcoholics Anonymous. At 6 months, 81.4% of a sample of 345 participants were successfully recontacted. Individuals assigned to the self-help group facilitation condition
had higher group involvement and significantly lower alcohol and drug problems at
follow-up.
The economic implications are mutual help organizations also bear consideration, as
they are extremely inexpensive (often even free or nearly so) relative to professionally
provided services. Humphreys and Moos (4) conducted a study of over 1,700 drug and
alcohol dependent inpatients who were treated in programs that either did or did not
make extensive efforts to link patients to mutual help groups that they could attend during and after treatment. One year later, in addition to having better outcomes, patients
in programs that encouraged mutual help participation had about 40% lower outpatient
and inpatient treatment costs. Apparently, these individuals relied on their mutual help
groups for further support rather than returning to professional services, which reduced
their costs while at the same time improving their health. As funds for professional
addiction treatment are often constrained, it thus makes sense for treatment to facilitate
patient involvement in mutual help groups so as to preserve slots in treatment for patients who would not otherwise recover with it.
Professionally Provided Treatments
Professionally provided treatments are delivered by individuals with special training and
qualifications. Treatment goes beyond simple medical detoxification services, which by
themselves tend to have little effect on the course of substance use disorders. Treatment
services may be provided in outpatient settings, in day hospitals and in residential settings (including correctional environments). A subset of such programs provide medications that aid in recovery. The most important and effective of these are opioid agonists
such as methadone (1).
56
It is commonly and understandably asked how much difference treatment can make. In
the typical 6 or 12 month outcome study, whether a randomized trial or a large observational study of everyday patients (e.g., VA-NOMP, CALDATA, TOPS, NTIES, SROS,
DATOS, NTORS), “about half ” is a reasonable heuristic regarding the likely amount
of change in substance use. That is, most studies find that about half of individuals are
abstaining after treatment (i.e., about 50% are not using any substance). If one shifts
the evaluation frame instead to the proportion of patients using a given substance, the
percentage decrease is again usually about half (e.g., in a sample in which 70% are using
cocaine at the start of treatment, about 35% will be doing so afterwards).
A number of variables influence whether “about half ” is a good estimate of treatment
improvement. In samples of individuals with heroin addiction, treatment will exceed
the about half standard if opioid agonist therapy (e.g. methadone maintenance) is employed. Because severe substance use disorders tend to have a chronic, relapsing course,
outcomes will tend to be better when treatment/mutual help involvement extends for a
longer period and when the time of follow-up assessment is shorter (e.g., outcomes tend
to be better 3 months after treatment than 3 years after). In patients with fewer social
resources and more comorbid problems, outcomes will tend to fall short of the about
half rule (e.g., an impoverished, multi-problem sample might attain an abstinence rate
of only 30-35%, a financially well-off, high-functioning sample might achieve 60-70%).
A common, but incorrect assumption about addiction treatment is that all of an addicted individual’s problems are addiction-related, i.e., they will improve with addiction
treatment. But in general, improvement in such domains as mental health and employment tends to be less than that in the substance use domain. This should not be
surprising given that many non-drug using people in the general population are for
example unemployed or have poor mental health. Further, in other areas of health care,
the treatment is not expected to resolve every problem in a person’s life, but to treat the
presenting disorder. That is, just as we do not judge a cardiologist ineffective if s/he
saves the life of a heart attack patient but does not in the process help him have a happy
marriage and a fulfilling career, we should not expect a substance use disorder treatment
professional to resolve all of a patient’s problems in life beyond the addiction itself.
Considerations in the Criminal Justice System
Many individuals with substance use disorders come into contact with the criminal justice system. Although some people believe that this is only because some drugs are
illegal to possess, in fact the legal drug alcohol is a primary driver of arrests, crime and
incarceration in much of the world. All treatment options available in the health care
system can be made available in the correctional systems, and in some cases can be provided at little additional cost (e.g., therapeutic communities within prison, which have
evidence of effectiveness) (1).
57
The criminal justice system presents opportunities for interventions that are not feasible
for voluntary patients in the health care system. Typically, such programs use contingency management principles to monitor individuals outside of correctional settings who
would otherwise have a custodial sentence. The two most common models are similar
but not identical, and are generally referred to as alcohol/drug courts and “swift, certain
and fair community supervision”.
In alcohol or drug courts, an offender is regularly monitored by a judge through scheduled court hearings. The offender also receives a range of treatment services. Use of
drugs and alcohol is monitored through biological tests, and the judge has discretion to
respond to instances of use for example with more regular testing, more treatment or a
legal sanction. Although some critics object to the “therapeutic jurisprudence” model of
intervention represented by drug courts, the general conclusion of the research literature
is that they reduce substance use, crime and incarceration, thereby representing a benefit
to the offender and to society as well (1).
Swift, certain and fair community supervision is like drug courts in that the criminal
justice system is involved in attempting to reduce substance use by criminal offenders,
but the judge’s monitoring of each individual is less intensive and formal addiction treatment, while offered, is not required. The two most well-known models are “24/7 Sobriety” which was developed for repeat alcohol-involved offenders (e.g., drink drivers)
and HOPE probation, which was developed for drug-involved offenders.
Swift, certain and fair community supervision break away from the traditional approach
to criminal justice in which possible severe penalties are threatened to be administered
at some future point. Instead, following on literature both from neuroscience, behavioral economics and learning theory, these programs uses modest sanctions to motivate
change by ensuring that they are swift and certain (7). Individual who will not alter their
drug use if faced with a 10% chance of being sent to prison in a year will do so faced with
a 100% chance of spending a single night in jail immediately.
Supervised individuals are required to take drug/alcohol tests and not allowed to use
substances. If they are not using, they continue about their lives normally, living and
working in the community. If however they show evidence of use, they are immediately
sentenced to a day or two in the local jail, after which they are released and allowed to
continue on the program. The small number of individuals who are unable to attain abstinence in these programs can be referred to more intensive interventions (e.g., a drug
court). Those who go on to commit serious crimes still face the usual criminal penalties.
A randomized trial of HOPE Probation was conducted with 493 drug-using individuals
who had committed a felony (8). Compared to individuals on standard monitoring, individuals randomly assigned to HOPE probation had about 2/3 fewer drug positive urine tests, fewer than half as many drug arrests and were also less likely to return to prison.
58
Although it has not been subjected to a randomized trial, research on 24/7 Sobriety for
alcohol-involved offenders supports the conclusion that it too is effective. Specifically,
counties that have adopted it have seen a 12% drop in repeat drink-driving arrests and a
9% drop in domestic violence arrests (9).
Summary
Substance use disorders result in substantial damage to public health and public safety,
but interventions that can help individuals with these disorders are available. Screening
and brief intervention can be employed for individuals with less severe disorders; it
shows good evidence of working for alcohol use disorders and for drug use disorders
in developing countries, with the developed world data on drug use being less positive.
Mutual help organizations are a major resource for individuals with substance use disorders. The evidence indicates that they help reduce consumption of drugs and alcohol and
also take a substantial burden off of the public purse.
Individuals with more severe problems can receive extensive treatment either in the healthcare or criminal justice system. A range of treatments are available, with a general
reasonable expectation that around half of patients will move to abstinence and the proportion using any given substance will drop by about half. Departures from the “about
half ” heuristic should be expected based on whether the treatment is evidence-based
and extensive, and based on how long after treatment outcome is assessed. Treatment
makes some impact on other problems experienced by people with substance use disorders. It does not however resolve all such problems nor should it be expected to.
Within the criminal justice system, additional models of intervention are available, including drug courts and swift, certain and fair supervision. The evidence supports the
conclusion that such interventions reduce drug use, crime and incarceration.
None of the interventions reviewed in this paper is sufficient in itself because of the
diverse problems, resources and preferences of the population who have substance use
disorders. Effective public policy involves creating a range of interventions that will provide the assistance and monitoring needed by the diverse population that has substance
use disorders.
59
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2. Institute of Medicine. Broadening the base of treatment for alcohol problems. Washington,
D.C.: National Academies Press; 1990.
3. Hingson R, Compton W. Screening and brief intervention for drug use in primary care:
Back to the drawing board. JAMA. 2014; 312, 488-489.
4. Humphreys K., Moos RH. Can encouraging substance abuse inpatients to participate in
self-help groups reduce demand for health care?: A quasi-experimental study. Alcoholism:
Clinical and Experimental Research. 2001; 25, 711-716.
5. Jason LA, Olson BD, Ferrari JR, Lo Sasso AT. Communal housing settings enhance substance abuse recovery. American Journal of Public Health. 2006; 96, 1727-1729.
6. Timko C, Debenedetti A, Billow R. Intensive referral to 12-step self-help groups and
6-month substance use disorder outcomes. Addiction. 2006; 101, 678-688.
7. Kilmer B, Nicosia N, Heaton P, Midgette G. Efficacy of frequent monitoring with swift,
certain, and modest sanctions for violations: Insights from South Dakota’s 24/7 Sobriety
project. American Journal of Public Health. 2013; 103, e37-e43.
8. Hawken A, Kleiman M AR Managing drug involved probationers with swift and certain
sanctions: Evaluating Hawaii’s HOPE. Report to National Institute of Justice, Washington,
D.C.; 2009.
9. Kilmer B, Humphreys K. Losing your license to drink: The radical South Dakota approach
to heavy drinkers who threaten public safety. Brown Journal of World Affairs. 2013; 20,
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public good: Evidence for effective interventions. The Lancet. 2012; 378, 71-83.
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Thomas F. Babor*
Chairman in the Department of Community Medicine and Health
Care, University of Connecticut School of Medicine.
ABSTRACT
This presentation reviews the science base for national and international drug policy in the context of the 2009 UNODC Political Declaration, which encourages UN Member States to pursue “a balanced and mutually reinforcing approach to supply and demand reduction,”
in addressing drug use as a health and social issue. It provides relevant information for policymakers, prevention professionals, public
health officials and other stakeholders interested in applying evidence-based practices in an integrated approach to reduce both the
supply and demand for controlled psychoactive substances and new synthetic psychoactive substances. The review builds on the traditional “four pillars” or cornerstones of drug policies (i.e., primary prevention, treatment, harm reduction and supply control, including
criminal justice measures), but at the same time it supports integration across these four areas to address the problems associated
with endemic and epidemic substance use. Consistent with the Political Declaration, the public health strategy suggested by this review
could be a starting point toward a multilateral approach to substance use problems. Drug policy efforts have the potential to achieve
population impact and cost-effectiveness.
* Thomas Babor is a Professor and Chairman in the Department of Community Medicine and Health Care, University of Connecticut
School of Medicine. He holds the University’s Physicians Health Service endowed chair in Public Health and Community Medicine. He
received his doctoral degree in social psychology from the University of Arizona, spent several years in postdoctoral research training
in social psychiatry at Harvard Medical School, and subsequently received a master of public health degree in psychiatric epidemiology
from the Harvard School of Public Health. His research interests include screening, diagnosis, early intervention, and treatment evaluation, as well as alcohol and drug policy.
He is Associate Editor-in-Chief as well as Regional Editor of the international journal, Addiction. He is the author or co-author of over
200 articles and book chapters, and has written or edited more than 15 books and monographs, including Drug Policy and the Public
Good, recently published by Oxford University Press, and Alcohol: No Ordinary Commodity-Research and Public Policy. Each book was
awarded a first prize in the public health category of the British Medical Association’s book competition in their respective years of
publication.
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Drug Policy and Public Health
Introduction
This article describes the application of a public health approach to analyze the scientific basis for policy responses to the problems created by the production and use of
illegal psychoactive drugs. The public health approach focuses on communities and
large populations as well as individuals. It recognizes that a variety of interventions are
required to address the agent (illicit drugs), the host (including vulnerable populations
like youth) and the environment in which drugs are distributed and used. The public health approach consists of two inter-related strategies. The first is designed to reduce the
demand for illegal psychoactive substances by means of prevention, early intervention,
harm reduction, treatment, rehabilitation, social reintegration, and health systems management. The second is supply-control efforts and related criminal justice interventions. The public health approach also includes certain “matters of substance” that reflect
the social and pharmacological complexities of psychoactive substance use as well as the
differences among the substances that cause harm.
Within this broad framework, this article reviews research on many interventions and
builds upon the traditional “four pillars”, or cornerstones of drug policies (i.e., primary
prevention, treatment, risk reduction and supply control, including criminal justice measures (1).
The range of policy responses implies that there is no single approach to drug policy that
will work for all substance-related problems in all countries. Although each has its merits, public health concepts provide an important vehicle to organize societal responses
to drug misuse by coordinating supply control and demand reduction measures to serve
better the public good.
From the beginning, the author would like to acknowledge the intellectual contributions
serving as the basis for this article. Many of the findings and conclusions are derived
from the book, Drug Policy and the Public Good (2) and a subsequent article (3), which
were written by an international group of scientists to provide a conceptual basis for
evidence-informed drug policy.
Matters of substance
The misuse of psychoactive substances is a global phenomenon. Illegal drugs are reported in almost every country of the world, but different types of drugs and levels of use are
found in different regions (4). Use of illegal drugs is generally more prevalent in high-income countries (HIC) than in low- and middle-income countries (LMIC).
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Psychoactive substances vary tremendously in their cultural symbolism, pharmacological properties, and reinforcing effects. They also vary in their health effects, degree of
intoxication, general toxicity, social dangerousness, dependence potential, and social
stigma. Illicit drug use is associated with acute health harms, such as overdose and
injury, as well as chronic harm from use (e.g., addiction). Other health consequences
include harm to others (e.g., failure in meeting role obligations, injury, involvement in
violence); and social harms such as crime, family disruption, traffic accidents and the
spread of infections.
Some of the harms associated with illicit drug use are not caused by the intrinsic properties of the drug, but rather by the physical, legal and social context of drug use. Laws
regulating controlled substances can have both negative and positive consequences for
public health. Drug control efforts generally raise drug prices and thereby reduce use,
but unbalanced enforcement of drug laws can also be associated with violence and the
spread of drug-related infectious diseases. The chemical substance itself, in its pure
form, is therefore only one among many factors that determines whether and how much
harm occurs.
Both the drug class and the pattern of administration affect individual and societal outcomes. Cocaine, opioids, and amphetamines entail greater risks, especially when they
are injected. Drugs such as cannabis and ecstasy involve less risk. Policies on substance
use need to take into account the social and pharmacological complexities of psychoactive substances as well as the relative differences among them.
Strategies and Interventions to Reduce Drug Use and Related Harm
In recent years there has been a dramatic growth in research on drug treatment and
prevention, but the systematic evaluation of policies dealing with supply control and
criminal justice approaches has been less extensive, in part because of the challenges of
appropriate methodologies, available data, and the cost of doing this kind of research.
The scientific evidence for prevention, treatment and drug control policy is derived from
a variety of research methods and measurement techniques, ranging from randomized
clinical trials of prevention programs to “natural experiments” that evaluate the impact
of new policies on substance use. Worldwide, at least 43 different types of interventions
have been evaluated for their ability to prevent and control of illicit psychoactive substance use and its associated problems (2).
For the purposes of this review, these interventions can be divided into three broad
groups based on their primary objective: 1) strategies to reduce the demand for psychoactive substances; 2) harm reduction measures designed to minimize harm to the substance user without necessarily affecting the use of the substance; and 3) interdiction, law
enforcement, prescription regimes and other measures designed to reduce or eliminate
the supply of psychoactive substances. Most countries have implemented a combination
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of strategies from these three groups, with varying levels of priority, but they have not
necessarily been based on evidence of effectiveness.
Interventions to Reduce the Demand for Illicit Psychoactive Substances
Strategies that have been used to reduce the demand for illicit psychoactive substances are primary prevention programs for people who have not yet begun to use these
substances or use them only occasionally; secondary prevention programs for people
who have begun to use psychoactive substances in a hazardous or harmful way; and
treatment services, for people with a pattern of more intense use, people at greater risk,
or those who are already suffering from dependency or other associated consequences.
Preventing Illicit Drug Use by Young People
Primary prevention attempts to prevent or delay the initiation of drug use. Many prevention programs consist of information about the negative consequences. Others seek
to minimize risk factors for alcohol and drug use during adolescence and at the same
time enhance protective factors associated with drug abstinence. Another approach is to
teach drug resistance skills. Family strengthening activities have also been developed to
prevent substance use.
Systematic reviews of randomized controlled trials show that knowledge- and awareness-focused interventions are generally ineffective for prevention of use of illicit drugs
(5, 6). Similar findings have been reported for mass media approaches (7).
Another popular program used extensively throughout the world is Drug Abuse Resistance Education (DARE). DARE uses police officers to provide information as well as
skills training to resist social influences to use drugs. Systematic reviews (8, 9) conclude
that the program does not prevent cannabis use or the use of other illicit substances.
Findings from a few studies (10, 11) indicate that some family-based and classroom interventions can reduce drug or alcohol use. These interventions are designed to develop
pro-social behavior and social skills.
Another primary prevention approach focuses on institutional drug policies, such as
drug testing for student athletes and job applicants, workplace drug screening, and drug
testing in the military. A review of school drug testing programs (12) concluded that: 1)
there are few research studies in this area; 2) the quality of the existing studies is generally low; and 3) research findings supporting the effectiveness of school drug testing are
mixed. Although drug testing, whether random or on suspicion, has been found to deter
drug use in some settings like the military, such programs could have negative effects
when used in school settings, such as reduced trust between pupils and staff (13). In
addition, urine and saliva tests have poor validity and low sensitivity.
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Despite the mixed results for most primary prevention programs, economic analyses
indicate that prevention programs may be cost-effective even if they are only modestly
effective because they are relatively inexpensive and even small changes in use rates over
the lifespan of the user can be valuable (14).
Secondary Prevention
Secondary prevention consists of programs aimed at preventing the progression of
substance misuse once it has begun, primarily through early identification of at-risk
substance users through standardized questionnaires. The dominant approach is called screening, brief intervention and referral to treatment (SBIRT). Screening and brief
intervention have been evaluated since the 1980s as a way to identify at-risk users of
alcohol and illicit substances and to manage their substance use in primary care and
other medical settings (15). These studies typically focus on drug users who are not seriously dependent on psychoactive substances, and who are identified through screening
in general medical settings and emergency departments. Brief intervention (BI) refers
to any time-limited effort (e.g., 1-2 conversations or meetings) to provide information
or advice, increase motivation to avoid substance use, or to teach behavior change skills
that will reduce substance use as well as the risk of negative consequences. This approach
is being used mainly by primary health care teams, although more recently is being used
in schools and other community settings.
Randomized controlled trials have shown positive results in studies investigating the
effectiveness of brief intervention among cocaine, heroin, and amphetamine users in
non–emergency settings (16-18). Baker et al. (19) found that the provision of a self-help
booklet and a single session of motivational interviewing were associated with reduced
amphetamine consumption among regular users. Other studies (20, 21) found that general practitioners can reduce excessive benzodiazepine use in their patients using brief
interventions such as letters or consultations. In a study of drug users (22) sponsored by
the World Health Organization (WHO) in primary health care settings in four countries
(Australia, Brazil, India and the United States), drug users scoring within the moderate
risk range on a WHO screening test for cannabis, cocaine, amphetamine-type stimulants, or opioids received brief motivational counselling for the drug receiving the highest risk score. Compared with control participants, those receiving the brief intervention reported significantly reduced drug involvement three months later. Despite these
positive findings, other trials (23) with drug users have shown no differences between
intervention and control groups.
A referral is recommended when patients are likely to meet diagnostic criteria for substance dependence or other substance-related disorders as defined by ICD 10. Referral
requires the primary care system to establish linkages with specialty care system so that
they may receive treatment in a timely manner. Research suggests that motivational-ba65
sed BIs can increase patient participation and retention in substance abuse treatment
(24). While referral may be difficult in some LMIC, this should not deter agencies from
performing SBI activities, as they have beneficial effects separate from the referral.
The integration of SBIRT into clinical settings attempts to raise awareness of substance
use issues among patients and help them to find relevant treatment solutions, where
appropriate. At the same time, prevention efforts may also be targeted at those with
minimal or mild drug misuse. Identified abstainers can benefit from supportive and
normative information to maintain healthy lifestyles and for those at risk for drug problems, early identification and brief intervention may prevent progression to more severe
drug problems.
Treatment Services for Drug Dependence
In contrast to brief interventions aimed at drug users with hazardous substance use,
most treatment programs for persons with substance dependence attempt to reduce
substance-related harm by promoting abstinence through the use of counseling, psychotherapy, pharmacological agents or peer support. Among the most systematically
evaluated programs are interventions focused primarily on users of heroin and other
opioids. Opioid substitution therapy (OST) has been found to reduce injection drug
use, overdose mortality, and HIV infection, and it is also associated with lower crime
rates (25).
Psychosocial interventions for users of cocaine, methamphetamine, hallucinogens, benzodiazepines, and club drugs have evidence of effectiveness as well (26, 27).
Peer-led mutual help organizations are voluntary associations of former drug users who
help each other to abstain through group meetings and other types of support. They are
typically operated by volunteers, charge no fees, and allow indefinite involvement. The
duration of NA (Narcotics Anonymous) membership is positively associated with higher self-esteem, lower anxiety, and longer abstinence from drugs (28, 29).
A behavioral approach called contingency management (e.g. voucher reinforcement)
(30-32) have been shown, in a substantial number of randomized trials utilizing specially-trained research therapists, to exercise powerful beneficial effect. Specific forms of
counseling and brief treatment for moderate drug use problems (33, 15) have also been
found to be effective.
In summary, there is good evidence that treatment for opiate addiction is effective, encouraging evidence that counseling for chronic marijuana smokers and therapeutic
communities for incarcerated drug users are effective, and modest evidence that stimulant dependence treatment is effective.
In addition to specific treatment modalities, policies affecting the type, amount and organization of health and social services play an important role in the overall effective66
ness of a service system (2). The number and organization of drug treatment services
differ markedly among countries in terms of their availability, accessibility, coordination,
cost-effectiveness, and degree of coerciveness. There is some evidence to suggest (34)
that when services are more available, accessible and coordinated, they are likely to be
more effective in reducing population rates of drug-related harm.
Harm-Reduction Strategies
Harm reduction involves diminishing the health-related, social, and economic consequences of psychoactive substance use without the user necessarily abandoning the use of
drugs. Harm-reduction is not contradictory to prevention or treatment, but complementary (35). In addition to harms related to drug use, harm-reduction strategies can
also minimize harms associated with the acquisition of drugs, like being exposed to
high-risk situations.
The harm reduction interventions for which there is the most evidence of their effectiveness are the distribution of new syringes and needles to replace used ones for injecting
psychoactive substance users, increasing the availability of naloxone for managing heroin overdoses, and vaccination against hepatitis B, also for users of injectable psychoactive substances (36-38).
Needle and syringe programs (NSP) target infectious disease contraction and transmission rather than drug use per se. In some cases, they have been found to encourage street
drug users enter addiction treatment and ultimately cease drug use (39). A recent review
found strong evidence that syringe exchange programs reduce injection risk behaviour
and promising evidence that this translates into reduced HIV transmission (40).
Two strategies have been used to expand access to the opiate antagonist naloxone, which blocks the ability of heroin to occupy receptor sites, and reduces the acute effects of
heroin overdose. In some countries, medical professionals are allowed to administer naloxone when responding to an overdose emergency. A second approach is to distribute
naloxone to drug users in the community, along with information on how to use it (41).
In summary, research shows that rates of HIV infection are lower among attenders versus non-attenders of needle and syringe exchange programs (42), and those participating in these programs also have better engagement with health and social services (39).
In addition, the use of opiate antagonists is capable of preventing overdose deaths.
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Supply Control
Interventions to Reduce or Eliminate the Supply of Illicit Psychoactive
Substances
In most countries, most of resources for preventing illicit psychoactive substance use are
invested in funding interventions to control the supply of illicit drugs. These strategies
seek to control the production, distribution, and sale of psychoactive substances, whereas criminal sanctions deal with punishment of drug sellers and users. The rationale
behind these measures is that the use of illicit psychoactive substances can be influenced
by measures that hinder the population’s access to these substances, reduce their availability, increase their price, and detract from their allure and image of being a normal
part of life (2).
Examples of interventions to control the supply of these substances include programs to
introduce alternative crops in the countries that produce illicit psychoactive substances;
strict regulation of the chemical precursors used in producing some of these substances
(e.g., potassium permanganate to produce cocaine and ephedrine and pseudoephedrine
to produce methamphetamines); the interception of contraband psychoactive substances; and regulatory control of the pharmaceutical industry, pharmacies, and medical
prescribers to prevent psychotropic drugs (analgesics, psychostimulants, etc.) from being funnelled into the illicit market. Each of these approaches is based on a different
set of assumptions about drug misuse. Except for decriminalization, these assumptions
refer primarily to the importance of limiting access to drugs by controlling supply, price
or the normative acceptance of drug use as normal or attractive.
According to Strang et al. (3), the empirical evidence supports five broad conclusions
on the effectiveness of supply control with regard to keeping prices high. First, when
enforcement is sufficient to keep prices high, drug initiation and use, and even problem
drug users respond to price changes (43). Second, illegality combined with enforcement
makes illegal drugs far more expensive at retail in developed countries relative to their
production and distribution costs (44). Third, in established markets, aggressive enforcement is a very expensive way to increase prices (45).
Fourth, alternative development and crop substitution programs in source countries
have had no detectable effect on the availability or price of drugs in consumer countries
further down the distribution chain (2). Where drug production or transit has been reduced in one country or region, these activities have merely resulted in the geographic
displacement of drug production, drug trafficking routes, and power centers in the drug
trade (46). For example, increased eradication efforts in Bolivia and Peru during the
1980s and 1990s pushed coca cultivation into Colombia.
Fifth, in some cases supply shocks have temporarily reduced drug availability, purity,
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and harms in countries with established markets. Examples include methamphetamine
precursor controls (47) in the USA and Mexico, the 1989/1990 war on Colombian traffickers (48), and the Australian heroin drought (4).
Law-Enforcement Interventions
The objective of criminal justice interventions is to deter individuals from using drugs
through the threat of sanctions (3). Mazerolle (50) reviewed studies of community police interventions designed to enforce the law through interaction with the community
and proactive policing (e.g., raids, actions against property where illicit traffic is taking
place), both in “hot spots” and on a broader scale. The results show a clear lack of effect
for this type of intervention on the frequency of crimes associated with illicit psychoactive substance use. This suggests that local or street-level enforcement is probably not a
strong strategy for reducing drug use because the number of retail sellers is so large as to
overwhelm the capacity of the criminal justice system to deliver punishment. Nevertheless, its primary effects may help to control the harms associated with drug markets, encouraging dependent users to make contact with service providers, and communicating
moral norms against drug use in those communities most affected.
Severity of Punishment
Interventions in the criminal justice sector have consisted mainly of increasing the severity of penalties for drug dealers. However, milder penalties or the use of alternative measures have also been proposed, since most of the cases involve small-time dealers who
are only the last link in the chain of organized crime and are easily replaceable (Global
Commission on Drug Policy). There is growing evidence that immediate, certain, and
modest sanctions following positive drug tests produce substantial reductions in drug
use and offending among drug abusers (51). In these programs, offenders on community
release (pre-trial, on probation, or on parole) are drug tested at least weekly, with a typical sanction for a missed or ‘dirty’ test being 24 hours incarceration (52). These coerced
or mandated abstinence programs have been used for drug and drink-driving offenders
on community release (pre-trial, on probation, or on parole, see 53; 52), as well as monitoring programs for addicted physicians and airline pilots (54).
Another function of law enforcement is to support referrals into treatment and provide
incentives to remain in treatment. Drug courts are one example of this approach (55).
They have been found to be more effective at keeping clients in treatment than suspended sentences or other diversion programs (56).
The ability to significantly suppress drug use in established drug markets through supply
control and user sanctions may be limited (57). Enforcement may therefore have greater potential in managing collateral effects of drug markets, coercing abstinence among
closely supervised offenders, and complementing traditional treatment interventions.
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Decriminalization and Depenalization
In some countries (e.g., Portugal, the USA) there have been recent efforts to reduce or
change the penalties for illicit substance use in order to remove the negative side effects of criminal sanctions. Following a period when incarceration and increasing legal
penalties were tried, some countries begin to explore the possible benefits of reducing
criminal penalties for possession of small amounts of drugs for personal use, particularly for cannabis. Most decriminalization or depenalization programs involve the substitution of civil penalties for criminal penalties for possession offenses, while retaining full
formal prohibition of what are considered more harmful substances.
Evaluations of such changes (58-60) suggest that decriminalization makes little difference to prevalence of cannabis use. The Dutch coffee shop system, in which cannabis is de
facto legally available to adults, is difficult to evaluate systematically, but cannabis use
rates for the Netherlands are not significantly different from other western European
countries. Those rates did, however, rise sharply among youth after the coffee shop system became more commercially sophisticated with better advertising during a period in
which use rates for cannabis did not rise in most other western countries. Drug use did
not fall in the Czech Republic when possession was recriminalized, and drug use and
problems decreased rather than rose in Portugal after decriminalization. The evidence
indicates that removing or reducing criminal penalties on possession does not lead to
substantial increases in use. However the research is limited because it almost all comes
from developed countries; most of the studies only focus on cannabis.
Prescription Regimes
Another broad approach to supply control has been applied to control the diversion of
psychopharmaceuticals (i.e., drugs designed for therapeutic purposes such as pain medications that are used or sold illegally because of their psychoactive properties). This is
accomplished by the regulation of pharmaceutical companies, pharmacists and physicians through prescription regimes. The objective is to manage access to pharmaceutical
drugs so as to deter unsanctioned and non-medical use while permitting access to these
medicines when used as approved treatments (3).
A variety of measures have been developed to prevent abuses such as “doctor shopping”
and diversion of psychopharmaceuticals from the medical and pharmacy systems. The
evidence suggests that prescription regimes affect the behavior of doctors, although medication substitution (i.e., change from one drug brand to another) can negate the effect
(61).
Price can be used to channel demand from a drug with more adverse consequences to
a less risky alternative. Advice to physicians, in the absence of regulatory enforcement,
seems to have limited effect on prescribing unless the advice concerns a new and serious
70
side-effect and alternative medicines can be prescribed. Shifting a prescribed drug onto
a special prescription register in conjunction with guidelines that limit prescriptions,
can reduce prescriptions of that drug. In summary, research on prescription regimes
indicates that the development of a strong pharmacy system can limit illicit diversion
of prescription medications. Nevertheless, such systems have not been able to prevent
periodic epidemics of prescription drug misuse in countries with a very high demand
for psychopharmaceuticals, such as the United States, Canada, the European Union, Japan and Australia, where non-prescribed medications come onto the market via theft,
unauthorized sales, prescription fraud, counterfeit drugs, and illicit internet sales (62).
These societies seem to be particularly vulnerable to leakage from the legal to the illegal
market.
Conclusions
The main message of this article is that scientific research is available to inform the development and implementation of effective drug policy. Yet current drug policy in most
societies takes little or limited account of this research. Among the 43 options reviewed
by Babor et al. (2), 17 show some evidence of effectiveness in at least one country. Unfortunately, policies that have shown little or no evidence of effectiveness continue to be
the preferred options of many countries and international organizations.
The 2009 UNODC Political Declaration called for an “integrated and balanced approach” to drug policy that harmonizes both demand reduction and supply control measures. The Political Declaration’s commitment to effective drug policy “based on scientific
evidence” provides an incentive to integrate demand reduction with supply control and
criminal justice measures. Research reviewed in this article documenting the effectiveness of demand reduction measures, especially treatment services, needs to be considered in relation to the public health benefits of coordinating criminal justice interventions
more closely with treatment referral options.
A substantial number of interventions are suitable for implementation in many, perhaps even all, settings in which there is opportunity for clinical intervention. This includes opportunistic screening and brief interventions, often at a stage before serious
drug dependence problems have developed. Criminalisation of possession for personal
use may serve as one barrier to treatment seeking in some cases though in others may
increase treatment-seeking. Police and other members of the criminal justice system can
work with health care providers to make treatment, care and harm reduction services
more accessible. Drug policy efforts have the potential to achieve population impact and
cost-effectiveness despite the discouraging experience in many countries to date. A significant benefit would likely result from an expansion of a public health approach which
seeks to coordinate successful efforts at supply control and demand reduction. In this
way it may be possible to reduce the extent of illicit drug use, prevent the development
71
of new epidemics, and avoid the unintended impacts arising from the marginalisation of
drug users through severe criminal penalties.
For example, prison programs represent a special intervention opportunity to treat drug
dependence, help to prepare offenders for release from prison, and also to manage other
associated health conditions, such as HIV and hepatitis B. Another area is opportunistic
screening and brief interventions (15), especially in combination with health promotion
efforts in health care settings to address smoking and other behavioral risk factors. A
third area consistent with the Political Declaration is the use of drug courts and other
diversion approaches to provide better opportunities for drug users to obtain treatment.
These efforts will not be successful unless there is greater attention paid to the development of a more integrated and coordinated system of treatment and prevention services.
In conclusion, drug policy has the potential to enhance its contribution to public health
and social welfare by focusing on interventions with the largest potential population
impact, the strongest evidence of effectiveness, and the best prospects for integrating
demand reduction and supply control measures. The scientific evidence reviewed in this
article is not sufficient to stem the rising tide of global drug problems. However many
countries are not utilizing existing resources to best effect. The evidence reviewed here
could be a powerful starting point to create more effective drug policy.
Acknowledgements
The author is grateful to the co-authors of Drug Policy and the Public Good, who contributed their time and expertise to develop many of the conclusions summarized in
this article, and to the World Health Organization, which supported an update of the
literature review. Nevertheless, the views expressed in this article are solely those of the
author and do not represent the policy positions of WHO.
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78
Drug
Prevention
Strategies
79
80
David R. Foxcroft*
Community Psychology and Public Health, Oxford Brookes
University, Oxford, U
ABSTRACT
Descriptions of prevention as primary or secondary, or universal, selective and indicated, set out the different forms that drug misuse
prevention can take. However, these classifications are limited because they do not consider how prevention interventions work. For
example, the function of some prevention programmes is to improve the developmental trajectory of young people through the enhancement of social competence and social skills.
In this paper, I set out a framework for describing prevention that brings together both form and function into a new prevention taxonomy. Examples of prevention programmes that emphasise the development of social competence and social skills in young people
will be given to illustrate this approach.
* David Foxcroft, PhD is Professor of Community Psychology and Public Health at Oxford Brookes University in England. His programme of work is focused on understanding (and improving) behaviour in context, especially how social structures (e.g. families, schools, communities, employers, regulation, government) can support improved health and wellbeing in communities and populations.
A focus is the prevention of risk behaviours in children and young people. David is President Elect of the European Society for Prevention Research, an Editor of the International Cochrane Collaboration Drug and Alcohol Group, a recipient of the U.S. Society for
Prevention Research Tobler Prize for his Cochrane work, and co-author of the prize winning book “Drug Policy and the Public Good”.
81
PREVENTION PROGRAMS AND EFFECTIVENESS: ENVIRONMENTAL, DEVELOPMENTAL AND INFORMATIONAL APPROACHES
Drug Prevention Programmes and
Effectiveness: Environmental,
Developmental and Informational
Approaches
Introduction
The field of drug prevention sits within the new field of prevention science, a multi-disciplinary endeavour to consider aetiology, epidemiology, intervention design, effectiveness and implementation for the prevention of a variety of health and social problems.
These include, but are not limited to, substance misuse, sexual health and teenage pregnancy, HIV/AIDS, violence, accidents, suicide, mental illness, delinquency, obesity, diet/
nutrition, exercise, and chronic illness. A common characteristic is the importance of
behaviour as a determinant of ill-health and health inequality.
Prevention science is a new and growing multidisciplinary scientific field, with strong
coverage in the United States, including a scientific society, methodology groups and
networks, and a growing impact journal. The recent establishment of the European Society for Prevention Research (EUSPR; www.euspr.org) and the EC funded Science for
Prevention Academic Network (SPAN; www.span-europe.eu) is seeking to emulate this
strong coverage across Europe. In line with the categories of prevention set out by the
European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), the EUSPR
aims to “advance the science base of environmental, universal, selective and indicated
prevention aimed at improving human health and well-being and addressing health
inequalities”.
If we are to undertake systematic and coherent research for prevention, covering environmental, universal, selective and indicated aspects, then it is important to have a
strong organising framework, or classification system, for prevention science. However,
my personal view is that in following the EMCDDA in listing environmental alongside
universal, selective and indicated prevention, we risk conflating two important dimensions: the form and function of prevention (1). In the original use of the phrase “form and
function”, form was specified to follow function, illustrated in this quote from 1896 by
the American architect Louis Sullivan (2):
“It is the pervading law of all things organic and inorganic, of all things physical
and metaphysical, of all things human and all things superhuman, of all true manifestations of the head, of the heart, of the soul, that the life is recognizable in its
expression, that form ever follows function. This is the law.”
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Sullivan’s maxim perseveres, and is just as relevant to prevention in the 21st Century as it
was to design in the 19th Century. Accordingly, I propose that prevention is best conceived, and classified, from a functional perspective.
The development of prevention classification
In 1983 Robert Gordon, then a Special Assistant to the Director at the United States National Institutes for Health, wrote a letter to the journal Public Health Reports (3) challenging the categories of primary and secondary prevention that had been widely used
since the 1957 report of the Commission on Chronic Illness (4). Gordon recognised that
the categories of primary and secondary prevention, whilst still useful in the context of
infectious disease with a clear biological origin, were less useful when considering chronic conditions that did not have a clear biological manifestation. Primary prevention
was defined as “…practiced prior to the biologic origin of disease…” and secondary
prevention as “…practiced after the disease can be recognised, but before it has caused
suffering and disability…”. Given that epidemiological research was drawing out links
between behavioural and social risk factors and health problems, Gordon wrote that it
was time to move on from the biomedically based categories of primary and secondary
prevention: “As more is learned about multifactorial chronic diseases with long periods
of latency, the concept of biologic origins of disease becomes progressively more diffuse.”
Instead, Gordon suggested that prevention should be classified according to the population groups in which there is optimal application. Universal prevention, the most generally applicable type, is a preventive measure that is desirable for everyone and can be
advocated confidently for the general public. On the other hand, where groups of people
were known to be at higher risk, and where the balance of risk against benefits and costs
from prevention indicated that universal approaches were not attractive, then selective
prevention which targeted preventive measures to higher risk groups was appropriate.
Indicated prevention is further along the continuum toward treatment, and is defined
as prevention targeted at individuals who have been personally identified as being at
increased risk for poor health.
In 1994, the United States Institute of Medicine (IoM) of the National Academies adopted the classification system proposed by Gordon (3), namely universal, selective and
indicated prevention. And more recently, in 2009, the IoM looked again at the definition
and classification of prevention, this time for a report on Preventing Mental, Emotional
and Behavioural Disorders in Young People (5). In this report the authors considered
alternative prevention classification systems, including the older notions of primary and
secondary prevention, as well as more recent developments such as personalised medicine which identify risk to individuals based on genomic analysis. The report concludes
that the original 1994 IoM classification system (6), largely based on Gordon’s 1983 proposed categories of universal, selective, and indicated prevention (3), provides the best
83
available system for classifying preventive interventions prior to the onset of disorders.
Prevention forms and functions
Classifying prevention according to the population level in which there is optimal application, namely universal, selective or indicated prevention, provides a useful clarification on the form, or configuration, that prevention takes. Universal prevention takes
the form of a whole population approach, where risk of developing a disease or disorder
is typically diffuse and preventive interventions are not based on level of risk. Selective
prevention measures are targeted toward sub-groups whose risk is significantly higher
than average, and indicated prevention measures are targeted to high-risk individuals
who are identified as having minimal but detectable signs, symptoms or markers foreshadowing a disorder.
However, there remains some conceptual confusion regarding particular prevention approaches, specifically where these approaches fit within the universal/selective/indicated
classification system (1). For example, environmental prevention is often distinguished
as a separate class of prevention, pertaining to public policies such as laws, regulations,
rules and taxation levels. Prohibiting drugs, restricting advertising of potentially harmful substances, gun control laws, enforcing laws regarding selling of alcohol to minors, or
increasing excise taxes on alcohol or tobacco are all environmental prevention measures.
Similarly, water fluoridation, or adding folic acid to bread flour, are also environmental
prevention measures.
Environmental prevention, however, overlaps significantly with universal prevention.
Laws, regulations, rules and taxation levels typically apply at a whole population level,
and are not usually targeted towards higher risk groups or individuals. So can we regard
environmental prevention as universal prevention: are they synonymous? The answer is
no, because although environmental prevention often takes a universal form, it doesn’t
always. For example, restricting alcohol sales to people 21 years and older targets a more
vulnerable group (children and adolescents) with the aim of preventing purchase and
consumption of alcohol before their bodies are physically mature. Similarly, gun control
laws may dictate that higher risk individuals should not be allowed access to firearms.
So, although environmental prevention is typically universal, it can also take the form of
selective or indicated prevention.
A suggestion, to try and get over this conceptual confusion, is that alongside the forms
of prevention in the universal-selective-indicated scheme, it would be helpful to classify
prevention according to its function, or purpose. Proposed functional types of prevention are environmental, developmental, or informational preventive measures. In this
typology clear definitions should emphasise distinctive functional characteristics:
•
84
Environmental prevention comprises interventions that aim to limit the availabi-
lity of maladaptive behaviour opportunities, through system wide policies, restrictions and actions. For example legal restrictions, economic (dis)incentives or
situational crime prevention.
•
Developmental preventive interventions aim to promote adaptive behaviours,
and prevent maladaptive behaviours, by focusing on the development of skills
that are key in socialization and social development of appropriate behaviours.
For example, parental monitoring practices, teacher behaviour management strategies, and individual social or life skills.
•
Informational prevention interventions aim to increase knowledge and raise
awareness about specific risk behaviours, through communications. For example
mass media campaigns to raise awareness or social normative feedback to challenge preconceptions.
These functions of prevention can be considered alongside the different forms of prevention, in a grid or matrix. This prevention matrix, it is suggested, provides an improved
classification system for preventive interventions; see Table 1 for an illustration for youth
alcohol misuse prevention with example prevention interventions at each intersection of
form and function.
The prevention matrix shown in Table 1 also prompts consideration of the profiling of
prevention planning or activities across a range of forms and functions. Rose (7) generally advocated population-based universal prevention strategies as a means of improving the distribution of behaviour across the population, but Frolich and Potvin (8)
have pointed out that such universal strategies can have the unfortunate consequence of
increasing health inequalities, because they are generally more impactful on better off,
lower risk, population groups. In fact Rose (7) (see also Allebeck) (9) acknowledged this
and, as Marmot (10) suggests, an optimal strategy is one which combines universal with
targeted approaches, in a progressive universalism.
Similarly, organising prevention activities across informational, developmental and environmental functions of prevention should promote optimal coverage, based on the
expectation that “one size does not fit all”. However, this assumption should, in the future, be checked against theoretical analysis and empirical evidence reviews that weigh
up the relative benefits and drawbacks of investment in the different functional types of
prevention.
85
Universal
Selective
Indicated
Environmental
Legislation to prohibit
substance use; suppression
of international supply
routes
Targeted enforcement
and actions to deal with
drug dealing in high risk
neighbourhoods; athlete
drug testing programmes
Legal orders to prevent
problem individuals from
accessing alcohol premises;
imprisonment
Developmental
Social/life skills programs,
for all school students,
that provide young people
with skills to cope with
social influences
Family/parenting
programs with families
in the most deprived
areas in a region or
country; or home
visiting programmes
with vulnerable pregnant
women
Individual counselling
programs with adolescent
males with impulse control
problems
Informational
Mass media campaigns to
raise awareness of danger
of drugs
Informational
interventions targeted at
young males in deprived
neighbourhoods with
strong gang cultures
Normative feedback
interventions for individuals
who screen positive for
substance misuse
Table 1 Prevention Forms and Functions: illustrative examples for substance misuse prevention
Theory and evidence
One of the major disappointments for policy makers and prevention scientists has been
the generally poor success of health promotion messaging and information campaigns
in the face of commercial and cultural influences on risk behaviours, for example diet,
smoking, exercise and drinking (the four major risk behaviours for non-communicable
diseases). The same goes for social cognition interventions based on well-established
psychological theories, such as the theory of reasoned action and planned behaviour,
and derivatives such as the theory of triadic influences, which propose that behaviour is
mediated through cognitive intentions to engage in behaviour. The idea is that if you can
change intentions then you can change behaviour, because behaviour follows intentions
(or more broadly put, “behaviour follows brain”). Cognitive psychologists, and social
cognitive psychologists, have traditionally suggested that behaviour (or action) is mediated through internal representations of the outside world that are held in our heads
(brains). In other words, brains receive inputs via perception and process these inputs
via a representational heuristic which produces outputs from the brain; these outputs are
typically behaviour of one form or another. Preventive interventions based on such theories have had limited success, and these theories are increasingly being challenged (11).
An alternative perspective, and one that deserves much more attention within the prevention science community, is the idea that behaviour is largely triggered by aspects of
86
the environment, and that cognitive processing is mostly secondary to behaviour that
emerges from the transaction between an individual and objects in their environment.
Simply put, the notion that “brain follows behaviour” (12) is arguably a more compelling
basis for prevention science and action. One leading theorist has proposed that behaviour typically results from “action-oriented predictive processing” (13); essentially the
idea is that individuals respond instinctively and automatically to their environment,
without any higher level cognitive mediation of action. The exception to this typical
pattern occurs when action, or opportunities for action, within a particular environmental context is not consistent with prior expectations, in which case individuals are
motivated to change their behaviour or their expectations to reduce this inconsistency.
Daniel Dennett (14) has linked this theory to the Umwelt concept and to Gibson’s (15)
notion of affordances.
Importantly for the proposed functional types of prevention, there is a clear theoretical
link between (i) environmental context and environmental prevention, where limiting
opportunities for action can lead to changes in behaviour and changes in attitudes, norms, values, habits etc.; and (ii) prior expectations and developmental prevention, where
attitudes, norms, values, habits etc. are internalised over months and years of socialization and make a significant contribution to prior expectations. By contrast, it is not
clear how informational prevention, that aims to change knowledge and awareness, can
have a direct and strong impact on the largely automatic, unconscious, action-oriented
predictive processing. Given this, a theoretically informed prediction of the relative effectiveness of different functional types of prevention is provided in Figure 1, which shows
that environmental prevention is generally more effective than developmental prevention which, in turn, is generally more effective than informational prevention. This prediction assumes that implementation or enforcement of prevention interventions across
all functional types is equally robust.
Moreover, within each functional type there will be interventions that are more
or less effective. To illustrate, within environmental prevention a strong intervention would be price or legislation policy controls that have a direct impact on
opportunities to engage in maladaptive behaviours, or concentrated policing and
urban renewal to remove drug dealing from particular neighbourhoods (Figure
1; A). By contrast, a relatively weak environmental intervention is server training, which
encourages bar staff to limit alcohol to people who are already intoxicated by offering
soft drinks instead, an example of “nudging” (Figure 1; B). The urban renewal of Bryant
Park in New York is a good example of a strong intervention, where targeted action against drug dealers along with inward investment in renewal transformed this public space
from a derelict area where drug dealing was rife, and where children were often offered
drugs, to one where drug dealing is no longer an issue and it is now a popular family and
leisure oriented public space (16). See Figures 2 and 3.
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Figure 1 Predicted Effectiveness across and within different functional types of prevention
Similarly, within developmental prevention, a strong intervention would be an early intervention prevention programme that impacts the ongoing socialization and normative
development of children and young people (Figure 1; C); compared with a brief skills-oriented school curricula for alcohol and drug misuse prevention for 14-year-olds, a
relatively weak prevention intervention for many young people who have been exposed
to years of marketing and social norms around the use of particular substances and who
may have already started drinking or experimenting with drugs (Figure 1; D). Evidence
for the effectiveness of early intervention prevention programmes can be seen in the
Figure 2: Bryant Park, New York, in the 1980s: a derelict, drug dealing public area (16)
88
Figure 3: Bryant Park, NY, 2013: a safe, family oriented public space 16
(photo with permission from @martinmkee)
results of two long-term randomised controlled trials. In one trial, students and their
families were randomly allocated to an intervention group or a control group; the intervention group received the 7-session Strengthening Families Programme 10-14 together
with a Life Skills Training classroom curriculum, whereas the control group had no additional support over usual practice (17). Five years later, the intervention group students were much less likely to be methamphetamine users (Figure 4). Similarly, an early
intervention prevention programme that focused on improving classroom behaviours
at ages 6 and 7, the Good Behaviour Game, followed up students from a randomised
controlled trial in Baltimore in the United States (18). Around fifteen years later, there
were important reductions in smoking and drug abuse for all males, compared with
the control group, and even more pronounced differences for higher risk males with
more challenging behaviours at the time of the intervention, in primary school (Figure
5).Within informational prevention a relatively more effective prevention intervention
could be social normative feedback, which corrects erroneous perceptions of peer group
levels of particular behaviours (E), although effect sizes for behaviour change tend to be
small and perhaps not useful for achieving improvements to population health; and a
relatively weak intervention is a mass media campaign to warn of the dangers of alcohol
or drug abuse (F). Of course, these are predictions, and further empirical and theoretical
work is needed to test them out.
89
Figure 4: Effectiveness of the combined SFP10-14 and LST prevention programmes on methamphetamine
use at 5-year follow-up (17)
Figure 5: Impact of the GBG on smoking and drug abuse diagnoses when students were aged 20-21 (18)
90
To sum up, in this paper I have suggested that a prevention taxonomy that incorporates
the function of prevention improves on the existing typology of universal, selective and
indicated forms of prevention. Three functional types of prevention are suggested: environmental, developmental and informational; and it is predicted that for many important risk behaviours environmental prevention will generally be more efficacious than
developmental and informational prevention efforts. Further empirical and theoretical
work is needed to test these predictions.
REFERENCES
1. Foxcroft DR. Can prevention classification be improved by considering the function of
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10.1002/ejsp.666.
Clark A. Whatever next? Predictive brains, situated agents, and the future of cognitive
science. Behav Brain Sci. 2013; 36(3):181-204.
Dennett D. Expecting ourselves to expect: The Bayesian brain as a projector [Commentary]. Behavioural and Brain Sciences. 2013; 36:209-210. doi: 10.1017/S0140525X12002208.
Gibson J. The Ecological Approach to Visual Perception. New Jersey, USA: Lawrence Erlbaum Associates; 1979.
Sheftell J. Inside the transformation of Bryant Park. NY Daily News. New York: http://
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[accessed September 2014], 2011.
Spoth RL, Redmond C, Trudeau L, Shin C. Longitudinal substance initiation outcomes for
a universal preventive intervention combining family and school programs. Psychology of
Addictive Behaviors. 2002; 2:129-134.
Kellam SG, Mackenzie A, Brown CH, Poduska JM, Wang W, Petras H, et al. The Good
Behavior Game and the future of prevention and treatment. Addiction Science & Clinical
Practice. 2011; 6:73-84.
Arzu Çiftçi Demirci*
Clinical Psychiatrist & Specialist at CEMATEM, Bakırköy Prof. Dr.
Mazhar Osman Mental and Neurological Diseases Hospital
ABSTRACT
Alcohol and drug use is an increasing public health problem. It has been threatening our society and mental health by causing serious
biopsychosocial problems. Teenagers have the highest risk concerning these problems.
Even though the rate of alcohol and abuse is lower than European statistics, increased migration toward big cities, high rates of unemployment and poverty, injustice in income distribution and increased divorce rates are affecting the society. Increase in opportunities
for young people as a result of urbanization and modernization is not parallel with the increase in duration or quality of education. Use
of communication tools for different purposes, increase in witnessing violence on media, increased individualization by the industrialization, and urbanization have been intensifying the problems in adolescence. While influence of family decreases in adolescence,
influence of peers is increasing and behavior of alcohol use spreads quickly among young people. Contrary to adult drug use behavior,
in adolescence drug use is a collective behavior and is encouraged by peer pressure. As well as preventing alcohol use in adolescents,
it is crucial to provide treatment and rehabilitation to young people who have just began or become addicted, in order to prevent them
from influencing other young people.
Alcohol and drug addiction is a lifelong medical condition which becomes more and more devastating as the use of drug or alcohol use
endures. Early intervention would lead less biopsychosocial devastation which would increase the chance that the individual is adopted
by the society in a healthy and efficient way.
Keywords: Alcohol and Drug Abuse, Children and Adolescents, Risk Factors, Early Intervention
* Arzu Çiftçi Demirci graduated from Ankara University, Faculty of Medicine in 1996. She completed her residency education at Bakırköy
Prof. Dr. Mazhar Osman Mental and Neurological Diseases Hospital between 1996 and 2001. She worked as a consultant physician at 70th
Year Physical Therapy and Rehabilitation Training and Research Hospital between 2002 and 2010.
Since 2010, she has been working as a physician in charge at Child and Adolescent Alcohol and Substance Addiction Therapy Center
(ÇEMATEM). She worked in fields such as psychosomatic diseases, psychiatric diseases related to the spinal cord injuries, and
consultation-liaison. In last four years, she has been working on the prevention and treatment of substance abuse and addiction in the
child and adolescent age groups.
93
ALCOHOL AND DRUG USE IN ADOLESCENTS
Alcohol and Drug Abuse in Adolescents
Alcohol and drug abuse increases every day and threatens our society and our mental
health by causing serious biopsychosocial problems. Today, it is necessary to establish
national and international associations to combat these problems.
It is known that psychoactive substances have been used for their pleasure-giving, painkiller and healing effects since the beginning of the history of humanity. Coca tree,
that is found in And Mountains and Rauwolfia Serpentia, which is found in Himalayas
were among the first plants used for these purposes (1). They were used for magic and
religious ceremonies by Shamans. In Hindu texts, marijuana was considered sacred (2).
Although some of the psychoactive substances are used in medicine today, most of them
are used illegally for pleasure and fun and become more popular. Unfortunately, the
science creates new monsters. Every day, new psychoactive substances having many negative effects threatening the society are launched in the market (3).
Today, it is accepted that alcohol and drug abuse is a public health problem. Adolescents
are considered to be the most affected group by this problem. Marijuana is the most
commonly used illegal substance by adolescents. It is followed by the amphetamine-derived stimulants in terms of annual incidence (4). Cigarettes, alcohol and marijuana
abuse cause transition to other psychoactive substances (heroin, cocaine, ecstasy, etc.)
that have a stronger and more addictive potential and they are accepted generally as the
transition substances.
Approximately 3 to 6.1% of the world population between the ages of 15 and 63 were
reported to use psychoactive substance at least one time during the previous year in 2009
by the World Drug Report 2012 by United Nations Office on Drugs and Crime (UNODC). Globally, about 200,000 people die from illicit substance abuse and associated health problems (HIV, Hepatitis B-C, accidents, other infections) (4).
According to 2010 results of the USA National Survey on Drug Abuse and Health (NSDUH), approximately 22.6 million (8.9%) Americans of 12 years old and above used
any of the substances in a month. While this was 8% in 2008, it increased to 8.9% in
2010. In 2010, marijuana became the most commonly used illegal substance in the USA.
The abuse rate increased from 5.8% to 6.9% and the abuser number increased from
14.400.000 to 17.400.000 between the years of 2007 and 2010. The existing illegal substance abuse rate in the adolescents of 12-17 years old was 9.3% in 2008, 10% in 2009 and
10.1% in 2010 (5).
The first study related to the prevalence of substance use in Turkey used an inventory
with 1,500 high school students in 1991. In this study, the rate of adolescents who used
94
any substance at least once in their life-time was found as 2.6% and the rate of marijuana
use was found as 0.7% (6).
In an ESPAD (European School Survey Project on Alcohol and Other Drugs) study conducted with high school students in Istanbul in 1995, it was found that the rate of adolescents who used any substance once in life-time was 7%, among this group; the rate of
marijuana use was 4%, the rate of volatile substance use was 4%, the rate of ecstasy use
was 1%, the rate of sedative-hypnotic drugs was 7% and the prevalence of heroin use was
1% in this group (7).
In the same year, the Ministry of Health performed a study in 7 different cities. In this
study that was conducted in high schools, the lifelong abuse rate of psychoactive substance other than alcohol was reported to be about 3.5% (8).
In the survey conducted with 5,823 junior high school students in Istanbul in 1996, lifelong abuse rates of marijuana, volatile substance, ecstasy, sedative-hypnotic and heroin
were reported as 4.2%, 4%, 0.9%, 5% and 0.7% respectively (9).
In the SAMAY study conducted in 15 cities in 1998 with the group of 15-17 years old,
the lifelong substance abuse rates were respectively as follows: marijuana 3.5%, volatile
substances 8.6%, sedative-hypnotic 3.2% and heroine 1.6%. The cities where the lifelong
marijuana abuse was reported were Izmir (4%), Istanbul and Diyarbakir (3.6%), Mugla
(3.4%) Antalya (3.2%) and Adana (3.1%) (10).
In 2001, another study was conducted in 9 different cities with 11,989 elementary school
students and 12,270 secondary school students (with the group of 10-12 and 15-17 years
old). Life-time prevalence of substance use in elementary school groups were respectively as follows: marijuana 0.4%, volatile substance 3%, other drugs and stimulators
0.4%. These rates were respectively as follows in secondary school group: marijuana 3%,
volatile substances 4.3%, heroin 2.1%, ecstasy 1.3% and cocaine 1.2% (8). When the
socio-demographic data of this study is considered, the risk of volatile substance abuse
was 1.7 times more in elementary school students of low income families. There was not
a difference in terms of income level for other substances. In secondary school, the risk
of ecstasy abuse was 1.6 times more in students of high income families. For the students
from private schools, the marijuana abuse risk was 2.6 times, the volatile substance abuse
risk was 1.8 times, heroine abuse risk was 3.2 times, ecstasy abuse risk was 4 times and
cocaine abuse risk was 3.8 times when compared to the students from public schools (11).
In the study conducted by UNODC in 2003 again with junior high school students, the
lifetime abuse rates were respectively as follows: marijuana 5.1%, ecstasy 3.2%, volatile
substance 5.2%, sedative-hypnotic drugs 5.4%, heroin 2.8% and flunitrazepam 3.1% (12).
In a study conducted in Istanbul in 2004 with 3,483 junior high school students, it was
found that abuse rates of at least one time were as follows: volatile substance 5.9%, marijuana 5.8%, flunitrazepam 4.4%, benzodiazepine 3.7%, ecstasy 3.1% and heroin 1.6%
95
(10). It was observed that the flunitrazepam abuse risk was more in students of high
income families compared to students of low income families (13).
In a study conducted in Istanbul in 2010 with the participation of 28,000 high school
students of first, second and third classes, it was found that the lifetime abuse rate for
marijuana was 3.3% and for psychoactive substances other than marijuana was 9.2% (14).
Again in a study conducted in Istanbul in 2012 with junior high school students, it was
found that the abuse rate of any substance was 10% and marijuana abuse rate was 3% (15).
In the study conducted in 2012, synthetic cannabinoids that were newly launched and
became common were not asked. The synthetic cannabinoids started to be commonly
used by the young as they could not be detected in toxicology tests in many centers, their
smell was not specific and they were initially marketed as “legal pleasure-giving substances” as being the inheritor of marijuana and they were marketed as herbal. As a result,
the low abuse rate of marijuana in this study should be approached with suspicion.
Yazman Ögel et al. Ögel et al. Ögel et al. U
NODC Ögel et al. Pumariega Evren et al.
1995
1996
1998
2001
2003
2004
et al. 2010 2012
45.5%
Tobacco
68%
30*%
64.9%
59%
48.3%
Alcohol
61%
34.2%
17.9%
50.7%
48.6%
51.2%
32.5%
Any
substance
-
-
-
-
6%
14.3%
10%
Marijuana
4%
4.2%
3.5%
4.8%
5.1%
Other than
marijuana
9.2%
5.8%
3%
Volatile
4%
4%
8.6%
4.4%
5.2%
3.3%
5.9%
Ecstasy
1%
0.9%
-
1.2%
3.2%
-
3.1%
-
2.7%
-
4.8%
1.6%
-
0.4%
Sedativehypotonic
7%
5%
3.2%
4.1%
5.4%
Heroin
1%
0.7%
1.6%
1.1%
2.8%
96
37%
50.2%
35.5%
4.9%
2.1%
According to 2013-2014 TSI (Turkish Statistical Institute) data, while the obligatory elementary schooling rate is 99.57%, the secondary schooling rate is 94.52% in our country
(6). There are only a few epidemiological studies conducted in Turkey and there is few
data about substance abuse in children and adolescents who could not continue their
education and had to work at a young age. In a study conducted in Sivas in 1999 with a
group of apprentices working in industrial zone, it was found that the abuse rate of any
substance was 42.8%, smoking rate was 21.7%, alcohol abuse was 12% and volatile substance abuse was 9.1%. 33.6% of the participants indicated substance abuse in childhood
(17). The apprentices working in industrial zones are accepted as a risk group for volatile
substance abuse in terms of both their professions and their age groups (18).
The children and adolescents who cannot continue their education for any reason are
traditionally employed as apprentices in industrial zones, particularly in vehicle repair
services, furniture shops, manufacturing plants of shoes, bags, leather where volatile
substances are widely used and they are exposed to gas emissions from solvents even
if they don’t use them. As the audits for these workplaces are insufficient and difficult,
there is a high risk for children and adolescents to be employed under poor conditions
and to be subjected to maltreatment (18).
Adolescence is one of the periods in human life that carry the greatest risk for substance
abuse. Adolescence, which takes place between childhood and adulthood, is a period of
physical development, mental maturation and transition to adult life (19). Adolescence
has characteristics different from any other period in human life. The mental needs and
trends of adolescents also change with their developing and changing bodies: they become distant from their families and have a desire to be an independent individual and
the search of identity comes to the forefront with the desire of freedom. In this period,
the adolescent may have many risky behaviors as he/she perceives himself/herself very
strong. Smoking is a symbol of adulthood for many adolescents. Unfortunately, it may
open the door of psychoactive substance abuse at the same time. Substance abuse is also
one of the behaviors that adolescents try in this period. Using substance may be a symbol
of freedom and autonomy for many adolescents (20).
It is very important to determine the risk factors for combating alcohol and substance
abuse.
The conducted studies also determined some common points in adolescents using substances. When the risk factors for substance abuse are reviewed, they can be classified as
follows:
- Individual factors: The psychosocial development of adolescents, interpersonal factors, the impact of family and friends
*Abuse during the last month, UNODC: United Nations Office on Drugs and Crime
97
- Environmental factors
- Social factors
Individual factors, such as oppositional defiant disorder, conduct disorder, attention deficit hyperactivity disorder (ADHD), depression or another Axis I psychiatric disorder
can increase the risk of substance use in adolescents. It is known that ADHD affects
5-10% of children and 4% of adults all around the world (21). It is also known that alcohol and substance abuse is very high in people having ADHD compared to normal
population. It was found that adolescent ADHD patients who had no treatment have
substance abuse disorders 3-4 times more than those treated since their childhood (22).
The child or the adolescent with oppositional defiant disorder and conduct disorder can
be angry, aggressive and have conflict with the authority and they are excluded in the
childhood or they tend to establish friendships with other adolescents having the same
behaviors with them in the adolescence. This situation poses a serious risk for criminal
behavior and substance use (23).
The failures in school and the lack of commitment to the school also pose a risk in terms
of substance abuse of the adolescent. Relationships with friends are very important in
adolescence. Friends are very important for the adolescent who leaves the parents and
makes progress in the way of being an individual. Belonging to a group, establishing
close relations and the desire to be loved… The adolescent is driven to adopt similar
behaviors when there is substance abuse in his/her group, when he/she has a friend who
commits crime, when substance abuse is accepted, even when substance abuse is approved. Similarly, it will be protective when the adolescent is in a group where substance
abuse is not approved (24).
Families have impact on the substance abuse of the children in many aspects. The parental use of substances seriously increases the probability of the children to abuse substances (25).
In adolescence, although the impact of friends becomes a more important factor, the relation between the child and the family can be the factor preparing the substance abuse.
The basic directors are the parents and their attitudes in the personality development of
the children.
The neglect of the child by parents, family violence and uninterested attitudes of parents
towards children increase the risk of problematic behaviors including the abuse of alcohol and substance in adolescence. The risk of substance abuse is increased in families in
which parents are separated, children have insufficient attention from the parents who
have many children, parents have conflicts in the attitudes of raising the child, children
are exposed to extreme discipline or extreme freedom and when the parents are not interested enough in the education and the future of the child, etc. Parental control in the
group with substance abuse was reported to be less than those with no abuse (26).
98
The children and the adolescents who were exposed to trauma or neglect during childhood were reported to have more substance abuse compared to the normal population
(27, 28).
Hopefully, the children and the adolescents whose parents are protective, accept the mistakes of the child and know where and with whom the child is, who are friendly, modest
and open to communicate, were protected against alcohol and substance abuse; that is,
the adolescent can prefer to be protected against alcohol and substance abuse even if he/
she meet them (29, 30).
The protective factor for the adolescent from substance abuse can be exemplified as follows: high level of intelligence and high level of self-respect, active handling abilities
taught by the family, nonexistence of substance abuse in the family history, commitment
to the social values, friends who don’t commit crimes and don’t use substances, friend
groups appreciating the social value judgments, education system supporting the success in different areas, having future-oriented aims, being committed to the school, sufficiency of health and social support services, the inner circle not accepting the substance
abuse, etc. (31).
As a developing and industrializing country, Turkey has unfortunately risk groups in
terms of substance abuse. Our children become open to the risks of technology and the
internet as the education doesn’t improve in parallel with the popularity of technological opportunities and the communication tools because of the rural-urban migration,
unemployment and asymmetrical income distribution (14). The facts that there are publications encouraging the abuse of substances such as alcohol and cigarettes, that the
celebrities are covered by the media for their alcohol or substance abuse may cause the
adolescent think these cases as “normal” or ordinary or they may imitate them. Other
factors increasing the risk of substance abuse are the availability of the substances, easy
access for the adolescents to the environments (club, disco, bar, etc.) where they can find
the substance or the insufficient inspection of these environments, etc. (31-33).
99
Medical and Social Results of Substance Abuse
Substance abuse is not a problem that affects only a marginal group. It is a serious health
problem that causes medical, psychological and social problems affecting the family,
inner circle and the society starting from the individual.
The social and medical problems such as being sexually abused, being exposed to physical violence, making illegal activities, etc. are very common in people having substance
abuse disorders. Comorbid psychiatric disorders (72%) are also very common in these
people. Some of these disorders are psychotic disorders, anxiety disorders, major depression and suicide ideation/attempt. The suicide rate in substance addicted people is 20-30
times higher than the general population (34).
It was found that 90% of the people who harm themselves (cutting or burning themselves, etc.) were substance abusers, that majority of them (66.7%) used more than one
substance and that the substance abuse was at addiction level (71.1%). It was observed
that the people who harm themselves started using substances at earlier ages compared
to those who don’t harm themselves (35). Among young people using substances, it is
very common to have AIDS, Hepatitis B and C resulting from intravenous substance
abuse and risky sexual behaviors.
In the studies, comparing people with and without psychiatric disorders, it was reported that although the frequency of violent behavior was 5 times more in people having
serious psychiatric disorders (schizophrenia, mood disorders), it was 12-16 times more
in people using alcohol and substances (36). In addition, substance abuse facilitates the
probability to commit a crime as it has negative effects on perception and opinion. Research reports that treatment can be successful if the required interventions and treatment
programs are applied to this population. Another indicator is that crime rates decrease
and the socialization of adolescents increases after the treatment. The treatment of substance abuse decreases the risk and crime rates, and increases the security in the society.
The children and adolescents stated that only 5% of them took the substance from someone they didn’t know when they first used it according to the studies conducted in
this population. The first offer comes from a family member, close friend or someone
they knew. When an adolescent using substance is treated, the other adolescents around
him/her are also protected. The situations such as leaving school at early age, behavior
disorders, increased rate of committing crime, escaping from home or school, traumatic
situations happening during substance abuse, the physical effects of the substance and
different psychiatric diseases worsen the picture in terms of the adolescent and the society. It is almost inevitable to leave the school after the gradual failure in school success.
These adolescents are labeled and excluded from the society.
Substance using is a collective behavior for adolescents. They use the substance together
and encourage their friends who don’t use it. Substance abuse is nearly contagious in
100
adolescents. For this reason, the treatment performed in adolescence will also protect
the other young around the treated person. During the prevention step, the first step of
combating against alcohol and substance; it is very important to raise awareness among
children and adolescents who haven’t met cigarettes and alcohol, to take measures to
decrease the opportunities to use cigarettes and alcohol, to prevent the encouraging
news and to organize campaigns to prevent the abuse.
It is necessary to develop different preventative programs for children and adolescents
who are in schools and who left the schools and started working at early age.
One of the most important reasons driving the young to use alcohol and substance and
to behave illegally in adolescence is leaving the school and uncontrolled leisure times. It
is required to pay more attention to return the children, who have problems, behavior
disorders and who derange, to school. It is necessary to strengthen the counseling systems of schools and to spare more time for the young under risk.
It is necessary to keep the school-age children in schools, to provide an education that
is not only academic success oriented, to direct each child to different areas that will
increase their self-respect, popularize the school and increase the commitment to school
in line with his/her abilities, to popularize sports and even to include sports in syllabus
as much as the branch courses without providing sports not only for game purposes.
Directing each child in line with his/her abilities will provide him/her to feel successful
and will increase his/her self-respect.
Teaching life skills such as the ability to say no, anger management, self-expression, establish relations both protect the young from alcohol and substance and also can protect
them from possible crimes, abuse, etc.
The role of the families is very important in terms of protecting our children from alcohol and substances. Consultancy services about the approach to the child’s problem,
adolescence, and correct parental attitudes should be provided to the families with the
cooperation of schools and family physicians.
Substance addiction is a brain disorder that has serious chronicle, progressive, biological,
psychological and social results and can be treated. The addiction continues lifelong and
progresses with relapses and recoveries. If alcohol and substance addiction is diagnosed
and treated early, the success rate will be higher as in all chronic diseases. Particularly
the substance addiction that starts in adolescence confuses the physical, cognitive, social
development processes that are not matured enough yet. If the addiction treatment is
performed only to remove the problems related to the substance, it will be incomplete
and the relapse will be inevitable. The treatment should be planned in a multidimensional way to cover the family, social environment and other psychiatric problems of the
adolescent. It is observed that the disease doesn’t only cause physical and mental losses
but it also results in social and vital losses, so that adolescents leave the school at an early
101
age and they have difficulty to work in a place for a long time, the family relations breakdown and the crime rates increase in time.
Today, the treatment methods applied in Turkey cannot remove totally the losses of adolescents resulted from substance abuse. Leaving the medical treatment early and returning to the same conditions after the treatment make it inevitable to restart using the
substance.
Correcting the behavior pattern of adolescents that they develop with substance abuse
takes a lot of time. For this reason, it is necessary to perform psychiatric treatment and
rehabilitation together, to aim the lasting behavior change, to provide return of adolescent to school if possible, to integrate the psychiatric treatment and rehabilitation with
vocational courses to provide the adolescent to look to the future with hope when it is
not possible to return him/her to school.
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Enes Efendioğlu*
President of Civil Life Association (CLA)
ABSTRACT
Engagement of young people is known to play a very critical role in preventing substance abuse among youth. Definition of youth
engagement is given as the sustained and meaningful involvement of youth in an activity focusing outside of him or herself, including
school or civil society volunteering, sports, arts, music, politics, memberships to different organizations and receiving and delivering
effective trainings from/ to other young people.
Several studies also prove that engagement of youth has a significant impact on the healthy development of a youth’s life. A scientific
study in the USA proved that students of grades 8, 10 and 12 who reported being involved in extra-curricular activities were less likely to
use both soft drugs, such as marijuana, and hard drugs, such as cocaine and heroin, than students who were less involved.
It is very clear that communities that show enthusiasm to engage their youth are much more likely to prevent their youth from risky
behaviors, including substance abuse and drug related problems.
Youth that are involved in important decision making that affects their lives, youth that are encouraged and supported to reach their
full potential and youth who receive mutual respect from adults, parents, educators and peers are more likely to live a healthy lifestyle.
This study focuses on different types of youth engagement in civil society and social communities, which are interested in preventing
their youth from risky lifestyles. It is a combination of field case studies from different youth projects and latest scientific data published.
Keywords: Youth and Drugs, Youth Engagement, Youth Work and Drug Policies, Young People and Drugs.
* Enes Efendioğlu was born in Istanbul and graduated from Asfa Science High School. He is currently a student in Bursa Uludağ University, Faculty of Medicine. He is the president of Civil Life Association (CLA), which is one of the few totally youth-led organizations
of Turkey, with more than 100 active volunteers and two branches in different cities. CLA works on youth health, participation and
disadvantaged groups.
He is at the same time working in the Secretariat of Alcohol Policy Youth Network, which is an umbrella organization for youth organizations across Europe for alcohol related harm reduction and prevention.
He has 3 medical articles published, attended more than 30 international events and organized more than 10 international youth events.
During his studies he has been a visitor scholar to Justus Liebig University in Germany, Wisconsin University in USA and Harvard Medical
School in USA.
In the future he would like to work in public health field by focusing on youth related policies and better living conditions for young
people.
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YOUTH ENGAGEMENT AS A KEYSTONE TO REDUCE SUBSTANCE ABUSE
Youth Involvement as a Basic Approach to
Reduce Substance Addiction
Introduction
Youth and the youth sector are two of the major building blocks of today’s fast-paced
and dynamic world which cannot be replaced by another factor. Developed and developing countries train their young population to take healthy decisions and carry their
social and cultural heritages further once they have taken over them and these countries
try to avoid any factors that would damage the youth sector, involuntarily affect young
population’s individual decisions and futures. As in every sector, there are major investments in youth health and more resources than education are allocated to public health
expenses in order to raise healthy generations in many countries of Europe. This paper
examines, with a new perspective, the influences of common education methods used
in youth education resulting in healthy lifestyle in general and substance abuse in particular. The paper first defines youth and youth sector and studies why drugs are a major
problem for young people. Risk factors in starting to use substances for youth are briefly
examined and basic characteristics of the prevention methods are explained. Youth involvement, its origins and methods are explained in order to understand to what extent
youth involvement covers the characteristics required in effective methods. In the last
section, characteristics of proven, effective methods and youth involvement’s principals
are compared and it is explained to what extent youth involvement can be effective and
how can it be used.
Definition of Youth and Youth Sector
Definition of Youth
Different organizations define youth in various ways. The United Nations Educational,
Scientific and Cultural Organization (UNESCO) defines youth as “period of transition
from the dependence of childhood to adulthood’s independence and awareness of our
interdependence” and it indicates that youth is a more fluid category than a fixed agegroup (1).
The British Youth Council defines the youth limit as the age of 31 and below while travel
companies and airlines companies consider the age of 26 and below in youth category
when making a discount. Governments’ definitions are different from each other as well.
Turkish Statistical Institution defines youth as the ages from 15 to 24 in a report dated in
2013. Many European countries consider the ages from 15 to 21, especially when calcu106
lating the youth unemployment rate (2).
Age of inclusion to European Union Youth Mobility projects -one of the major components of youth involvement, especially in Europe- is 13 to 30. This is one of the most
inclusive age ranges (3).
Based on this data, definition of youth period is made differently by different organization and can be changed from time to time. In the most generally accepted definitions,
age is not stated but the youth is defined as a transition period from childhood to adulthood.
Definition of the Youth Sector
The youth sector is organizations in which the youth is structurally brought together
and which ensure youth’s representation as well as bring them together on activity basis.
These organizations can be categorized as Youth Organizations and Organizations for
Youth. The difference is the structure establishing the organizational system.
Youth Organizations
Youth organizations are created entirely by young people and they serve the youth. Some
of their features are:
1- Members are volunteers and the management usually consists of individuals belonging to the youth age category.
2- Membership is entirely volunteer-based and each member has right to terminate
their membership.
3- Management structure is entirely democratic and all members have the right to be
included in the management chart.
4- It works for youth’s benefit. This can be in general areas such as education, culture,
sports, finding employment, aiming to develop the youth or any other specific fields
needed by youth.
Youth Organizations Working on Membership Basis
Youth organizations working on membership basis generally have individual or corporate membership systems. These organizations can be established by individuals’ membership or it can be a federation or network consisting of organizations.
Youth organizations are mostly democratic and independent organizations established
to ensure that youth gains planned or unplanned experiences and tests its governance
systems as well as develops its personal and social skills and involves in social life. Such
organizations are established for youth to have or express opinion on a subject or carry
out activities according to their areas of interest, world perspective, political thoughts
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and cultural tastes.
Based on the activity type, youth organizations can be local, national or international.
Local youth organizations operate in a specific local region and aims to increase youth’s
behavior and capacities. National youth organizations work from a specific region but
have national outputs while international youth organizations have international-scale
outputs.
Youth Councils
Youth councils and their members are deemed to be an umbrella structure rather than
a real youth organization. This is because the membership to these councils is not generally at personal level but rather at organizational level. Youth councils are mostly umbrella structures for independent youth organizations and can work on the regional or
international level (4).
Organizations Established for Youth
Centers established for youth are different from other youth organizations because they
don’t have age limitation and the membership type is different. Membership system of
these organizations is mostly on a voluntary basis but not necessarily. They may have a
professional staff. They don’t need to be democratic organizations.
Youth Centers
Youth centers differ from youth organizations on three bases: age of the participants,
voluntarism type and administration type. A youth center mostly offers basic physical
facilities to the youth and employs professional trained youth experts (5).
Youth and Substance Abuse
It is a known fact that substance abuse of especially young people has caused severe consequences in all world countries in the recent years (6). Many scientific studies demonstrate that the reason why substance abuse is widespread among young people is especially “curiosity”. Adolescence and youth are periods of change in biologic, cognitive and
social areas. Young people come across a series of new situations including alcohol and
substances. Reducing the stress caused by biologic and social changes, peer pressure and
willingness to be included in a group are major factors in starting substance abuse (7).
Regardless of the reason to start substance abuse, it is an ever increasing problem and
causes an obvious increase in crime rates (8).
In this sense, although there are statistics to explain to what extent the youth uses substances or where they first encounter the substance, in some countries such as Turkey,
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studies in this area remain insufficient and inconclusive in terms of obtaining a clear
statistical data.
According to online data published by European Monitoring Center for Drugs and Drug
Addiction, substance abuse rates especially among youth are a concern in European
countries.
Heroin abuse rates in the ages from 15 to 34 are as follows: 18% in Czech Republic and
17.5% in France. Generally speaking, these figures show that 1 in every 5 young people
use heroin (9).
Proven and Effective Methods in Youth Protection
There are major methods that are proven to be effective in substance abuse and prevention of addiction. These methods include methods whose effectiveness were proven
by scientists as a result of statistics and follow-up studies since the commencement of
scientific-based studies and which demonstrate the obvious decrease of the number of
substance abusers.
International Standards Guidelines to Prevention of Substance Abuse prepared by the
United Nations Office on Drugs and Crime gathers all proven methods yielding positive
results in decreasing or preventing substance abuse among young people (9).
The Office categorizes these methods by area and type of application: Family, School,
Social Group, Working Environment and Healthcare Sector.
It is interesting to note that almost all of the successful approaches regarding Social
Group and Working Environment are in older ages. This paper shows that approaches
aiming the youth and give effective results in youth accompany the school environment
and family factors.
In this source, methods that are proven to give effective results in youth and youth sector
include trainings to develop personal and social skills and to encourage them to continue education.
Training for personal and social skills means inclusion of young people by specialist
educators and teachers in different activities based on their skills and social capabilities.
These training programs are organized to cause the youth gain expertize and competences and it is understood that such skill developing programs contribute positively to
young people’s abilities to cope with problems and crisis and to their successful conflict
resolution process and that these programs help the youth stay safe and healthy (10).
In another study, factors that are positively and negatively influencing substance abuse in
trainings aiming to develop social and personal skill sets were focused on (11). Factors
that give positive influences include determining a training method which:
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- develops personal and social skills of participants in different areas,
- is issued in accordance with a road map in a planned manner,
- is provided by referral by experts in the field or by means of direct training,
- is interactive.
Some of the factors which cause negative influences or reduce effectiveness of the training during implementation of these personal and social training methods are determined as follows:
- use of non-interactive training methods as the main training methods during training,
- awakening of curiosity by giving specific information about a particular substance
or trying to ensure the protection by fear,
- based on only individual and emotional structuring; not being organized and integrated with the society.
Although to be explained in detail in the next chapter, it is interesting to note that being based on individuals’ personal characteristics is one of the features of unsuccessful
methods in this study. Another interesting point is the emphasis on the necessity of interactive methods. Didactic education methods that the youth of today has been subject
to from primary school to university have been proven ineffective by the United Nations
Office on Drugs and Crime and it is stated that prevention of the individuals from substance abuse can be ensured with an inclusive and adaptive system based on integration.
In another classification, each method and prevention approach has their own characteristics and generally speaking, preventive methods are categorized in two groups:
- Education and prevention activities by explaining the young people about the substance and telling them why there are harmful,
- Prevention through social responsibility activities carried out by integrating the youth
to extracurricular activities without mentioning of the substance abuse and addiction.
Due to raising curiosity factor stated by United Nations Office on Drugs and Crime,
scientific studies carried out in recent years have demonstrated that interactive or traditional training methods are not more effective than activities carried out to raise social
responsibility awareness (9).
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Definition and Bases of Youth Involvement
Youth involvement is defined as follows; inclusion and significant involvement of any
young person to an activity by focusing on something other than themselves (12). Such
activities involving young people can be in sports, art, music, volunteerism, politics,
social activism etc. and can be carried out under all circumstances. Here, it is noted that
activities that are stated to have played a major role in reducing and preventing substance abuse in the previous chapter should focus on something other than the person
himself/herself.
Where does the youth involvement take place?
Youth involvement is a method and type of activity that can take place in different phases
and organizations including civil society organizations, youth organizations, music platforms, sports participation, ethnic/cultural organizations, work/career planning activities, school activities, social activism, policy activities, and religious activities.
How does a participant young person behave?
- A young participant is mostly in a mental activity and spends most of his/her time
on organizational activities,
- Talks frequently to other people about round activities/the organization,
- Plans and launches activities himself/herself, motivates other young people,
- Working with other people in joint projects in similar field of activities,
- Manages and refers other people within his/her own organization,
- Energetically carries out advocacy activities on behalf of the institution,
- Refers to individual moves and adult assistance when needed, as long as it is convenient.
It is worth mentioning here that every young person has different levels and types of
involvement. Each person plays different roles in different activities depending on their
different characteristics and their experience level.
Some young people enjoy bringing out their leadership features and leading others while
others would like to support them being in the background.
There is still need for studies on the influences of these involvement activities at different
levels on their later life and character development.
How does a participant young person think?
A young person’s way of thinking is one of the key factors to be questioned in order to
understand to what extent s/he is a participant and how s/he feels as a part of the group
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s/he belongs to. It is stated in many reference documents that some thoughts are important to demonstrate young people’s involvement level:
- A young participant knows that his/her activity and organization are important and
indispensable,
- A young participant is familiar with the organization,
- A young participant thinks that the organization’s establishment and presence are
very necessary and can explain this necessity.
How does a participant young person feel?
A young participant
- Cares about the activities of the institution where s/he works,
- Feels a sense of belonging to the organization and feels connected and linked with
other employees and volunteers in the organization,
- Is aware that the activity s/he carries out is an important part of his/her identity,
- Feels satisfied and happy with the achievements and completed works within the
organization,
- Feels a sense of possession in activities and projects and manages and refers to these
activities,
- Feels unhappy, disappointment and sadness when projects and activities are not
successful.
What are the Fundamental Influences of Youth Involvement?
Youth involvement has some obvious influences demonstrated by scientific studies. Influences of youth involvement on the substance abuse which is the main subject of this
study are demonstrated in various scientific studies and reviews.
- Reduction of alcohol abuse (13)
- Reduction of marijuana, cocaine and heroin abuse (14)
- Less risk of school failure and dropout (15)
- Less sexual activity and less unwanted pregnancies in girls (16)
- Lower levels of anti-social and criminal behaviors (17)
- Less depression (18)
How do young people become active participants?
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- Include young people in decision-making on issues affecting themselves,
- Create opportunities for young people to work more actively with adults,
- Inspire and teach young people to deal with problems of other young people,
- Promote youth leadership,
- Create opportunities where young people frequently come together to the work on
social issues,
- Listen to the views of young people and actively consider,
- Assist them in the development of young people themselves.
Is youth involvement really an effective protection method?
This study defines proven protective methods after having defined the youth sector and
the youth involvement. It will then focus on the place of youth involvement in effective
prevention methods.
In various studies in this subject, it is demonstrated that social and personal skill development of young people reduced dropping out of school and failure in school as a risk
factor. Contrary to the common belief, it is demonstrated that extracurricular activities
don’t reduce the success of young people at school, but increase it on the contrary.
Going back to the analysis above, a method must be based on a social integration basis,
but not on the person’s emotional state, in order to be deemed effective. This is caused
by the fact that people can experience sudden mood changes against physical events and
this entire process can be unsuccessful in a minute. When studies carried out with individuals using substances are observed, a sudden mood change, physical and mental trauma can result in relapse of substance abuse (9). This results from the fact that prevention
methods are based on moods and personal characteristics. When people feel sad and
insecure on the inside, the prevention method is no longer effective. It is then important
that people’s integration to different groups and as the definition of involvement states,
they turn to something other than themselves if the prevention methods will be successful. Youth involvement meets this requirement because it ensures that young people
focus on the organization in general rather than themselves. As this requirement is met,
the method of prevention of young people without mentioning substances and drugs is
chosen – which is scientifically proven effective and becoming more widespread. Thus,
the method’s effectiveness is increased.
Another important factor in this document released by the United Nations Center of
Drugs and Crime is that the training methods are interactive. Non-formal training techniques used in youth projects which are the most active part of the youth involvement
quickly replace didactic, formal education methods. The youth sector is the only sector
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where all education is carried out with non-formal training methods. Other than the
youth sector, all education is carried out with didactic and non-interactive style in traditional education institutions. In youth projects, young people experience completely interactive and participant learning process and stay away from didactic education
methods which are scientifically proven ineffective.
In today’s education system, standard education at schools is a system in which the young
people are completely responsible of themselves and is based on individuality. In such a
system, it is most likely to lose the young people who are under risk, absent from school,
drop out the school or experience financial difficulties; moreover these kids are more
likely to find themselves using drugs. Ideally, a participant system which is designed for
general population but based on integration, working in harmony, social responsibility
awareness and in which young people can move must be structured. This is the only way
that young people can be saved.
Another element in the report prepared by the United Nations Center of Drugs and
Crime is that preventive activities must not raise curiosity in young people. Researchers
reveal that especially methods used in prevention that raise curiosity or fear in youth are
not effective; on the contrary they increase the rate of substance abuse. In this point, it is
understood that the youth involvement, as a more effective method, doesn’t mention the
addictive substances and make up for young people’s social and personal inadequacies
to ensure prevention.
Especially in the youth period, young people are searching for independence under influence of different trends and the fact that they are constrained by effective laws that are
stated as a more effective control method can have the opposite effect on them partly due
to the influence of industry as illustrated by different country cases.
Although data on short-term abuse hasn’t still published yet, reactions given to regulations regarding alcohol abuse in 2013 in Turkey caused factors associated with alcohol
to be brought up more often and for short-term, alcohol and similar topics became the
hot topic to discuss while more visibility is intended.
Looking this issue from another perspective, strict law control and similar protective
methods that are deemed as effective methods have consequently contribute, to a certain
extent, to avoiding substance abuse in society and youth. However, the process doesn’t
contribute to young people’s personal development, therefore the benefit remains limited. Youth involvement ensures young people to avoid substance abuse while develops
their personal and social competences as well as improving their critic analytic thinking
skills and social responsibility awareness.
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Problems in Youth Involvement
Although it is very fundamental and effective method to prevent substance abuse, youth
involvement has some minor problems in practice. These are not actually about realizing
the youth involvement but rather about the young people’s access to physical conditions.
1- Youth involvement is usually specific to a certain age group:
Although youth involvement has a wide range of 13-30 years in different programs, it is
usually specific to an age group. It is obvious that this age limitation is very important in
terms of which groups can benefit the program and setting limits. But this occasionally
limits young people’s access to these possibilities.
2- Youth involvement usually requires fundamental economic opportunities:
Although there are many financial possibilities for young people to be mobilized and to
travel so that they are more adapted to the world around them, they also need minimum
level of economic opportunities in order to travel or to meet the different tools of the
youth involvement. Especially for young people coming from families with low income
levels, it is almost impossible to travel and be mobile which are very important in youth
involvement. Many studies show that children coming from such families are under
great risk of substance abuse and they must be given more opportunities than their peers
to show more active participation.
3- Difficulties in accessing the groups under risk:
Young people dropping out the school, having difficult times at school or having poor
social life are under great risk of substance abuse. Looking from this perspective, youth
involvement is a tool that can be accessed by young people with higher social status and
therefore accessibility to the youth involvement must be improved by governments and
social groups especially for young people in risk group to be able to show more active
participation.
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REFERENCES
1. http://www.unesco.org/new/en/social-and-human-sciences/themes/youth/youth-definition/ (Accessed on 27.09.2014)
2. http://www.byc.org.uk/about-us/our-vision,-mission-and-values.aspx (Accessed on
27.092.14)
3. http://www.ua.gov.tr/programlar/erasmus-programı/gençlik-programı/öğrenme-hareketliliği/gençlik-değişimleri (Accessed on 27.09.2014)
4. Alcohol Policy Youth Network, Bled Youth Paper on Alcohol, Slovenia 2013 s.8.
5. Alcohol Policy Youth Network, Bled Youth Paper on Alcohol, Slovenia 2013 s.9.
6. http://www.uc.edu/news/NR.aspx?id=17936 (Accessed on 27.09.2014)
7. Kendler KS, ‘’Exposure to peer deviance during childhood and risk for drug abuse: a Swedish national co-relative control study’’, 2014
8. Leshner Alan, ‘’Addiction is a brain disease and it matters’’, 2003.
9. United Nations Office on Drugs and Crimes, International Standarts on Drug Abuse Prevention.
10. Eder Donna, The Effect of Middle School Extra Curricular Activities on Adolescents’ Popularity and Peer Status. Youth Society. March 1995.
11. Alberta Health Services, Community Action on drug abuse prevention. 2010.
12. Centers of Excellence for Children’s Well-being. What is youth engagement? 2010.
13. Komro K.A., Perry C.L., Murray D.M., Veblen Mortenson S., Williams C.L., & Anstine S.
Peer-planned social activities for preventing alcohol use among young adolescents. Journal
of School Health. 1996; 66(9), 328-334.
14. Jenkins J. E, The influence of peer affiliation and student activities on adolescent drug
involvement. Adolescence. 1996; 31, 297-307.
15. Mahoney J. L. & Cairns R. B., Do extracurricular activities protect against early school
dropout? Developmental Psychology. 1997; 33, 211-253.
16. Allen J.P., Philliber S., Herrling S. & Gabriel K.P. Preventing teen pregnancy and academic
failure: Experimental evaluation of a developmentally based approach. Child Development.
1997; 64, 729-742.
17. Mahoney J.L., School extracurricular activity participation as a moderator in the development of antisocial patterns. Child Development. 2000; 71(2), 502-516.
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Community Psychology. 2002; 30(1), 69-86.
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Fatima El Omari*
National Center on Treatment, Prevention and Research on
Addictions, Arrazi University Psychiatric Hospital Rabat-Sale,
Morocco
ABSTRACT
Although illegal and forbidden by Muslim religion, drugs remain a matter of concern in Morocco. To conduct well designed drug use
school surveys, Morocco adopted the MedSPAD (Mediterranean School Survey Project on Alcohol and Other Drugs), which is supported
by the Pompidou Group at the Council of Europe. This project includes countries like Algeria, Morocco, Lebanon, Tunisia, and Egypt. The
intention was to cover in Mediterranean countries the mandatory school-going age group of 15-17 year olds.
After conducting a pilot survey in 2003, the project has been conducted in two big cities (Rabat-Salé), to cover after that in 2009 a
country wide one. The second national Medspad was launched in 2013.
The Objectives of the Moroccan Medspad were to determine the prevalence of substance use among 15 to 17 years old youths, to seek
the age at onset of drug use, and to learn about teenager’s knowledge, point of view and behaviors regarding drugs. This project
sought to examine some drug use predictive factors to implement strong policies for developing mental health and drug prevention
in Moroccan schools.
Medspad Surveys showed that students clarify drug uses. The young age of initial drug use imposes the implementation of preventive
and counseling programs for very young students (elementary school) prior to onset. The development of effective school prevention
policies and community intervention programs (prevention, treatment and rehabilitation) may be most urgent. Similar surveys will be
conducted to observe the trend of drug use within Moroccan youths.
Keywords: Psychoactive substance, misuse, youth, school, prevention
* Psychiatrist and Addictologist, working at Arrazi University psychiatrist hospital and supervising the National Center of Treatment,
Prevention and Research in Addictions in Rabat-Salé (Morocco).
Professor at the Faculty of Medicine in Rabat and lecturing psychiatry and addictology courses.
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MEDITERRANEAN SCHOOL SURVEY PROJECT (MEDSPAD) ON ALCOHOL AND OTHER DRUGS: THE MOROCCAN EXPERIENCE
The Mediterranean School Survey Project on
Alcohol and Other Drugs in Morocco
Introduction
Recent epidemiologic surveys indicate that substance use by youth in many countries
remains a matter of concern. Although illegal and forbidden by religion, alcohol and
drugs are available in many Muslim countries. Few epidemiologic studies conducted in
Morocco show that drugs use is increasing among young population and among women
(1, 2, 3, 4).
MedSPAD, or Mediterranean School Survey Project on Alcohol and Other Drugs, is a
cross sectional survey conducted in schools. MedSPAD is an adaptation to the Mediterranean and North African context of the European ESPAD survey (European School
Survey Project on Alcohol and other Drugs) which is conducted in almost 36 European
countries.
The MedSPAD project came into being after the conference organized by the Pompidou
Group in 1999 on co-operation in the Mediterranean region, which showed the need for
better understanding of drug use among adolescents and young adults in the countries
of the Mediterranean region (5). The conduct of the MedSPAD survey for Morocco was
entrusted to two joint teams from the Ministry of Education and Arrazi University Psychiatric Hospital in Salé.
This large-scale survey was in response to a joint policy decision by the Ministry of Education and the Ministry of Health, to evaluate the problem of drug use among youths
and draw up appropriate recommendations for evidence based prevention policies.
Morocco adopted then the Mediterranean School Survey Project on Alcohol and Other
Drugs (Medspad). After conducting a pilot study in Rabat during 2003 (N=400) (5) to
validate the feasibility and validity of the survey, the survey included two big cities (Rabat and Salé) with a sample of 1,117 youths during February 2006 (3). The first country
wide survey was launched in December 2009 and included a representative sample of
6,371 Moroccan high school students (4). The second national Medspad was launched
during May 2013, and concerned a sample size of 5,801 students.
The intention of Medspad was to cover in all Mediterranean countries the mandatory
school-going age group of 15-17 year olds, and to improve knowledge about youth drug
use in this region. Similar MedSPAD surveys are carried out in countries around the
Mediterranean basin, like Algeria in 2005, Lebanon in 2008 (6), and Tunisia in 2013 (7).
Because of geographical proximity and cultural similarities, these surveys can be used to
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compare data between countries.
The objectives of the Moroccan Medspad were to assess the prevalence of substances use
among 15-17 years old students at Moroccan high schools, and to establish the age at onset of drug use. The survey seek to understand Teenager’s point of view and behaviours
regarding drugs, and to examine some drug use predictive factors, which might serve
as a basis for framing recommendations and taking action related to drug prevention
policies in schools. By conducting further surveys, we will be able to have an idea about
the tendency of drug use among Moroccan Youths.
Methodology
Sampling:
Medspad is a cross sectional survey, conducted using a representative sample size by
using Grape sampling method. Participants from 2006 MedSPAD were recruited through a representative sample of public urban high schools in two Moroccan cities (Rabat,
and Salé). High Schools were selected, and drawn to target 15 through 17 year olds, thus
the three last grades (10th, 11th, and 12th grade) were included. Our sample schools, and
grades were randomly selected. The total sample size was N=2139 students (3).
In the countrywide Medspad surveys (2009 and 2013), participants were recruited through a representative sample of Moroccan schools. Schools were randomly selected,
and drawn to target 15 through 17 years old. The four last grades (9th, 10th, 11th, and 12th
grade) were included (4).
Questionnaire:
The instrument used was an anonymous self-administered questionnaire modeled on
the ESPAD survey (8). The questionnaire was translated into Arabic and was revised
several times, then reworked in relation to the questionnaire used in the 2003 pilot survey and the one used by the Algerian team, in an attempt to adapt it to the Moroccan
context, the Moroccan youth vocabulary and local terms for the different drugs. The
questionnaire takes about 30 minutes to complete. It was also reworked in relation to the
2006 MedSPAD survey in Rabat-Salé (3) and items on the use of Nargileh, cocaine and
crack were added. Other items were added to the original questionnaire to meet the expectations of the Moroccan Ministry of Education. In the Medspad 2009 (4), questions
about heroin, same nicotinic derives were also added.
The questionnaire items included information about different psychoactive substances
use, youth socio-demographic information, school and home youth behavior, relationship with parents, parent education, and family socio-economic level. Prevalence included life time, last 12 months, and last 30 days use of seven substances in Medspad 2013
(tobacco, alcohol, cannabis, psychotropic (sedative and hypnotic) used without medical
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prescription), cocaine, crack and heroin). Questionnaire evaluated also youth perception of the drug use high risk, and their attitude against drug user; student knowledge and
opinion about drugs.
Surveyors:
Ten voluntary surveyors were recruited among the trainee psychiatrists (Residents)
from Arrazi University Psychiatric Hospital in Salé. They were trained in how to conduct surveys in schools and same instructions were issued to them regarding the following
specific points:
- To present Ministry of Education authorization to schools responsible,
- To have youth verbal consent before conducting the survey.
- To introduce themselves as independent researchers not as employees for school or for
the ministry of education.
- To emphasize the scientific purpose of the survey and the importance of responding
sincerely.
- Not to allow staff from school to participate in the survey, or provide information about
drugs. Only surveyors have to be present in class with students.
- To choose class and grade randomly,
- To respect confidentiality,
- To fill up school survey evaluations for each class (number of presents, absents, refusals, event, questions, time).
For ethical reasons, the survey was not carried out until the Ministry of Education had
given its official agreement. Youth verbal Consent was required to participate to the
survey.
The timing of the survey was not random. To avoid bias, a period of time was chosen
when there were no examinations, no religious festivals or school holidays.
Statistical Analysis:
Medspad data was analyzed using SPSS software application. After basic contingency
table analyses, bivariate relationship was employed to analyze the relationship between each student`s characteristic variable and substance use, and will be assessed via
chi-square tests. The “gender” variable was incorporated in the study of the prevalence
of psychoactive substances. We used the chi square test and the Student “t” test in the
comparative studies. In the study of associations we used the Odd Ratio (OR) test. The
significance threshold is determined by the variable “p”, which is deemed significant
when p<0.005. Only data concerning 15-17 years old students will be presented in this
paper.
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Sponsoring:
Survey is supported by the Pompidou Group at the Council of Europe. It is a collaborative work between Arrazi University Psychiatric Hospital in Salé and the Moroccan
Ministry of Education. The Moroccan Ministry of Education provided logistic support
for conducting the Medspad.
Results
MedSPAD surveys found higher use prevalence among boys than girls for all psychoactive substances. The downward trend in the prevalence curves for the all psychoactive
substances points to experimental use of drugs. Tobacco is the most-used substance, followed by alcohol, then cannabis in the case of boys and psychotropic substances without
medical prescription (sedative and hypnotics) in the case of girls. Cocaine, crack and
heroine come last and are little used among the pupils surveyed. In addition to a predominance of drug use among boys, it was seen that drug preferences differ according to
gender among the 15-17 year-olds. Drugs freely available and those which are the easiest
to obtain are the substances most used by the pupils in the survey (tobacco, alcohol and
psychotropic substances in the case of girls). This predominance of use among boys and
the difference in preferences may be explained by the ease with which boys can obtain
drugs. These findings were similar across all Moroccan Medspads. Substance use frequencies show also that youth are in the experimentation phase for different substances.
Data revealed that 15-17 year old men consume more than women, and prevalence increases significantly with student age (p<0.0001). For example, Data from Medspad 2009
show that during life time, nargileh is the most used drug by 15-17 years old students
(19.4%, n=853), tobacco prevalence is 18.4% (n=830); with 27.7% for male, and 10.4%
for female. The life time prevalence of alcohol is 7.7% (n=348); 11.8% for male, and 4.2%
for female. Cannabis is consumed among 7.2% of 15-17 years old students (12.5% for
male, and 2.5% for women), and psychotropic drugs are in 4% (n=182); 4.8% for men,
and 3.4% for male. Cocaine is used in 1.2% of 15-17 years old youths (2% for male, and
0.5% for female), crack in 0.7% (n=31) (1.1% for male, and 0.3% for female). Other illicit
drugs are consumed by 15-17 years old students in 5.8% and the other drugs cited were
opiate substances, ecstasy and inhalants. Substance use frequencies show that youth are
in the experimentation phase of different substances.
According to all Medspads, the age at onset for substances seems to be more and younger. In Medspad 2013, the mean age at onset for tobacco is 14,21,7. It is 14,51,8 for alcohol, 14,91,4 years for cannabis, and 14,81,6 years for psychotropic drugs.
Students seem to be more and more familiar with drugs. Over 9 out of every 10 pupils
questioned (93%) have already heard about alcohol. 91% of the pupils know hashish, and
89% of them are familiar with sleeping and sedatives pills consumed without medical
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prescription. Regarding the sources of information about the dangers of alcohol and
drugs, the main sources mentioned in Medspad 2009 were the internet (63.4%), and
the media (60%). School programs represent only (37.4%). In Medspad 2013, the main
source of information about drugs was media (48%), internet represents 26%. Only 17%
of students learned about drugs via school programs.
Almost 25% to half of students do not perceive the high risk of taking drugs. While not
always significant, in general the perception of risk appears to be related with less drug
use.
All Moroccan Medspad Surveys showed that there is a significant correlation (p<.001)
between drug use and some variables. Substance users are more likely to have low grades
at the last semester, absence from classes, spending nights outside home without parent
authorization, dissatisfaction about relationships with parents and friends, lack of knowledge about drug use risk, and family member or friend who uses the same drug. Surveys
did not find a significant correlation between parent’s education or family socio-economic level and youth drug use, and the rural or urban residence. These factors could be
predictive of drug use, and should draw the attention of parents and educators.
Discussion and Conclusion
Psychoactive substance use affects secondary school youth in Morocco. Our prevalence
rates are almost similar to those found among our Algerian and Tunisian neighbors and
are lower than those reported in the MedSPAD Lebanon survey (6, 7). They are much
lower than the rates found among young Europeans or Americans (9, 10).
The early age of first drug use which was found should give cause for concern. It calls for
the implementation of prevention and awareness-raising programs at an early stage for
the youngest youths, given that the drugs most used by pupils are those easier to have,
such as tobacco and alcohol. The implementation of drug use policies since primary
school is necessary to prevent drug use.
Psychoactive substances still at the experimental stage, preventive measures to avoid the
progression to addiction and psychiatric or infectious related complications are essential
for this age group (3, 4).
Some aspects of the pupils behaviors are correlated in a statistically significant way with
drug use, such as missing school, staying away from home, having below-average grade,
or being dissatisfied with parental relations. These factors might be predictive of drug
use and should help set up evidence based prevention programs including families and
schools.
The conduction of similar surveys will help set up the tendency of drug use in Morocco.
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REFERENCES
1. Nations Unies Office Contre la Drogue et le crime (ONUDC), Royaume du Maroc, le
premier ministre, agence pour la promotion et le développement économique et social des préfectures et provinces du nord du royaume: Le Maroc, enquête sur le cannabis
2005, Vienne/ Rabat, Novembre 2006. http://www.unodc.org/pdf/research/Morocco_survey_2005_ex_sum.pdf
2. Toufiq J., Othmani SE., Ktiouet. J.E, Paes. M. Enquête nationale sur l’usage du tabac, du
cannabis et des autres drogues en milieu marocain. Psychotropes. RTL 1997 (249-63).
3. Toufiq J, El Omaei F. Résultats de l’enquête MedSPAD 2006 sur l’usage de la drogue en
milieu lycéen de Rabat-Salé. http://www.onlcdt.mjustice.dz/onlcdt_fr/fichiers_communications/communications[5].pdf
4. Toufiq J, El Omari F. Sabir M. Usage de drogues en milieu scolaire marocain. RapportMedSPAD2009-2010. https://wcd.coe.int/com.instranet.InstraServlet?command=com.instranet.CmdBlobGet&InstranetImage=1892062&SecMode=1&DocId=1768784&Usage=2
5. Mabileau-Whomsley F., Le Groupe Pompidou et la coopération dans la région méditerranéenne: le projet MedSPAD, revue toxibase n° 18 - 2e trimestre 2005 (41-42). Awareness
and practices related to addictive substances among schoolchildren in Lebanon in 2008.
6. Pompidou Group of the Council OF Europe. Awareness and practices related to addictive
substances among schoolchildren in Lebanon in 2008. http://www.coe.int/T/DG3/Pompidou/Source/Activities/MedNET/2009_MEDSPAD_Lebanon_en.pdf
7. Enquête MedSPAD en Tunisie : Résultats de la pré-enquête, Juin 2013. http://south-programme-eu.coe.int/Source/Pompidou_Group/Rapport_preenq_ Tunisie_MedSPAD_
juin2013_fr.pdf
8. Bless R., Muscat. R, la validité et la fiabilité des enquêtes scolaires fondées sur la méthodologie ESPAD en Algérie, Libye et Maroc (MedSPAD)- MedSPAD- Groupe POMPIDOUP-PG / Res- Med (2004) 2 F, Conseil de l’Europe.
9. Olga Balakireva, Thoroddur Bjarnason, Anna Kokkevi, Ludwig Kraus . The 2011 ESPAD Report. Substance Use Among Students in 36 European Countries Björn Hibell, Ulf
Guttormsson, Salme Ahlström, http://www.espad.org/Uploads/ESPAD_reports/2011/
The_2011_ESPAD_Report_FULL_2012_10_29.pdf
10. Monitoring the future 2012 Survey, Teen drug use USA 2012. http://www.drugabuse.gov/
related-topics/trends-statistics/infographics/monitoring-future-2012-survey-results.
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Gaetano Di Chiara*
Professor of Pharmacology
ABSTRACT
Adolescence is a developmental stage characterized by pruning of synapses and stabilization of neural connections in the CNS. Adolescence is also the period of highest prevalence of use and abuse of cannabis and ecstasy and cross-sectional and prospective
epidemiological studies indicate a strong association between heavy adolescent cannabis and ecstasy use and long term changes
in cognitive and affective functions. The dopamine (DA) system appears particularly sensitive to the long term effects of adolescent
cannabis and ecstasy use.
As this system is a major target of the action of drugs of abuse including cannabis and ecstasy, and is important for reward, reinforcement and motivated behavior, long term changes induced by these drugs are predicted to be associated with changes in reward,
reinforcement and motivation, including changes in the reinforcing properties and abuse liability of other drugs of abuse. Both human
and animal studies provide strong evidence for these predictions and reveal that epigenetic changes affecting the reinforcing properties of these drugs can even be transferred to the progeny.
* Born in Cagliari, November 22, 1945-1970, Degree in Medicine and Surgery, Summa cum Laude, Faculty of Medicine and Surgery,
University of Cagliari, Italy 1971-1973, Postdoctoral Fellow, Laboratory of Chemical Pharmacology, NIH, Bethesda, Md, USA (BB Brodie’s laboratory) From 1980, Full Professor of Pharmacology and Pharmacotherapy, Faculty of Medicine and Surgery and Faculty of Pharmacy,
University of Cagliari, Italy 1997-2006, Dean, Faculty of Pharmacy, University of Cagliari, Italy 2009-Present Director, PhD in Toxicology,
University of Cagliari, Italy Scientific Societies
1996-1998 President of EBPS (European Behavioral Pharmacology Society) 2000-2002 President of FENS (Federation of European
Neuroscience Societies) 2000-2005 Chairman of IBRO Western European Regional Cttee 2005-2007 President of SINS (Societa Italiana
di Neuroscienze)
Cultural Associations
· Gruppo 2003 per la ricerca scientifica (Vice President)
· Highly cited researcher (ISI Thompson) in
· Neuroscience and Pharmacology
· ISI Web of Knowledge Citation Report
Publications found: 264 Times cited: 21175 Average citations per item: 80.21 H index : 74
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LONG TERM CONSEQUENCES OF ADOLESCENT CANNABIS AND ECSTASY EXPOSURE ON DOPAMINE FUNCTION AND REWARD
Cannabis as a Drug of Abuse:
Epidemiology and Neurobiology
Cannabis, among illegal substances, is the one consumed by the largest number of individuals during their life (lifetime prevalence). The prevalence of Cannabis use in the
various countries is highly correlated to the income pro-capite; accordingly, it is highest
in North America, Australia and Europe.
Cannabis use starts in adolescence and its prevalence is maximal between 15 and 24
years (late adolescence, early adulthood), the period that corresponds to high school
and university, and drastically decreases in adulthood, with the acquisition of working,
familiar and social responsibilities.
The high prevalence of Cannabis use and the social perception of a relatively low associated risk contrasts with the results of biological and clinical studies. These studies have
clarified the mechanism of action of Cannabis and have demonstrated its homologies
with other substances of abuse, particularly with opiates and in addition have shown its
long term effects on cognitive functions and mental health.
This short article intends to review the present status of Cannabis as a substance of abuse
in its epidemiologic and neurobiological aspects.
Prevalence of Cannabis use in Europe
In Europe, according to the European Monitoring Centre (EMCDDA), 22% (70 million)
of those between 15 and 64 have used cannabis at least once in their lifetime, 7% (23 million) in the last year and 4% (14 million) last month. These percentages increase (17%)
when considering the use in the last year in the age band of 15-24 years. The prevalence
of the use of Cannabis can be better appreciated when one considers that the cocaine
prevalence is about 10 times lower. Particularly significant is the last ESPAD survey, conducted in 2011 among students in 36 European countries with an average age of 15.8 years, that is, in the mid-adolescence. Approximately 19% of males (M) and 14% of females
(F) stated that they had consumed cannabis at least once, with peaks of 48% M / 38% F
in the Czech Republic and 39% M / 40% F (!) in France. In the USA, the corresponding
figures are 40% in males and 35% females. The average prevalence of cannabis use in
the previous year was 15% in males and 11% females. The average prevalence in the last
month was 8% in males and 5% in females, with a ratio between the two sexes of 22.5%
in France, 18% in the USA and 15% in the Czech Republic and Spain. The lifetime prevalence of cannabis use in Europe between 1995 and 2011 has increased by 6 percentage
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points. According to the last report of the European Observatory (EMCDDA) Cannabis is the most common primary drug after heroin, for patients who undergo specialist
treatment of drug dependence (109 thousand) and is the drug most frequently reported
among those who are undergoing treatment for the first time. In Europe, the number of
consumers of cannabis that are undergoing treatment for the first time has increased by
approximately 45 thousand in 2006 to 60 thousand in 2011.
A three-stage model: availability, use, abuse
Genetic epidemiology studies conducted in twins show that substance abuse is
dependent on genetic and environmental factors, the latter divided into shared
and non-shared between subjects. These three types of factors, in turn, can act
on each of the stages that constitute the natural history of substance dependence,
i.e., availability, use and abuse. Recently Verweij et al. (67) conducted a meta-analysis of studies on the use and abuse of cannabis carried out on twins. The
analysis shows that genetic factors account for about 50% of the variance for both
the initiation of use and the problematic use of cannabis. The remaining 50% is divided
between the risk of environmental shared and non-shared factors. A typical aspect of
the use of Cannabis is that the drug is offered by the most experienced to novices. Given
these characteristics, it is expected that the initiation into cannabis is related to its availability. In fact, the rank order of the European nations with regard to the prevalence of
students who said they had had the opportunity to consume cannabis but not to have
consumed it, corresponds to the prevalence of the use (ESPAD 2011). Thus the prevalence of the availability of Cannabis is highest in the Czech Republic (57%) and in France
(44%), countries ahead also as far as regards the use prevalence. Gillespie et al. (27) studied the relationship between twins in the availability of cannabis, initiation and abuse
and the contribution to each of these aspects of genetic and environmental shared and
non-shared between the twins. The data obtained are consistent with a model in which the availability of Cannabis acts on initiation through shared environmental factors
while the initiation acts on the abuse through non-shared environmental factors, as well
as through genetic factors. Thus, the two aspects of the prevalence of use and availability
are inextricably linked and influence each other. This relation, amplified by the influence
of the dynamics of the group, family and social relationships typical of adolescence, may
at least partially explain the high prevalence of cannabis use among adolescents.
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Global burden of disease (GBD)
The notion of GBD was introduced by the World Bank to assess the socio-economic
impact of diseases and disorders. GBD is expressed in terms of years spent in disability
(YLD) and years of life lost (YLL) and, overall, as life years lost adjusted to disability
(DALYs). Since the GBD resulting from substance dependence is sensitive not only to
the potential for abuse of a specific drug but also its diffusion, the DALY expresses better than any other index the socio-economic impact. Fig. 1 shows the GBD resulting
from addiction to various drugs, expressed in DALYs. In countries with high per capita
income, the burden resulting from addiction to cannabis in 2010 was higher than that
resulting from addiction to amphetamines (DALYs in millions of years: Australasia 9.3
to 5.8, Western Europe4.3 vs 3.4, North America 8.1 vs 3.3 (13).
Fig. 1 Global burden of disease due to Cannabis dependence expressed as DALY in comparison to other
substances of abuse in the GBD 2010 (13).
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Abuse potential
Cannabis is a drug commonly considered as ‘’light’’. This dates back to the late 60s, when
cannabis began to spread among young people. In those years one would only know that
its active ingredient was THC (43, 44) and would have to pass more than 20 years before its mechanism of action and homologies with other drugs were demonstrated (22,
45). Surely the fact that cannabis, unlike other drugs, is virtually devoid of lethal effects,
has greatly contributed to the notion of ‘’light’’ drug. However, the evidence provided
by epidemiological and clinical studies over the last 10 years calls for a verification of
this notion. In the 2011 ESPAD administered to students (mean age, 15.8 years), the
CAST questionnaire in order to determine the prevalence of individuals at high risk of
abuse and dependence on cannabis. Among those who had consumed cannabis in the
last year, 33% of subjects (36% of males and 29% females) were classified as high risk
and problematic cannabis consumer. These observations have recently been confirmed
and extended by the prospective study by van der Pol et al. (66) on a cohort of 600 daily
users of cannabis in which they observed a cumulative incidence of dependence of 37%
over three years. The abuse potential of a drug can be expressed in terms of percentage
probability of the transition from use to problematic use and to abuse and addiction. In a
longitudinal study, conducted in Germany, of the transition as a function of age, between
14 and 24 years, from the initial use to problematic use of cannabis, nicotine and alcohol,
Behrendt et al. (7) observed a probability of transition from first use to dependence of
36% for nicotine, 11.2% for alcohol and 6.2% for cannabis; the probability of transition
to abuse was 25.3% for alcohol and 18.3% for cannabis. More recently, Lopez-Quintero
et al. (2011) have analyzed data from the NESARC in terms of the cumulative probability of the transition from first use to dependence (Fig. 2) for cannabis, nicotine, alcohol
and cocaine. This probability was 2% for cannabis, nicotine and alcohol, and 7.1% for
cocaine after one year from initiation, 15.6% for nicotine, 14.8% for cocaine, 11% for
alcohol and of 5.9% for cannabis after 10 years from initiation and 67.5% for nicotine,
22.7% for alcohol, 20.9% for cocaine and 8.9% for Cannabis if referred to lifetime. From
these simple comparative data it can be concluded that a feature of addiction to cannabis
compared to other drugs is the reduced and restricted latency to onset from the first
contact with the substance. This aspect has been studied in more detail by Wagner and
Anthony (68) who estimated in the two sexes and between 15 and 44 years of age, the latency of addiction to cannabis, alcohol and cocaine. In the case of cannabis, dependence
developed differently in the two sexes, with a peak (max 4%) after three years of use in
males and a low plateau (max <1%) between 0.5 and 4.5 years in females (Fig. 3a). Also
in the case of alcohol the trend of the latency of dependence was different in the two
sexes, but in males showed up later (5 years) and the sex difference was less pronounced
(max <4%) compared to Cannabis (Fig. 3b). The latency of addiction to cocaine had a
similar pattern in both sexes, with an earlier (1 year) and higher peak (up to 5-6%) with
respect to Cannabis and alcohol (Fig. 3c). Expressing the data in terms of the cumulative
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probability of dependence it is observed that in males addiction to cannabis reaches the
highest levels (14%) at 30 years, while addiction to cocaine increases up to 40 years (max
22%) and alcohol up to and possibly beyond 44 years (max 30%). Therefore, the study of
Wagner and Anthony (68) shows that in males the instantaneous probability of the onset
of addiction to Cannabis has a very narrow time window, when it reaches values higher
than both alcohol and cocaine, which, in the long period, on the other hand, have a higher chance of inducing addiction. One possible interpretation of the gender difference
in the risk of developing dependence on cannabis is that there is a genetic factor linked
to sexual maturation particularly sensitive to exposure to Cannabis (40).
Fig. 3 Estimated risk of developing cannabis (a), alcohol (b) and cocaine (c) dependence in males and females and time elapsed from the first use among users 15-44 years old (68).
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Fig. 2 Probability of transition to nicotine, alcohol, cannabis and cocaine dependence among users of these
substances (modified from Lopez-Quintero et al., 2011).
Cannabis as a gateway
One of the most controversial aspects of the epidemiology of Cannabis is the possibility
that its use in adolescence facilitates the transition to the use and abuse of illicit drugs
with a high potential for abuse (34). Several epidemiological studies show that early
use of cannabis is associated with a higher risk of abuse and dependence not only on
Cannabis but also to other illicit drugs such as cocaine, methamphetamine and heroin
(35, 3). Various mechanisms have been proposed to explain this association. Even if not
explicitly the gateway hypothesis states that the relationship between cannabis and drugs
with a high potential for abuse is causal in nature i.e. due to the properties of Cannabis
(34). Alternatively, the association between the use of cannabis and other drugs may
result from a commonality of individual factors, genetic or environmental (common
liability). For example, a reduced impulse control or a greater tendency to seek gratification (reward seeking), due to genetic factors, could lead to greater individual vulnerability to the use of illicit drugs other than cannabis. Another possibility, proposed by
Wagner and Anthony (68), is that people who use cannabis have a greater opportunity
to be exposed to other drugs with which they share the illegal market. The hypothesis
of a causal relationship is very controversial because cannot be proved by epidemiological methods; at best, one can exclude the role of contributing factors, both genetic
and acquired. For this purpose, some studies have used statistical methods (e.g. Fitting
model) (1); other studies have compared the risk of dependence within pairs of identical
twins, identical to genetic and lived in the same family environment but discordant for
cannabis use in adolescence (41, 2). In both cases, the early use of cannabis resulted in a
probability of abuse of other illicit drugs 2-5 times greater than that of subjects who had
not used Cannabis. However, while the approach of Linskey et al., would exclude a role
of genetic and environmental (family) factors common to both twins, does not exclude
the role of individual environmental factors not shared among twins. These limits are
partially controlled by the longitudinal study of Lessem et al (39), which includes both
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twins brothers and sisters and confirms and extends the results of studies of Linskey et
al. Therefore, the current hypothesis is that the use and abuse of cannabis in adolescence predisposes to the use and abuse of drugs with high potential. Lessem and coll. (39)
suggest that the use of cannabis involves the fall of a taboo, that of using an illicit drug,
which paves the way for other more powerful and dangerous drugs.
The choice between the different hypotheses on the association between Cannabis use
and abuse of other illicit drugs has implications not only scientific, but also social and
political. For example, on the basis of the assumption that the use of cannabis predisposes to the use of harder drugs, campaigns for the prevention of cannabis availability and
use in adolescence have been launched in the United States with the idea that this would
help to reduce the incidence of addiction to cocaine and heroin in adulthood. On the other hand, it has been suggested that the assumption of an association between Cannabis
and hard drugs due to their common illicit nature, did provide the basis for the decision
of the Netherlands to partially legalize Cannabis.
Levels of THC in Cannabis products
Acute and chronic effects of Cannabis on behavior are mainly due to its THC content. It
is therefore expected that magnitude of Cannabis effects is a function of its THC content.
Indeed, several studies have shown that the risk of anxious states, psychosis, cognitive
disturbance and car accidents in Cannabis users is correlated to drug potency in terms
of its THC content. In the latest 30 years, the THC content of Cannabis herbal crops
and products is progressively increased worldwide. As an example in the USA the THC
content in marijuana was 2% in 1980, 4.5% in 1997, 8.5% in 2007 and 9.6% in 2010 (Fig.
4). The THC content of Cannabis products, reported by EU (EMCDDA, ESPAD) and by
WHO observatories (UNODOC), refers to data coming from analysis of tons of Cannabis herb and resin seized and imported from countries where Cannabis is cultivated in
open fields.
Fig. 4 Changes in THC levels in cannabis
crops in the last decades (from: The University of Mississippi Cannabis Potency
Monitoring Project, cited by Department
of Justice US, National Drug Intelligence
Center, 2008)
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According to the latest European observatory report (EMCDDA 2013) THC content in
marijuana and hashish is on average 7-8% (ranging from 2% to 16%). Cannabis market
is however more variable than what appears from the above data. Thus, introduction
of preparations not imported but obtained through unique cultivation techniques, as
an example preventing female flowers pollination (sinsemilla), or obtained by breeding
plants cultivated in artificial conditions (hydroculture), has radically modified Cannabis
market and its THC content. Sifaneck and coworkers (55) have described the situation
of Cannabis market in New York city, where, in addition to commercial marijuana, sold
by the street at cheapest price, imported and obtained from cultivation in open fields,
it is available the designer marijuana, obtained by locally crops in artificial conditions
(Haze, Skunk, White Widow) more expensive and purchased by toll-free call, delivered
at home and paid by credit card.
Effect of Cannabis legalization on THC content
Netherlands has partially legalized Cannabis and this legislative change has been associated with an increase of THC content in Cannabis products. Pijlman and coll. (49)
have studied the THC percentage in imported marijuana and hashish and derived preparation, Nederwijete Nederhasij, obtained from selected species locally cultivated, both
sold in Amsterdam Coffee Shops. Imported marijuana and hashish showed an increase
in THC content from 5% and 11% respectively in 2000 to 7% and 18.4% in 2004, while
locally produced marijuana and hashish changed their content from 8.6% and 20.7% in
2000 to 20.4% and 39.3% respectively in 2004. From 2004 the potency of local marijuana, in terms of THC content, has remained at the high levels reached previously, while
the potency of imported marijuana is almost doubled (EMCDDA, Cannabis Report).
In the USA, in the middle of 2013, the States that legalized Cannabis for medical use
were 20. Sevigny and coll. (54) have observed an increase of about 1% in THC content
of preparations sold in the illegal market in those States where legalization has been accompanied by establishing authorized dispensaries, real Cannabis supermarkets. In the
USA the increase in THC content induced by legalization has not been so drastic as in
Netherlands given that legalization occurred later, when the content of THC was already
increased due to introduction of new farming techniques (sinsemilla).
Cannabis abstinence syndrome (DSM-V)
Cannabis meets the DSM-IV and DSM-V criteria for Cannabis Use Disorder (CUD).
However, Cannabis ability to induce physical dependence and a withdrawal syndrome
after quitting its use was not reported in the DSM-IV (1994), because the lack of sufficient clinical evidences. In the meanwhile reliability and effectiveness of Cannabis withdrawal syndrome has been demonstrated by pre-clinical, clinical and epidemiological
studies, justifying addiction in the DSM-V (28). The withdrawal syndrome is observed
133
in about one third of users who regularly consume Cannabis and in 50-95% of the individuals who consumed high doses of Cannabis in experimental context. Intake of 180
mg of THC per os every day for 11-21 days induces tolerance to the main effects of Cannabis and physical dependence. Withdrawal from Cannabis is characterized by craving,
irritability and aggressiveness, dysphoria, depressed mood, anorexia, sleep disturbance
and weird dreams, motor disturbance. During Cannabis withdrawal, physical signs are
less intense compared to those of alcohol and heroin withdrawal, but not the craving
that is as well intense. Withdrawal syndrome has a motivational role in Cannabis use, as
demonstrated by the fact that abstinent users consume Cannabis in order to attenuate
the negative effects and this makes more difficult stopping its use (see refs. 143 and 144
in Hasin et al. 2013).
Tolerance and physical dependence to Cannabis may be induced rapidly in laboratory
animals, in which it might be precipitated by rimonabant administration, an antagonist
of cannabinoid CB1 receptors. In experimental animals behavioral features of withdrawal syndrome are reminiscent of opiates withdrawal. As in the case of opiates and
cocaine, Cannabis withdrawal is associated, in the rat, to a reduction of dopaminergic
transmission in the nucleus accumbens shell (see below) and this effect might have a role
in Cannabis abuse and dependence, through a negative reinforcement mechanism. According to this, the Cannabis dependent individual continues to take the drug to avoid
the withdrawal state (15, 61).
Cannabis reinforcing properties
The study of the behavioral and reinforcing properties of drugs of abuse in experimental
animals has a fundamental importance in understanding the mechanism by which these
substances produce dependence in humans.
A fundamental property common to all drugs of abuse is that of acting as a reinforcer
for behavior and thus to be self-administered by laboratory animals. For many years any
effort has been made to obtain self-administration of the active component of Cannabis,
9-tetraidrocannabinolo (THC), in different animal species, from primates to rodents,
but it has been unsuccessful.
Only recently a consistent self-administration behavior of THC has been obtained and
its features satisfy validated criteria to test food and drugs reinforcing properties.
Thus, it has been demonstrated that THC is self-administered intravenously by monkeys
(squirrel monkey), both by subjects previously trained to self-administer cocaine and
by naïve ones (63, 31, 33). THC doses producing this effect are around 4 microgram/
Kg. In the rat intravenously self-administration has been obtained for WIN 512,202-2,
a synthetic agonist of cannabinoid CB1 receptors but not for THC (24, 38). The reason
for this discrepancy is likely due to the peculiar pharmacokinetic of THC in the rat,
that does not allow the maintenance of a strict temporal contingency between operant
134
responding and rewarding effect of the drug, an essential condition for acquisition of a
reinforced behavior.
Stimulation of dopamine transmission
Another THC property common with other drugs of abuse is its ability to stimulate
dopamine release in the ventral striatum, and preferentially in the shell of nucleus accumbens. This property of THC and its synthetic analogue, WIN 512,202-2, has been
demonstrated by means of different techniques both in the rat, following passive administration (microdialysis and fast scan cyclic voltammetry) (62, 11, 47) and active
self-administration (38), and in humans (C11-raclopride binding measured by PET) (8,
59).
Maximal stimulation of dopamine release by THC administered intravenously is quantitatively superimposable to that induced by heroin (62). These effects are blocked by an
antagonist of CB1 receptors as well as by an antagonist of opioid receptors, naloxonazine, at the same doses able to block stimulation of dopamine transmission by heroin (62).
The stimulant effects of THC on dopamine transmission are due to a stimulation of
firing activity of mesencephalic dopamine neurons projecting to the nucleus accumbens (26). Given that opioid receptors blockade prevents also THC self-administration
in monkey (32), these observations, with the demonstration that THC releases beta-endorphins (58), suggest that Cannabis releases endogenous opioids acting on mu receptors and this effect might contribute to both reinforcing properties and ability to release
DA in the nucleus accumbens (Fig. 5).
Fig. 5 Simplified schematic drawing showing cannabinoids and opiates action in the ventral tegmental
area (VTA). Opiates and cannabinoids would stimulate dopamine (DA) neurons by blocking the
GABAergic brake by VTA neurons on dopaminergic neurons. CB1 cannabinoid receptors of type 1;  mu
opioid receptors; NAcb nucleus accumbens.
135
The ability of THC to stimulate dopamine transmission in the shell of nucleus accumbens is common not only to heroin and opiates in general but also to all drugs of abuse,
from psychostimulants to nicotine and alcohol (16). These observations by one hand suggest that dopamine plays a role in the reinforcing properties of Cannabis and in general
of drugs of abuse and on the other hand suggests that Cannabis shares with other drugs
of abuse peculiar properties at the basis of their abuse liability.
To dopamine in the nucleus accumbens shell different functions, involved in the ability
to induce dependence, has been attributed. Among these the ability to facilitate acquisition and expression of incentive properties by conditioned pavlovian stimuli.
Experimental studies on behavioral and biochemical properties of THC and its synthetic
analogues confirm the status of Cannabis as a substance endowed of ability to induce
dependence not differently from other substances defined as heavy drugs. In fact, THC,
administered in appropriate doses, is provided of all the main characteristics of drugs
with high abuse potential, such as heroin, having in common with this drug dependence
liability for its stimulant effects of mu opioid receptors.
Neurobiology of Cannabis as a gateway
Given the difficulty (see above) to demonstrate, by an epidemiological approach, the
existence of a causal relationship between Cannabis use and abuse of other heavy drugs,
studies on animal models become essential in order to provide an experimental evidence
on this issue.
By a neurobiological point of view the more consistent relationship is between cannabis
and heroin. These substances indeed share common pharmacological properties, mediated by an action on mu opioid receptors, strictly correlated to their ability to induce
dependence, such as reinforcing properties (self-administration) and the ability to stimulate dopamine release in the nucleus accumbens shell (see above).
Moreover previous exposure to THC or other synthetic cannabinoid agonists has been
reported to sensitize to the stimulant motor effects (behavioral sensitization) of both
THC and morphine, but not of psychostimulants (cocaine and amphetamine) and vice
versa (9). On the other hand previous, exposure to morphine induces sensitization to
morphine but also to THC (cross sensitization).
Recently, in our laboratories we obtained the more striking evidence on THC ability,
administered during adolescence, to increase the rewarding and reinforcing properties
of heroin (10, 38).
Previous studies on this issue have shown as THC exposure both in adult (57) and adolescent rats (18) increases the rate of responding during intravenous heroin self-administration. This effect, in the paradigm of self-administration utilized in these studies,
is difficult to interpret since it might be suggestive of both an increase and decrease of
136
heroin reinforcing properties. At variance with this, our study used a progressive ratio
paradigm, where the number of responses the animal has to perform to obtain intravenous injection of the drug increases progressively. The maximal number of responses
the animal is able to emit (breaking point) is a measure of the drug ability to reinforce
behavior. By using this paradigm we have observed that adolescent pre exposure to THC
increases, in adult rats, the maximal number of responses the animals emit and thus
heroin reinforcing properties. This effect was, in turn, correlated to the inbred rat strain
utilized since it was observed in the Lewis strain, addiction prone, but not in the Fischer
344 strain (10).
These results suggest that, similarly to what hypothesized for the psychopathological
effects, Cannabis renders manifest a vulnerability risk factor, likely genetic in nature,
which may lead to use and abuse illicit drugs with high abuse potential.
Synthetic cannabinoids
From 2004, several synthetic cannabinoids have been detected in Herbal Highs, also
known as Spice. Spice are smokable herbal mixtures marketed as legal alternatives to
Cannabis and sold under many names (Spice Gold, Spice Silver, nJoy, Blaze, Orange, Lilla, K2, etc.) in the “smart shops” and through the Internet (42, 25) (EWS, 2009; EMCDDA, 2009). From 2008, Spice became very popular in Germany after several cases of
intoxication characterized by extreme anxiety/panic, paranoia and hallucinations (25,
53, 51). Spice comprise inert or psychoactive plant material (e.g. Leonotis leunurus, Pedicularis densiflora) laced with various synthetic CB1 and CB2 cannabinoid agonists (6,
64). In 2013, the annual report of the European alert system on drugs (EWS) reported
84 new cannabinoids (53). Many of these compounds belong to the class of aminoalkylindole such as the naphthylmethyl indoles (JWH-018, JWH-015, JWH-073, JWH-122,
JWH-210, WIN-55212), phenylacetyl indoles, (JWH-250 e JWH-251), benzoylindoles
(pravadoline, AM-694, RSC-4). In addition, in other preparations cyclohexylphenoles
have been detected (CP-47497, CP-55940, CP-55244). Synthetic cannabinoids produce
pharmacological effects similar to those reported by Spice consumers (37, 23). Smoking
Spice induces more intense and long lasting euphoria compared to Cannabis, frequently
accompanied by paranoia, panic psychosis, hallucinations, seizures, tachycardia, headache, nausea, vomiting and a stronger withdrawal (EMCDDA, 2009) (20). For these
reasons, Spice consumption has been monitored by the EMCDDA. Among all synthetic
cannabinoids analyzed, one in particular, JWH-018 (1-Pentyl-1H-indol-3-yl)-1-naphthalenylmethanone) (Fig. 6), has been detected in more than 140 specimens of Spice both
in Europe and in Japan (64, 17), although in different amounts depending on the Spice
analyzed. JWH-018 has been synthetized in 1995 by John William Huffman at Clemnson University (USA) for scientific purposes. Compared to THC, JWH-018 exhibits an
approximate fourfold higher affinity for the CB1 (Ki ~ 9 nM) receptor and tenfold affinity for the CB2 receptor (Ki ~ 3 nM) (60, 12, 29, 5). In vitro studies on liver microsomes
137
(69) and in urine (56) showed the presence of several pharmacological active metabolites (52). The higher potency of JWH-018 compared to THC in vivo and the formation of
metabolites, are likely to be the reason why Spice induce higher dependence and withdrawal when compared to THC and Cannabis. Unpublished data of our laboratory show
that rats consistently acquired operant behavior (nose-poking) that resulted in JWH-018
intravenous infusion (self-administration studies). Using in vivo microdialysis we found
that JWH-018 (0.25 mg/kg ip) preferentially increased DA release in the NAc shell vs.
NAc core or mPFCX and this effect was blocked by CB1 receptor antagonists (Rimonabant, AM 251) and was absent in CB1KO mice. Electrophysiological recordings from
DA neurons of the VTA revealed that JWH-018 was able to decrease GABAA-mediated
post-synaptic currents in a dose-dependent fashion. Finally, we found that JWH-018
produces CB1 receptor-dependent behavioral “tetrad” effects (hypothermia, analgesia,
catalepsy and hypomotility) in mice and rats. These findings link JWH-018 to other cannabinoids with known abuse potential, and to other classes of abused drugs that increase
DA signaling in the NAc shell (14) (De Luca et al., in preparation). The diffusion of the
Herbal Highs has contributed to make the global scenario of Cannabis consumption
considerably wider. Despite the efforts to ban their sale, these products continue to be
easily purchased without age limit and therefore represent a great risk for health.
Fig. 6 A sample of Spice Diamond containing JWH-018.
Medical marijuana
As of May 2013, 19 states of the USA and the District of Columbia have approved laws
to protect from the federal justice, that consider Cannabis use as a criminal offense, the
prescription and sale and use of cannabis for therapeutic use. Some of these states have
also endorsed laws that protect from the federal justice the dispensaries of marijuana for
therapeutic use. Kleber and Dupont (36) have highlighted the totally abnormal aspects
of medical marijuana. First, it is abnormal the fact that it is a smoked medication. In fact,
there is no FDA-approved drug administered through this form. The reasons for this are
obvious: marijuana smoking is more dangerous than tobacco; in addition, precise dosing is impossible. Thus, smoking does not allow a reproducible and predictable dosage
138
between different subjects and in the same subject, due to the differences in the percentage of THC in the different preparations of marijuana and THC extraction efficiency
among different people and situations. As reported by Kleber and DuPont (36): “Medical marijuana bypasses the century-old, scientifically based drug approval procedure
and the carefully regulated distribution of medications through licensed pharmacies’’.
The fact that marijuana has been introduced in therapy on the basis of a referendum
and political decision, bypassing all the rules which drugs are subjected to, establishes a
dangerous precedent for public health. The fact that smoking is a pharmacotherapeutic
non-sense while it is the common mode of use of cannabis for recreational purposes is
symptomatic of the fact that the so-called medical marijuana is nothing more than a
shortcut for legal recreational use of cannabis. In fact, less than 5% of individuals authorized to purchase medical marijuana suffer from those conditions that justify its compassionate use (HIV, cancer, multiple sclerosis)(46). Actually, the most frequent justification for medical marijuana prescription is the treatment of pain (82.6% -87%), anxiety
(38%) and depression (26%) (46, 30). Moreover, it has been reported that the 96% of
medical marijuana users had used cannabis in their lifetime, while in general population
this figure is 4 time less. The most parsimonious explanation for these observations is
that the therapeutic use of medical marijuana is a shortcut to obtain in a legal way cannabis for recreational purposes.
The impact of legalization
In November 2012, Colorado and Washington States have legalized cannabis for recreational use. From a scientific point of view, the legalization of cannabis is a natural
experiment and a large-scale business. It is highly probable, however, that this is not
without consequences for the health of citizens. Given that, the effect of legalization
on health can be detected only after several decades, the current studies are focused on
some aspects of the market such as the extent of demand and supply (production), the
price, the titer of THC and its consumption, both expressed as prevalence (% of subjects) and as the quantity of cannabis used. According to Sevigny and Pacula (48), the
differences in legislation between the States and the continuous changes in the law in
the same state make it difficult to draw general conclusions. As for the market, available
evidence suggests that the two markets, legal and illegal, are closely interrelated, especially when the control is loose. Rendon (50, p. 147) wrote, “the legalization of marijuana
for medical use in California has changed everything about the market for pot and is
pushing changes for growers, breeders, and the plant itself ”. Thus, substantial amounts
of medical marijuana are produced in excess and diverted to the illegal market. In Colorado, a recent investigation documented dozens of cases of diversion of cannabis to
the illegal market from dispensaries, patients and authorized physicians (Investigative
Support Center, 2012). The data on the effect of the legalization on cannabis use, expressed as prevalence and therefore on the number of users, are not concordant. In fact, the
139
number of studies indicating an increase is equal to the number of studies that do not
find significant changes. However, there is no doubt that, by expressing the use in terms
of quantity consumed, legalization has produced an increase in consumption by regular
users. Pacula and Sevigny (48) have observed that the effect of legalization on cannabis
use depends on social (changes in social norms or in perceived risk), environmental
(local presence of dispensaries and ease of access to cannabis) or market factors (scale of
production and price). For example, an increase in demand due to the first two factors
will produce an increase in the price which in turn will tend to limit the use. Conversely,
an increase in the production of cannabis, by reducing the price, would promote dissemination and use. Another possible consequence of the legalization of cannabis regards
the influence on alcohol consumption. Alcohol and marijuana may be complementary,
being consumed jointly, or be consumed in alternative. In the first case, the effect on
driving is quite negative, since alcohol and cannabis act on two different driving modes,
outcome-related and, respectively, habitual, each of which can, in an asymmetric way,
compensate for dysfunction of the other. In the second case, alcohol, impairing executive functions, exerts the most severe effects. Cannabis, however, by interfering with the
habit mode, forces the subject to shift on the outcome-dependent mode. In this case, the
choice of alcohol or cannabis by adolescents and young adults depends on the price. According to Anderson and Rees (4), the legalization of cannabis has led to a substitution
of alcohol with cannabis in States where this has coincided with a reduction in the price
of cannabis, due to an excessive production, and a convenience of cannabis compared to
alcohol. This conclusion, however, is contrasted by Sevigny and Pacula (48).
Conclusions
The issue of the legalization of Cannabis can be looked up in different ways depending
on the perspective from which it is considered. From a social point of view, legalization
is a clear contradiction because, by increasing the availability and use of cannabis for
adults, reduces the perception of cannabis as a danger on the part of its consumers most
at risk, adolescents, for which, however, remains illegal. From the point of view of economic liberalization, through the excise duty charged by states, can become a significant
source of revenue for states and create an economic linkage made up of manufacturers,
retailers and distributors, licensed doctors etc. Legalization, however, does not involve
the extinction of the illegal market, which could even become competitive with the legal
one, in relation to the amount of taxes levied by the states. Paradoxically, then, minors,
who are also the largest consumers and those most at risk for possible long-term effects
of cannabis, cannot directly access to legal cannabis, since they banned from that. However, they are more exposed to cannabis because of the diversion of cannabis from the
legal to the illegal market. Therefore, apart from the possible economic benefits and tax
advantages, the legalization of cannabis does not reduce, but rather heightens the danger
of long-term sequelae on the health of adolescents.
140
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144
Gregor Burkhart*
Senior Scientific Analyst – Prevention. MD, MPH
ABSTRACT
Recent findings in social neuroscience corroborate that adolescent involvement in risk behaviour is not due to lack of information,
irrationality or faulty calculations, but to the mere presence of peers in a group context and to often erroneous perceptions of social
norms. Most traditional prevention (and harm reduction) approaches ignore this principle and rely heavily on cognitive processes (information provision) or on improving competences of the individual. Environmental approaches in turn modify the physical, economic
and social contexts in which people take their decisions about substance use and get involved in problem behaviour. It doesn’t operate
through persuasion but by changing social norms or their perception. Beyond social context, lack of impulse control seems to be the
common determinant of many problematic behaviours.
The presentation gives an overview on how this can be tackled in universal prevention programmes by improving external (social)
control and in indicated programmes by improving internal control. In an integrated renewed perspective, prevention strengthens
and facilitates socialisation, which means to transmit accepted attitudes, norms, beliefs and behaviours, both at population level and
for vulnerable groups/individuals. It might help to get past the debate whether prevention has to target abstinence or risk reduction.
* Gregor Burkhart has been responsible for prevention responses at the EMCDDA since 1996. He developed databases on best practice
examples (EDDRA), on evaluation tools (EIB) the Prevention and Evaluation Resource Kit (PERK) and the recently published Prevention
Profiles on the EMCDDA websites. His main activities are to develop common European indicators on the implementation of prevention
policies in member states and to promote a better and clear understanding of universal, selective, indicated as well as environmental
prevention in Europe.
Gregor works on methodologies for monitoring prevention responses and how to improve and how to evaluate them. He is guest lecturer at the University of Granada (Faculty of Sociology).
He is the co-founder of the European Society for Prevention Research and holds a doctoral degree in medicine (medical anthropology)
on the influence of culture on the classification and perception of body and diseases in the Candomble cults of Bahia, Brazil as well as
a MPH degree from the University of Dusseldorf.
Currently he is an advisor at the Organisation of American States on prevention policies and programmes in South America.
145
DRUG PREVENTION APPROACHES IN EUROPE FROM THE INDIVIDUAL TO THE ENVIRONMENT
Drug Prevention Approaches in Europe:
from Environment to the Individual
For many prevention professionals substance use is the main risk factor for substance
use disorders (SUD), and therefore any substance use must be prevented or early detected and discouraged. Although use of a drug is a necessary step in the progression to
abuse and dependence, other variables may be of crucial importance in the transition
from use to abuse. Personality factors that predict initial acute drug effects and early use
may significantly contribute to continued use, escalation and dependence (1). Traditional prevention work however focuses exclusively on substance use and is based on a
stage model, where the use of legal substances precedes and prepares for the use of illicit
drugs. More recent research however has introduced an alternative view, the common
liability model: early-manifesting personality traits such as for example neurobehavioural (i.e. cognitive, affective and behavioural) disinhibition predict both early initiation of
substance use and rapid escalation into problem use.
Sloboda et al. (2) provide an exhaustive revision of the vulnerability models relevant
for prevention that include many early developmental factors in early childhood which
dynamically interact with environmental factors – in family and school – later in childhood and adolescence.
These findings suggest more sophisticated prevention interventions that target individual vulnerability traits or unfavourable environments, instead of only aiming to prevent
or detect drug use.
Another common view of drug prevention, particularly among lay audiences, is that it
consists of informing (generally warning) young people about the effects (most commonly the dangers) of drug use. Prevention is, in line with this, then often equated with
(mass media) campaigns. However, there is currently no evidence to suggest that the
sole provision of information on drug effects has an impact on drug use behaviour, or
that mass media campaigns are beneficial for all (3).
Recent findings in the field of neuropsychology (4) shed light on why information provision doesn’t deter young people from certain behaviours since these are rather determined by social context and not really by individual choice.
Galvan et al. (5) found that the activity of the nucleus accumbens within the limbic system – responsible for drive and impulsivity – begins to increase in adolescence, while
the prefrontal cortex – responsible for behavioural control – is not yet fully developed at
this age. This imbalance alone does not necessarily result in impaired judgement of risk.
An additional developmental process however, the increase of oxytocin receptors in the
146
limbic system during adolescence, explains why adolescents — compared with children
and adults — respond more intensely to emotional and social stimuli and have increased
awareness of others’ opinions (4): there is an important overlap between neural circuits
responsible for social information processing and those for reward so that reward-seeking is increased in the presence of peers, when the brain’s socio-emotional system is
stimulated.
The interplay of these processes suggests explanations of why so much adolescent
risk-taking (especially substance use and reckless driving) occurs much more frequently
in peer group environments. When adolescents are alone or not emotionally excited, the
cognitive control of the prefrontal cortex is strong enough to control or regulate impulsive and risky behaviour. When alone, adolescents perform the same or even more careful
risk assessment of situations and behaviours than adults. Only in the presence of peers
or under conditions of emotional arousal the earlier developing limbic regions manage
to override the less developed behavioural control of the prefrontal cortex, resulting in
poor and impulsive decisions. Therefore, it seems to be normative, biologically driven, to
a certain degree inevitable and functional that adolescents are prone to risk-taking during adolescence. Mature judgment needs time to develop, and therefore cognitive-informative techniques don’t seem to be feasible to make adolescents wiser, less impulsive,
or less short-sighted.
These findings have manifold implications for prevention.
•
They help to understand why pure information provision has poor effects on behaviour especially in this age group
•
They offer explanations for the harmful effects of those mass media campaigns that increase normative beliefs, i.e. give the implicit impression that most or
many people do engage in a given problem behaviour.
•
They help to understand why the effect of drugs legislation – which sanctions
only individuals – on adolescent behaviour is so weak and often fails to dissuade
them from continuing drug use (6). The effect of informal social control and social sanctions (from family and peers) may be more important than the certainty
and severity of formal sanctions (7).
•
They provide the theoretical underpinning of why adolescents – who appear to
be little impressed by possible legal sanctions – are so much influenced by social
norms, peer environments and social control. Only “in places where informal
social controls have been weakened, young people tend to see delinquent behaviour as a sign of strength, incarceration as a rite of passage, and law enforcement
as illegitimate” (8). Reinforcing these informal social controls and changing the
perception of normality ought to be core objectives of prevention.
Prevention can therefore be conceived as strategies that help young people to adjust their
147
behaviour, capacities and wellbeing within their living conditions, social norms, interaction with peers, social status and opportunities and their own personality traits, hence it
is evidence-based socialisation (9). Its aim is then not solely to prevent substance use or
to delay initiation, but also to reduce its intensification or prevent escalation into problem use. Socialisation is a process of transferring culturally acceptable attitudes, norms,
beliefs and behaviours and of responding to social cues in an appropriate manner with
adequate impulse control.
This was the argument for the EMCDDA to adding environmental prevention to the
classical three prevention strategies of the Institute of Medicine (10) that are based on
the overall level of vulnerability of the people addressed: universal, selective and indicated prevention.
Environmental prevention strategies aim at altering the immediate cultural, social, physical and economic environments in which people make their choices about drug use.
These strategies typically focus on social norms and climate, or physical and economical
changes instead of persuasion and are also used in other behavioural domains, e.g. violence, delinquency or obesity.
This contextual perspective takes into account that individuals who might become involved with substances are influenced by a complex set of factors in their environment.
These include social norms, defining what is considered normal, expected or accepted in
their reference group, the rules or regulations and taxes of their states, the publicity messages to which they are exposed, and the availability of alcohol, tobacco, and illicit drugs.
Environmental prevention strategies therefore often entail unfashionable but effective
components at macro level (i.e. at the level of legislation or society), like market control
by taxes and publicity bans or coercive measures like age controls and tobacco bans.
Many often environmental and unconscious cues influence human behaviour, such as
images, spatial and acoustic arrangements, and associations or observed behaviours of
others. Since certain industries try to use these cues in their interest, the term ‘industrial
epidemics’ has been coined for obesity, tobacco and alcohol use (11). Public regulation
and market interventions are considered the only evidence-based mechanisms to prevent harm caused by commodity industries (12). But also the efforts to create protective
and positive school and family climates belong to environmental prevention. Their modus operandi is also not persuasion but positive ‘scaffolding’ in the sense of providing
opportunities, stimuli and encouragement for changes in confined contexts. There is
evidence that school climate (like ‘alienation’) and the nature of school environments
much influence substance use and violence in school (13). Also students’ perceptions
of being treated fairly, school safety and teacher support are related to substance use.
Interventions that increase student participation, improve relationships and promote a
positive school ethos (involvement, engagement and teacher-pupil relations) therefore
appear to reduce substance use.
148
Interventions in nightlife settings can also exemplify the potentials of environmental
prevention. Mainly, the known environmental determinants of alcohol abuse and violence apply to nightlife settings as well: unclean conditions, poor ventilation, high levels
of noise and music, low comfort, high density of patrons, predominant patronage by
males, high numbers of intoxicated patrons, and high boredom (14). Most are related to
automatic processes, as most patrons wouldn’t be aware of these determinants of their
behaviour. A European review (15) found that important environmental contributions
to alcohol-related problems include a permissive environment, discounted drinks promotions, poor cleanliness, crowding, loud music and poor staff practice. Club owners
and managers may be more motivated to use environmental approaches to reduce drug
use and other risky behaviours on premise because such occurrences are not profitable
for business, increase the risk of city and police interference, and create problems within
their own neighbourhood context (14).
In two European reviews of prevention interventions in nightlife settings (16, 17) environmental approaches emerged as the most effective strategies: combination of training,
cooperation and enforcement and ‘classical’ environmental measures such as taxation,
reduced BAC limits, and reinforced minimum legal purchasing age.
Even if environmental prevention targets predominantly legal drugs and antisocial behaviour, its approaches are important for the whole prevention field because early, widespread and accepted use of alcohol and tobacco are related to illicit drug use in many
countries. Especially in the adolescent population the importance of alcohol for the initiation in illicit drug use is essential: EMCDDA analyses of general population surveys
in nine European countries (18) showed an increased prevalence of amphetamine and
ecstasy use amongst frequent or heavy alcohol users. In prospective longitudinal studies
tobacco smoking has shown to mediate the initiation into cannabis use (19-21) and predicts an earlier initiation into that (22). It seems that the social and physical contexts of
consumption are influencing the level of alcohol, tobacco and illicit drugs use. Environmental prevention focuses on these contexts.
Besides the perceived availability of substances, normative aspects such as cultural values, descriptive norms, and the social acceptance of use seem to influence the initiation
into problem behaviour and substance use. Several longitudinal studies have confirmed
that descriptive norms and the misperception of normality (“Everybody does that”) are
important predictors of tobacco smoking (23), frequency of alcohol consumption and
readiness to take high risks to use cannabis, alcohol and tobacco (24). Kuntsche and Jordan (25) confirmed that close contacts with substance-using peers are strongly related to
individual substance-use. In classes where students saw others coming cannabis-intoxicated to school or taking cannabis in school premises, the students used more cannabis
themselves and had more cannabis-using peers, but similar relations were not found for
alcohol. Cannabis use in the school environment seems to create an atmosphere that
149
favours cannabis use independent of students having cannabis-using peers. The authors
suggest establishing an overarching environment of disapproval as an effective means of
preventing cannabis use by adolescents.
It is unlikely that environmental prevention affects behaviour of especially vulnerable
individuals, but the prevention paradox postulates that the majority of alcohol-related
problems in a population are related to low or moderate drinkers simply because they
are more numerous than heavy drinkers - despite the higher individual risk of adverse
outcomes for this group. A study in 23 European countries (26) confirmed the existence
of this prevention paradox for adolescent boys and girls for measures of annual consumption and heavy episodic drinking. Nevertheless, a minority with frequent heavy
episodic drinking accounted for a large proportion of all problems, illustrating limitations of the concept. There is also some evidence for the validity of this phenomenon for
other substances (27).
The practical implication of the prevention paradox is that prevention approaches
should be combined: environmental and universal prevention strategies should aim to
reduce initiation and overall levels of substance use and its normality at population level
whereas targeted strategies ought to address particularly vulnerable subgroups and individuals, addressing harm related to early age drug use or frequent cannabis use.
It would therefore make sense to use more elements of environmental prevention in
complement and support of persuasive prevention strategies, while being aware that vulnerable subgroups and individuals need targeted interventions.
However, in Europe as a whole, the use of environmental interventions in school settings
remains rare. In some areas, such as the promotion of protective school climates and
the development of school drug policies (e.g. guidelines on responding to use or sale of
drugs by pupils), progress has been made.
The distinction between universal, selective and indicated prevention is used to classify
different preventive approaches, based on differences in the vulnerability (and risk) of
the target group. Universal prevention addresses the population at large - regardless of
differing vulnerabilities of individuals or sub-groups. It aims to reduce substance-related
risk behaviour by providing young people with the necessary competences to avoid or
delay initiation into substance use, like a ‘behavioural vaccine’. This approach starts from
the assumption that all members of the population share the same general risk for substance abuse, although the risk may vary greatly among individuals. In Europe at least,
universal prevention predominantly happens in schools, as they facilitate access to the
largest target populations.
The overall effectiveness of school-based (universal) prevention has been repeatedly questioned, but there is sufficient evidence from review level (28-31) that programmes
based on the social-influence approach have been shown consistently to be more effec150
tive than programmes based on any other approach. The approach consists of components such as social skills training (listening, flirting, empathy, and communication),
strengthening personal skills (goal setting, coping, identifying feelings) and correcting
normative beliefs (i.e. on the level of acceptance and use of substances among peers).
It has to be delivered in an interactive way that engages young people. It is yet not fully
understood which elements within social-influence programmes contribute most to behaviour change. While the ‘life-skills’ (i.e. social, personal and refusal skills) components
are well known and researched by now (32, 33), the role of social norms (see above)
for intervention effects is only recently gaining attention of research. Its premise is that
particularly young people tend to overestimate prevalence and frequency of substance
consumption amongst peers, and that these perceptions lead them either to initiate or to
intensify consumption beyond intention. Similar misperceptions have been found in a
range of other health and non-health behaviours. The evidence from trials, done above
all in the USA, but also in Australia and Europe suggest the social norms approach to
be a new avenue for reducing substance use related harm (34). The importance of these
mediators was shown by an analysis done as part of the first European drug prevention
trial EUDAP (35). It found that the level of normative beliefs (but not the level of social
and personal skills) mediated the programme’s effect on cannabis use.
In Europe as a whole, a small shift has been noted towards the use of positively evaluated
universal prevention approaches in schools, such as personal and social skills training,
and a move away from activities such as basic information provision, where the evidence
for effectiveness is weak. Additionally, there have been increasing reports of successful
transfers of positively evaluated North American and European school based prevention
programmes (e.g. the Good Behaviour Game, EUDAP (www.eudap.net - implementing
the Unplugged programme), the Örebro programme and Preventure (see below) into
and within European regions.
Selective prevention intervenes with specific groups, families or communities which,
mostly due to their scarce social ties and resources, may be more likely to develop drug
use or progress into dependency. Often this higher vulnerability to problem drug use
stems from social exclusion, lack of opportunities and less nurturing family or community environments. Accordingly, European countries most frequently report about
vulnerable groups being young (drug law) offenders, youth in deprived neighbourhood,
homeless youth, some ethnic minorities and immigrant groups, school drop-outs, students, who are failing academically and vulnerable families. These vulnerable groups are
mostly identified using social, demographic or environmental risk factors known to be
associated with substance use disorder (SUD), and targeted subgroups may be defined
by family status or place of residence such as deprived neighbourhoods or those with
high drug use or trafficking.
Effective components of selective interventions include: changing access within the en151
vironment, promoting the development of personal and social skills, promoting positive
relations in families, addressing social influences, providing social support and helping
participants develop goals and alternatives, developing positive schools and enhancing
motivation to avoid substance use (36). Interventions, which are not restricted to addressing drug use alone, adapt to young people’s experiences and avoid rigid abstinence-oriented messages, have proven to be more effective. They rather address relevant
social needs that are connected to drug use than simply drug use behaviour (37). It
is also important to deliver the effective components in appropriate ways, given that
vulnerable groups are not so easily ‘available’ as pupils in schools and do typically not
approach public services.
In summary, prevention targeting vulnerable people may moderate the effect of an early
developmental disadvantage, its translation into social marginalisation and progression
into substance abuse. Several research studies have shown that interventions delivered
during the early school years, aimed to improve educational environments and reduce
social exclusion, also have a moderating effect on later substance use (38), despite not
being drug specific in the sense that they would specifically target youth who experiments with drugs.
Outcomes of the prevention programmes described here can also be beneficial in behavioural domains beyond substance use, such as prevention of violence, delinquency,
academic failure and teenage pregnancies or unprotected sex. Substance use prevention
professionals are often unaware that smoking, drinking, safe sex and healthy nutrition
among adolescents share common determinants. Recent empirical studies and reviews
identified as common factors for all of them the beliefs about immediate gratification
and social advantages, peer norms, peer and parental modelling and refusal self-efficacy
(39).
Prevention of different problem behaviours belong to segregated political portfolios in
most countries, and therefore a cohesive, coherent and efficient approach to adolescent
vulnerability in general is often lacking. Besides, many interventions in this field continue to be based on information provision, awareness-raising and counselling; approaches with limited evidence of effectiveness.
Two important target groups for selective prevention in Europe are school students with
academic and social problems and young offenders. Expert assessments from European
countries suggested an increase of interventions for both these groups between 2007 and
2010, although no further changes were observed in 2013.
Specifically for young offenders, the majority of countries have reported the introduction of alternative measures to penal sanctions. One programme of note in this area is
FreD, a set of manualised interventions over several weeks, which has now been adapted
and implemented in 15 EU Member States. Evaluations of this programme have shown
152
a fall in repeat offending rates.
While both professionals and policy makers in Europe have easily adopted the concept
of selective prevention, several researchers (40, 41) have however alerted for potentials
of harm (iatrogenic effects) when prevention professionals single out and group together
vulnerable young people in selective interventions. Problem behaviour may get worse after some of these interventions as members of this selective group model to each other’s
problem behaviour (‘deviance modelling’). In this way they may corroborate to each other that their deviant behaviour is ‘normal’ while the surrounding social environment is
not (‘norm narrowing’). Such iatrogenic effects are not to expect in universal prevention,
where – on the contrary – some programme evaluations in school and family settings
(42) found that the more vulnerable subgroups within the universal target population
benefited relatively more from the intervention, possibly because they adjusted their
behaviour to that of the ‘conventional’ majority.
Indicated prevention aims to identify individuals with behavioural or psychological
problems that may be predictive for developing problem substance use later in life, and
to target them individually with special interventions. Identifiers for increased individual risk can be dissocial behaviour and early aggression, and alienation from parents,
school and peer groups. Vulnerable individuals are screened and need have to be defined
on the basis of ‘properly diagnosed’ risk conditions (Attention Deficit Disorder, Conduct
Disorder, etc.). The aim of indicated prevention is not necessarily to prevent the use of
substances but to prevent or at least delay development of a dependence, to diminish the
frequency and to prevent more risky patterns of substance use (e.g. moderate instead of
binge-drinking).
In the EU, the term ‘early intervention’ has been coined for those specific forms of indicated prevention, which consider exclusively the level of drug use as predictor for developing SUD and aim to intervene early within a drug use career. Even if somehow
established now in European policy documents for this purpose, the original and correct
meaning of the term in the scientific literature refers to intervening early in lifetime (i.e.
first childhood) to prevent a range of behavioural problems in disadvantaged children
(43). Most of the interventions called ‘early intervention’ could better be described as
Brief Interventions (BI), sometimes including elements of motivational interviewing
(MI).
There are no systematic reviews or meta-analyses assessing the effectiveness of interventions that target individuals with behavioural or psychological problems – independent
from any substance use. Nevertheless, the few available single intervention studies in
Europe tend to be better designed and with stronger outcomes than those in the selective
prevention field.
For example the indicated school-based programme Preventure targets only adolescents
153
(ages 13-14) with specific personality risk factors for early-onset substance use disorder
and other risky behaviours, in only two sessions. Even when implemented by non-specialists, participants showed a lower likelihood of later drinking or less steep increases in
consumption and binge drinking. Effects beyond substance use included reduced scores
in depression, panic attacks, truancy and shoplifting (44). For young alcohol drinkers at
baseline, the findings suggest that only from four to six young people need to be exposed
to the intervention in order to prevent one from later heavy drinking. This number-needed-to-treat (NNT) is one of the most favourable found until now in prevention interventions. Similar results were found for Coping Power, a programme targeting young
people aged 8–13 with disruptive behaviours in the Netherlands which showed at follow-up better results for smoking and cannabis use compared to treatment as usual (45).
Prevention in Europe has developed and made some progress in recent years, but the
situation is still far from perfect. Too much prevention in Europe continues to appeal
to cognitive processes only, namely information provision. And too often interventions
only target individual behaviour, ignoring the fact that it is socially embedded.
154
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Marilyn Clark*
Department of Psychology, University of Malta
MaryAnne Bonavia
ABSTRACT
Adopting a career approach to substance use, this paper seeks primarily to explore the career path of recreational marijuana users
in Malta who are in the period of emerging adulthood. It also seeks to explore their understandings of what constitutes recreational
drug use and the representations of their own use of marijuana. The method adopted is a sequential transformative strategy (Creswell,
2003) and is primarily constructivist although some quantitative work is engaged into recruit a number of participants for in-depth
interviewing. Utilizing a screened sample of Maltese emerging adults aged 18 to 30 who self-identified as recreational marijuana users,
the qualitative research maps the contingencies associated with the marijuana using career path and documents how participants’ use
initiated, escalated, de-escalated, desisted for some time and then started again.
The study points to the non-linearity of the marijuana using career and the changing motivational patterns operating in the various
stages. The findings also highlight how the sample defined their use as ‘unproblematic’ and ‘controlled’ and therefore not impinging
on their adaptive functioning. Continued control of the behavior was stressed. The use was, however, identified as having an important
value in their life, indicating attachment to the behavior that might potentially turn into excessive use. The paper concludes with some
implications for further research and policy that emerge from the findings.
Keywords: Recreational Marijuana Use, Career Path, Emerging Adults, Contingencies
* Marilyn Clark is an associate professor at the Department of Psychology at the University of Malta. She holds a masters’ in social
psychology from the University of Liverpool and a PhD in sociological studies from the University of Sheffield.
Her main research interests are addictive careers, criminal careers, stigma, youth and emerging adulthood. She held the post of chairperson of the National Commission on the Abuse of Alcohol, Drugs and other Dependencies (NCADAD) within the Ministry responsible
for social policy from 2010 till 2013.
She is currently a member of the Centre for Freedom from Addiction within the President’s Foundation for the Wellbeing of Society. She
has published extensively in a number of peer reviewed journals and books.
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EXPLORING THE CAREER PATH OF RECREATIONAL MARIJUANA USERS IN MALTA: A STUDY AMONG EMERGING ADULTS
Exploring the Career Path of Recreational
Marijuana Users:
A Study among Emerging Adults in Malta
Introduction
This paper explores the career path of emerging young adult marijuana users between the ages of 18 and 30, residing in Malta, who self-identified as recreational users
and who have undergone a standardised screener which indicated that their use is non
problematic. It has a number of objectives: to identify the contingencies associated with
the career path of recreational marijuana use through a documentation of the lived experiences of recreational users; to document the practice of marijuana use among this
group; and to understand their representations of their marijuana use. By documenting
the experiences of self-identified recreational marijuana users, the paper contributes
further to the debate of whether controlled marijuana use may be conceptualized as
recreational. There is a growing research tradition focusing on groups of recreational
drug users (e.g. 1, 2, 3). This approach is framed within youth or cultural studies and the
research methods have typically been qualitative (4). The use of the term ‘recreational’
however is not without its problems and has not gone uncontested (5). Research into
recreational drug use analyses drug consumption patterns that do not cause severe harm
to drug users, that is restricted to the leisure sphere and that does not interfere with the
adaptive functioning of the drug user. Research reports on recreational drug use have
demonstrated that illegal drug use does not necessarily lead to addiction but can also be
a controlled activity whilst still posing a number of risks (6, 7, 8).
The approach adopted in this research is a sequential transformative strategy and is primarily qualitative although some quantitative work is engaged in to recruit a number
of participants for in-depth interviewing. The research process takes place in two stages
whereby a sample of self-identified ‘recreational’ users recruited online is screened for
exclusion from problematic use using a standardised tool (CUDIT-R) followed by in
depth interviews to document the lived experiences of nine participants. The goal is to
contribute to the changing shape of the addiction field.
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The drug using career
It has been proposed by the author in another paper, and by other authors (9, 10) that
utilising a career approach where behaviour is located as occurring along points on a
continuum and is influenced by contingencies, is a useful way of conceptualising drug
using behaviour. This approach has been successfully applied to criminality and the model lends itself to providing a framework for studying drug using behaviour in the lifespan. A drug using career has a beginning and an end and a career length in between.
During their career, drug users engage in drug taking at differing rates. This concept of
career emphasizes the subjective point of view of actors on the path they are taking in
life (11, 12, 13). The actor, aware of the implications of past events for his/her biography,
interprets future contingencies as a continuation of that story. The career therefore arises
from the person’s awareness of a past sequence of events associated with a particular
identity, deemed significant by oneself and others and seen to extend into the future.
It may be conceptualized as a corridor with various doors running along its sides (14).
The drug user may enter the drug using career or exit back to being ‘straight’ at any
of the available doors. The career approach emphasises agency and choice suggesting
that the actor is not constrained to remain in the corridor. This contrasts significantly
with the medical model which when applied to drug using behaviour ‘is founded upon
the subordination of personal agency (and thus the possibility of individual control) to
some hypothesised pathological mechanism’ (15: 385). Neuro-adaptation is called upon
to conceptualise a ‘hijacked’ brain leaving the individual with little or no control over the
behaviour. Vrecko (16), writes that “addiction is no longer imagined as a brain disease;
it is a brain disease as a matter of facts”. The idea of addiction as a brain disease is in
strong disagreement with the opinions of social scientists who emphasise the social and
cultural elements of the phenomenon. While biological processes are perforce involved
in drug using behaviour and cannot be ignored, the reductionism of such an approach is
as simplistic as it is appealing. While the medicalization of addiction has allowed a pragmatic, humanitarian approach of demonstrable benefit to individuals and communities
(as with methadone maintenance protocols), the metaphor may have been taken too literally by some. Dunbar et al (17)) contend that drug using behaviours ‘have both social
and organic aetiologies and physiological and cultural sequelae that have multiple triggers and pathways, ranging from the cultural to organic, but are probably informed by a
combination that we could usefully consider a ‘cultural biology’’. Peele (18) stresses that
while the addictive experience ‘stems from a pharmacological and physiological source”,
it “takes its ultimate form from cultural and individual constructions of experience.”
(18:97). An explanatory model that describes well the reality of drug using behaviour
must be able to account for non-biological factors namely, cultural, social, situational,
ritualistic, developmental and cognitive factors. The career approach is best able to do
this. Because humans are self-reflexive, they exert control over the direction their lives
take (19). Career contingencies set the stage for a variety of steps where the individual
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may become more involved and committed to the behaviour.
The concept of career emphasises both subjective (e.g. identity change, subjective feelings of loss of control) and objective (e.g. financial and legal difficulties) contingencies
encountered in the career path (20). In this regard Peele, (21) notes that “while in some
cases addiction achieves a devastating pathological extremity, it actually represents a
continuum of feeling and behaviour more than it does a distinct disease state” (21:2,).
On the one end of the continuum is behaviour involving no attachments, while on the
other end is behaviour involving extreme attachment. In this paper, the subjective point
of view of the actor in relation to the path one’s life is taking is given importance. Studies
of careers explore why people start engaging in a certain behaviour, why that behaviour
becomes more salient and frequent (escalation), how that behaviour is maintained and
finally why individuals desist. The concept allows for controlled involvement and unassisted change, phenomena for which there is plentiful evidence: e.g. Armor et al (22),
for controlled drinking, Blaszczynski et al (23) for controlled gambling, Siegal (24) for
controlled cocaine use and Biernacki (25) for unassisted change from heroin addiction.
Contingencies operate at different stages and are interpreted by the self in light of his/
her psychological state, biological condition and social/cultural context. It is therefore
being proposed that use may remain recreational and the individual may fail to progress
along the continuum. While many individuals experiment with drugs, Orford (9:201)
has shown how ‘the majority of people are found to conform to a relatively moderate
norm with smaller and smaller proportions of people displaying consumption in excess
of this norm to a greater and greater degree’.
‘Recreational’ use
Although the term ‘recreational’ in relation to substance use has been contested authors
such as Parker (26), suggest that as long as a person has control over their drug use this
is qualified as recreational. He writes:
We are concerned specifically with ‘recreational’ drug use in this debate; that is the occasional use of certain substances in certain settings and in a controlled way. The issue
is whether the ‘sensible’ use of cannabis and more equivocally amphetamines, LSD, ecstasy and cocaine has become sufficiently widespread and socially accommodated as to
ensure that, first within their own social worlds and then in the wider society, we see
‘recreational’ drug users and their drug use being acknowledged as unremarkable and
within normative boundaries (26: 206).
MacKenzie et al. (27:25) talk about recreational use of illegal drugs as being ‘pleasurable
and predictable without the severe health, familial and social consequences associated
with drugs’. An EMCDDA (28) publication considers ‘young people’s recreational drug
use to be drug use that occurs for pleasure, typically with friends, in either formal rec162
reational settings, such as nightclubs, and/or informal settings, such as on the streets
and in the home. According to Siegel (29), recreational drug use refers to an individual’s
experience of using drugs in order to create a recreational experience, with the individual having full control over the usage. Parker et al’s (30) normalisation hypothesis
is a framework that analyses the increased usage of illicit drugs being considered as
normal during recreational activities that young people engage in. This theory refers
to the positive attitude young people take towards drug use and the availability of such
illicit drugs. Parker (31) suggests that when illicit drugs become more available their
consumption will be considered as normative within the young people’s culture. Recent
studies see recreational drug users as neither part of a subcultural network nor deviant
and marginalised (30, 32, 33, 34). On the contrary, these scholars argue that recreational
drug users today are often successful in their educational and professional lives and that
their experimentation with drugs may be understood as a way of counterbalancing the
high demands on young people in post-modern society. In this perspective, drug use is
not a deviant activity but part of the work hard/play hard lifestyle of today’s youth (33).
Parker (26) however, recognises that there could also be a slippage from recreational use
into problematic use where users are no longer fully in control. This is likely to occur
when young people continue to experiment with different illicit drugs which are available to them and continue to increase the social networks where drugs are available. Parker
(26) suggests that it is only the minority of recreational young users that transition into
problematic use, and the reason for this could be due to the lack of knowledge and understanding of the risks of drug taking and addiction identifying important educational
implications for preventing movement along the career path.
According to Quintero (35) recreational drug use can also be described as socio-recreational drug use, referring to the intentional use of illicit drugs to get high, have fun and socialize with peers. In his study, recreational users reported using illicit and pharmaceutical drugs in order to feel good, to enjoy themselves as well as to get high, suggesting that
recreational users consume drugs for personal pleasure, to experiment with something
different or to enhance particular experiences. Ungerliedel and Beigel (10) have termed
this situational drug use. Duff et al (36) found that recreational users used illicit drugs
in order to get high and have a good time when in clubs and parties, to socialise with
peers and feel part of the peer group, and to experiment and experience something new.
According to South (37) recreational users balance their drug use with the management
of everyday life such as work, family, friendships, etc. This is in line with the argument
(33, 34) that recreational drug users do not have any problems within their educational
and professional life, and that these young people engage in recreational drug use as time
out from the high demands of postmodern society. Pedersen and Skrondal (38) however
view recreational users as an ‘at risk’ population since recreational use can transition to
problem use. In Kjellgren, and Soussan’s study (39) users defined their drug intake as
recreational expressing feelings of wellbeing, feeling good and happiness. However, they
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add that once that feel good feeling is gone, participants expressed a very unpleasant
experience and feeling of confusion.
Johnson’s study in 2008 suggests that marijuana may be used recreationally. The sample,
who were either in employment or have finished high school, expressed that they were in
control of their marijuana usage since they would not use marijuana when they needed
to concentrate or when it was not appropriate to be stoned. Some of the respondents
reported that when they engage in recreational marijuana use they were able to perform
better in arts, enjoy the great outdoors and enjoy themselves in activities they were engaging in. The participants in this study expressed how they were capable of continuing to live a conventional life with commitments towards family, friends, employment,
social activities, etc. A study by Zimmermann and Weider (40) found that recreational
marijuana users made choices with regards to when and how much they should smoke,
made conscious decisions about when and when not to use and had a subjective sense
of control. They also found that recreational marijuana users only used marijuana on
specific occasions, such as during parties, whilst at concerts, whilst having sex and whilst
engaging themselves in leisure activities. Pearson (41) notes that the area of recreational
marijuana use is still very much under researched. Further research in recreational use
is needed in order to enhance the knowledge on what recreational marijuana use means
and how this differs from problematic use. This study contributes to this end.
Methodology
The approach adopted in this study is a ‘sequential transformative strategy’ (42). This
strategy has two distinct data collection phases, one following the other. In the present
research the quantitative method was used first and priority is given to the qualitative
phase. The quantitative work served only to establish a sample. Data was obtained via
two routes: first a screener (CUDIT-R) that would identify marijuana users was distributed online using convenience sampling. Respondents who scored such as to classify
them as problem users were excluded from the second tier of the study; second, 9 self-identified recreational users who did not fit into the category of problem use as identified
by the screener and who volunteered for interviewing, were contacted for an in-depth
interview. This choice is informed by the principles of theoretical sampling. The screening device is the Cannabis Use Disorder Identification Test – Revised (CUDIT-R) created by Adamson et al (43). The 8-item CUDIT-R has improved performance over the
original scale and appears well suited to the task of screening for problematic cannabis
use. CUDIT-R is able to effectively distinguish between different levels of cannabis use
and identify cannabis use disorders. CUDIT-R questions were assigned a score that was
added up to classify respondents into four categories on the continuum of marijuana
usage (43). The screener results show that 30.3% of participants were abstainers, 28.8%
were rare or social recreational users, 9.1% were heavy social recreational users whilst
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31.8% were problematic users. This latter category was excluded from the second tier
of the study. Cut-off values for possible presence of a cannabis use disorder is 13 for the
CUDIT-R. For the purpose of the present study anyone scoring higher than 13 were not
allowed to participate in the qualitative interviewing. The screener was posted on the
social network, face book, on the page of “Legalize it Malta”, where participants were able
to view and participate anonymously in the study through the use of a SurveyMonkey
questionnaire. A total of one hundred and twenty seven valid responses were collected from individuals who took the CUDIT-R test, 89.6% of participants were Maltese,
and 3.2% were British whilst 7.2% were of other nationalities. The highest proportion of
CUDIT-R participants were males (55.2%), whilst (44.8%) were females. The majority
of participants (28%) were aged between twenty one and twenty five years, followed by
21.6% which were aged between twenty six and thirty and thirty five and older. Nine
self-identifying recreational marijuana users between the age of 18 and 30 were selected for in-depth interviewing. The interview guide was semi structured and included
three sections. The first section explored the young person’s definitions of recreational
marijuana use and their representations of their own use. The second part of the interview tool explored the drug using career and addressed onset, escalation, commitment
and desistance. The last section addressed motivations for use. The questions to be used
during the interview were first translated into Maltese and back translated so that bilingual comprehension could be established. The order in which questions were asked
was not fixed, but followed the pace of the interviewee and the subject matter that was
being discussed at that time. The study attempted to capture participants’ viewpoints.
The full range of the phenomena was explored through the social interactive process of
the interview and reported explicitly in the attempt to establish rigor (44). A pilot study
was conducted to gain experience conducting the interview before going into the field
and to ensure the interview questions were understandable. The interviews were then
conducted and all carried out within three weeks, at a location chosen by the participants. The preliminary verbatim transcription of the text was engaged in. The text was
then analysed using techniques from the grounded theory approach. Thus open coding
identified properties and dimensions of categories and sub-categories in the data. The
text was closely examined and data was broken down and analysed by grouping concepts, explaining properties and locating dimensions of the property. This was followed by
axial coding, where categories were related to subcategories according to properties and
dimensions elicited from the data. Major categories were than integrated and refined through selective coding evolving into an overarching theoretical scheme that was linked
to the conceptual framework.
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Data Analysis
The Drug Using Career:
The drug using career looks into drug using trajectories marked by onset, escalation,
maintenance and even desistance. It is conceptualised as a process that involves socialisation whereby people learn to use drugs and recognise their effects, may involve an
increase in drug taking with drug use becoming a feature of self-identification. This
section of the analysis will be exploring participants’ experience in their marijuana use
progression. Goldberg (45) suggests that a career is a process where an individual starts,
continues, shows commitment and eventually exits from a specific activity. However,
Goldberg (45) also suggests that individuals do not always follow this pattern, meaning
that individuals may exit the career path and then go back to any stage of the career, as
well as remain in any one of the stages. Since all the participants are current marijuana
users none are currently in the stage of desistance but may have experienced this at some
stage in their career progression. The non-linearity of the career is emphasised.
Onset:
Reasons for initial experimentation with marijuana are likely to be different from those
for continued and repeated use. An emergent theme that surrounds the onset of the
marijuana using career is peer influence and socialisation. Participants suggest that they
started to use drugs because of curiosity and friendship patterns which provided a context regulated by norms that allowed it: ‘we were at a house party, some of my friends
were in a garage smoking weed and I joined them…. I have heard them talking about it
and this seemed to be my opportunity to try it…. From then onwards we used to meet up
and smoke a joint’, Interviewee 4, ‘I was with my friends in a car and we smoked in the car
and we had great fun’, Interviewee 6. Relationships with drug using peers facilitate drug
availability blurring the line between users and dealers (46, 47). Peers provided models
of use, access to drugs and motivated and supported initial use. Another emergent theme
that was highlighted by participants was the media and the music industry, ‘I was a fan of
Nirvana and everyone seemed to take drugs, so for me it looked cool to start taking drugs
in order to be like them, I also used to watch a lot of movies and people were taking drugs
too so I taught it’s something glorious to do’, Interviewee 1. Pederson (48) suggests that the
music industry tends to influence young people to engage in recreational marijuana use,
pointing to a cultural accommodation of the illicit.
Curiosity emerged as a major factor ‘in the beginning it was more curiosity, it was trying
new things you know and experience different things like alcohol, and marijuana was one
of them’, Interviewee 5, ‘at the beginning I didn’t know what it does, I didn’t even know how
to smoke but I was very curious about it and wanted to experiment with it’, Interviewee
7. Learning to experience the effects of the drug and regulating the amount used in any
one episode was an important contingency at this stage (49). One participant reports
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‘sometimes someone would smoke a bit extra and get a ‘whitey’ get dizzy, we call it that,
but we never had bad energy or anything like that. And if I smoked a bit extra well that was
my fault till I learnt how much I should use but I never had any bad experiences, maybe
you feel a bit knocked out have a good sleep and wake up relaxed.’
In Parker et al study (26) peer pressure as a significant factor was almost unanimously
rejected by their interviewees. This was also the case in this study: ‘I don’t think there was
peer pressure to use it, maybe hearing it from friends, but not peer pressure it was more out
of my curiosity to use it’, Interviewee 5. Peer pressure however remains one of the main
lay interpretations of the motivation for initial use and is often encapsulated in government policy that informs prevention interventions with young people.
Therefore one can conclude that peer contacts facilitating access to the substance, curiosity, and learning the effects of the drug and how to use it are key contingencies for the
onset of recreational marijuana use.
Escalation:
While the onset of the career may be characterised by the learning of the mood swing
(50), seeking the mood swing results in increased frequency of drug taking behaviour.
‘It’s like from when I started I increased my use till I started to smoke every day for a lengthy
period of time and then there was I time when I stopped completely and then I started again
to smoke daily but lately I spent five months not smoking’. This quote is clearly indicative
of the nonlinearity of the drug using career and that escalation does not necessarily lead
to commitment to the behaviour but can revert back to abstinence. Thornberry (51)
suggests that many young people increase their drug use in their late teens; in fact he
identifies this period as the peak of the recreational drug using career, where escalation
normally occurs. An emergent theme from the data with regards to escalation was the
positive experiences, the lack of negative experiences and the associated rituals, ‘I had
turned 17 and it had become like a daily thing, in the beginning it was like, holy shit let’s
get some weed, wow and this kept on going for quite a few years, …it was like a ritualistic thing’, Interviewee 1, ‘The increase occurred because maybe because I was enjoying
more the experience and was able to understand the pleasure and the highs that weed was
giving me and most of all even if you like… use marijuana a lot there is no hangover or
any physical effects and that was cool’, Interviewee 5. Carnwath and Smith (52) suggest
that as the individuals learn what the positive effects of marijuana are, they are likely to
increase their consumption, and start engaging in ritualistic behaviours with their peers
while still being able to continue living a conventional life. ‘The increase occurred because maybe you were enjoying the experience so you want a bit more of it, it’s like a phase,
but then it’s like you have too much of it and it sorts of fades out’. Another emergent theme from the data shows that as the young people gained more independence by either
moving away from home or by engaging in employment, their consumption increased.
According to Arnett (53), in the past half century what most people experience during
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the years from age 18 to 29 has changed dramatically in industrialized societies. Instead
of entering marriage and parenthood in their early twenties, most people now postpone
these transitions until at least their late twenties, and spend their late teens through their
mid-twenties in self-focused exploration. Emerging adulthood presents opportunities
for continued exploration and increased independence. According to Arnett (53) it is
also the most self-focused stage of life. I also got myself a job and that allowed me to have
my own money… so there I could also buy my own, I sort of had the independence and
the use of marijuana increased drastically’, Interviewee 7, ‘I left home and went to live on
campus eemmm and my marijuana use increased, I felt free’, Interviewee 4. ‘I was able to
purchase my own and share with my friends, obviously creating a stronger bond with my
friends at the time’, Interviewee 9. The move to purchasing one’s own ‘stash’ resulted in
an escalation of use because one no longer needed to rely on peers for supply. According
to Elders (54), as young people grow older they will start gaining independence from
their families as well as engage in jobs and hence gain financial independence. Elders
(54) adds that independence can be seen as a driving force for young people to increase
their drug consumption. The period of emerging adulthood presents the young person
simultaneously with increased independence from the clutches of watchful guardians
and free time since they still have not taken on the career and family commitments of
adulthood. Age and the cultural conditions of emerging adulthood in late modernity in
the western world therefore appear to be an important contingency for escalation. ‘yes
my consumption increased drastically, I used to have a lot of free time, so I had more time
to spend with my friends and smoke’, Interviewee 7, ‘The increase in my consumption also
occurred because I had more money available and more free time therefore I was able to
smoke as much as I liked’, Interviewee 9. Hathaway (55) suggests that when young people
start to gain independence, mature, grow older and engage in employment or higher
education, they will have more freedom and free time and their marijuana use tends to
escalate. Independence from parents during emerging adulthood is an important motivator for escalating use I had gone away for school and being on campus I ended up
smoking more, Interviewee 4. Arnett highlights that emerging adulthood, with the freedom it brings often results in experimenting with alternative lifestyles and may present
some risks. Lack of life structure has been identified as an important contingency for
progression from controlled to excessive use (56). Conventional commitments serve to
steer the user away from excessive use. This is clearly illustrated in the following quotation: ‘yes many factors right for example not having anything to do and I couldn’t care less
cause I would tell myself that I have nothing better to do…….. but then you need to come
to the understanding that if there is stuff to focus on , it comes natural to reduce or to stop,
you learn to control, but there were times when I did not control’ (interview 7).
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Commitment to controlled use:
Emergent themes from the data show that participants who are in the maintenance stage
of the drug using career are committed towards their consumption; however their use
remains controlled, ‘I enjoy it really, I enjoy it with friends, have a good laugh, it has a
lot of positives and I have learned to use it regularly…. to experience these but obviously
my use has decreased, now I have control over it, however I feel somewhat committed to
marijuana’, Interviewee 5, ‘I use it to relax, when I feel like smoking, but this is not a daily
thing as it used to be, I now make careful decisions when to use’, Interviewee 4. And ‘this
year was a year of self-discovery and questioning a lot, I do not want to be high all the time,
I started tackling my issues more ethically then before, and actually my consumption is now
more controlled………, however I still feel that marijuana is an important facet in my life’,
Interviewee 1. ‘ I always ensure to have my own supply, and always will cause marijuana
is the best thing that ever happened to me, however I have learnt to limit the use, I only
use it when I am creating music or drawing and at times for relaxation purposes too, but
now I know my limits, and never over indulge myself…. I have learnt when to use it and
when not but I have to tell you again, marijuana is important to me and I am all the time
discovering about the different benefits of using marijuana even for medical reasons, but as
I said before the use is not like it used to be, it has been reduced a lot’, Interviewee 6. This
suggests that even though participants ensure that they have their own supply and show
a commitment towards their marijuana use, they have learned to control their use and
ensure that they do not go over their limits. Carnwath and Smith (52), suggest that when
individuals start to deescalate from their drug use, they normally engage themselves in
the maintenance stage, where they start to use drugs as they feel like but this is more
controlled and many individuals remain in this stage for a long period of time. Hathaway
(55) suggests that as individuals grow older they may become more committed to other
things in their life, and their marijuana use, even though it remains important in their
lives, will start to de-escalate.
Another emergent theme from this study suggests that marijuana can enhance the individual’s activities, ‘I realize that when I smoke it helps me to concentrate on what I am
doing more for example if its drawing or making a piece of art I can really focus on what I
am doing very much’, Interviewee 5. Osborne and Fogel (57) suggest that their participants were able to concentrate more on what they were doing and were able to enjoy any
activities they engaged in.
Therefore one can conclude that marijuana has a significant value in the participants’
lives since it provides them with a sense of wellbeing and a relaxed feeling, and enhances
creativity. Gifford and Humphreys (58) warn of the possibility of slipping into problematic use when individuals start to rely on drugs in order to feel good. According to
Brown (59) individuals learn to engage in certain behaviours in order to feel good, change their mood as well as enhance their emotional state. He adds that when this occurs
169
individuals start to experience a need for the behaviour and that it becomes the main
source of managing subjective states.
Desistance:
Desistance was temporary and occurred for a number of reasons. A commonly cited
contingency for desistance is financial restriction: ‘in fact I did stop using, totally stopped using because I was saving and did not want to spend money on it’, Interviewee 4, ‘I
do go through phases where I completely stop due to financial matters, heqq my priorities
have to come before cannabis, so yes I do stop at times for financial matters’, Interviewee 7.
When their finances improve, they are more likely to reengage within the career.
Another emergent theme with regards to desistance shows that participants in fact had
desisted from using marijuana due to the lack of availability, ‘I did stop using because I
was away from home, for a couple of years and it was not available’, Interviewee 3, and ‘I
was in Iceland for 2 months and it was not available, so I had to stop smoking, anyways it’s
not like heroin you can do without no problem, to tell you the truth I didn’t even have any
cravings for it when I stopped’, Interviewee 1. Hathaway (55) suggests that contingencies
for desistance could include family commitments, lack of affordability, job satisfaction
or lack of availability.
The present study indicates that temporary desistance is mainly engaged in in order to
gain control over use, ‘I noticed that I was smoking a lot and I wanted to regain control
over it, so I quit smoking marijuana for several months and I realized that I was able to
control my use, and when I feel like it’s going to start taking over I quit again in order to
be able to have full control over my marijuana use and keep it recreational’, interviewee
5, and ‘it’s just like anything, like drinking alcohol, you come to a point where you have to
quit in order to regain control, and I do quit to keep in control of it, because as I said earlier
marijuana is not addictive…. If it was I would not be able to just quit when I decide that
I need to have full control over my use and keep my use only recreational’, Interviewee 6.
One can conclude that according to participants, they had desisted from their drug using
career mainly due to financial reasons, lack of availability and mostly in order to regain
control over use. However, one is to note that even though participants had experienced
desistance at a certain point in their life, they are currently still engaged in the drug using
career, and therefore they have moved back and forth within their career.
170
Participants’ perceptions of Recreational vs problem use:
The issue of control was central to the participants’ understanding of what constitutes
recreational use. The participants identified recreational use as meaning that the individual has control over the consumption of marijuana,
‘Recreational use would be anything you do not do for a need but you need to have control
over it, you only use it casually, emm when you want, there is no need or longing for it’
Interviewee 1.
Related to the construct of control is the understanding that if use is to be defined as
recreational then it is used primarily to give pleasure. ‘Just doing it for the pleasure of it’,
Interviewee 8. Recreational use was also seen as use that does not impact one’s adaptive
functioning adversely. ‘if it remains, recreational, as long as it does not interfere with your
normal life’. Interviewee 1
A rather eloquent interviewee identifies these three issues that are clearly related:
In my opinion, recreational use can be defined as use for an enhanced experience or an
enjoyable time without dependency on the substance. Recreational use would be less often
and also without significantly affecting day to day activities. Interviewee 9
The same interviewee also highlights that recreational use implies that the individual
is able to engage in alternative courses of action given the choice and is therefore not
strongly committed to the behaviour.
‘The difference between recreational use and other types of use is the fact that some people
rely on cannabis to have a good time. Although it can give off a good experience, it is just
one of a variety of options in terms of having a good time such as drinking at clubs, leisure
activities and so forth. However if the drug is relied on in terms of having a better time,
then this is the difference……. Although I value it a lot and wish for it to be much more
widely available, I would not say it is a big or significant part of my life. Just an occasional
experience’ Interviewee 9
Frequency of use was also seen to be an important factor in distinguishing between use
that is problematic and use that is recreational. An emergent theme from the data suggests that participants view problem use as messing up with the daily routine and that
conventional lifestyles are interrupted, ‘messing up with your daily life, daily routine and
only focus on pleasure experiences’, Interviewee 1 and ‘daily use can have an impact on
your life’, Interviewee 9
Participants saw the development of a ‘want’ to a ‘need’ as defining the transition to
problem use. This need was identified as both physical and psychological but the physical aspect was mostly emphasised. ‘having a physical addiction to a substance and you
cannot control it’, Interviewee 5, ‘your body needs to do it’, Interviewee 4 and ‘you can
become dependent on them and experience withdrawal symptoms’, Interviewee 6.
171
Participants’ representations of their own use:
Participants classify their marijuana use as recreational since they claim to have full
control over it ‘recreational because I can stop whenever I want to, and even when I did
stop I didn’t have any cravings ….’ Johnson (60) suggests that recreational marijuana users
know when it is appropriate to use, have clear norms surrounding its use and have full
control over their use. Participants reported making use of marijuana as a form of relaxation. ‘Mostly when I am at home, emm sometimes when I’ve had a bit of stress, I do
use it to calm me down, I guess it’s something that relaxes me’, Interviewee 4. And ‘after a
party to relax or with friends or a nice day’, Interviewee 1. ‘Generally winding down after
a party, it’s generally a few puffs and then it’s great so for relaxation purposes’, Interviewee
3. An emergent theme highlights how recreational users see their use as an enhancement
of their everyday activities ‘Makes me enjoy being outside even more…. A simple walk isn’t
just a walk but I will be able to enjoy the great outdoors even more and appreciate nature
in a superb manner’, Interviewee 8. ‘In the evenings at times I say to myself, let’s roll a joint
and enjoy, however I make sure that I do not over do this since I want to keep my use as
recreational’, Interviewee 7. Another emergent theme that emerged from the interviews
is that marijuana is used as a means to enhance creativity, ‘my context is that I notice that
it makes me more creative and helps me to have a vision for my art and my music’ and, ‘it
opens up a part of me, which I didn’t know it was there it makes me really creative, it helps
me to put my vision of music or art into place’, Interviewee 6. ‘I use when I am at home
and either need to relax or need to concentrate and focus on a drawing or painting I am
working on, it seems to make me more relaxed and more ideas come to my mind’, Interviewee 5, ‘marijuana helps me to perform better with my band’, Interviewee 7. Therefore
this suggests that participants like to engage in marijuana use when they need to perform arts or focus on creativity. This is in line with Osborne and Fogel (57) who suggest
that individuals who engage in recreational marijuana use do so in order to enhance the
artistic and creative ideas.
172
Discussion
This paper contributes to the continued debate on recreational drug use and drug using
careers. The recreational drug users quoted in this paper are all characterised by a specific self-representation: they define themselves as recreational drug users, describing
their drug use as being occasional and controlled. This paper provides further evidence
for the viability of the concept of career when exploring drug using behaviour. The interviewees highlighted how both subjective (e.g. feelings of loss of control) and objective
(e.g. financial difficulties) contingencies were encountered in the career path. Tentative
flirtations with marijuana were initially experienced by the participants in the stage of
onset and escalated into more frequent, less restrained use as the career progressed into
the escalation stage. This was recognised by the participants as excessive and they choose
to deist only to take on the behaviour again in a more controlled manner. The non-linearity of the carer is emphasised. This sheds light on a number of important issues.
The first concerns the continued theoretical elaboration of what constitutes recreational
use. The definition provided by Parker (26:206) : ‘occasional use of certain substances
in certain settings and in a controlled way’ is inadequately operationalised. This paper
identifies other phenomena that may be integrated in this definition making it more
conceptually dense and useful for further research and theory development in the area.
It is proposed that apart from the factors of frequency of use and control other elements
are introduced into the definition of recreational use. These emerge from the current
research and include:
•
Clear norms surrounding the consumption of the behaviour and the user’s ability
to adhere to those norms. An example of a norm would be the dismissal of drug
use in certain contexts e.g. at work, or at certain times of the week and day e.g.
Monday morning. Recreational users therefore describe their use as ‘appropriate’
to the context. While this is similar to Parker’s notion of settings the inclusion of
the consideration of norms in settings is of added value.
•
Changes in risk assessment e.g. drugged driving.
•
Lack of centrality in the person’s life. The behaviour does not take precedence
over other activities and a refutation of alternative courses of action does not
occur ((20).
•
Lack of preoccupation. When a person’s thinking is dominated by the behaviour,
this leaves little energy left to concentrate on other aspects of one’s life which
come to be neglected, resulting in a reduction in adaptive functioning.
•
Continued adaptive functioning: social, occupational and recreational activities
are not reduced or abandoned and the individual does not experiences recurrent
physical, psychological or social problems.
173
•
Lack of difficulty in reducing or giving up the behaviour when the context requires it.
Orford (9) emphasises that criteria are subjectively experienced. This leads to the second
major theoretical issue identified by Shiner and Newborn’s (61) critique of the normalization hypothesis. Could it be that the verbalizations documented by recreational users
with regards to being in control, using occasionally, continuing with everyday activities,
showing lack of preoccupation are simply neutralizations engaged in by drug users to
maintain a positive sense of self in the face of the knowledge that they are engaging in a
behaviour that is frowned upon in society? This is certainly a possibility that must not be
dismissed and that requires further research.
Thirdly, the current research also points towards the importance of developing further
theoretical models on what constitutes a transgression on the limits of recreational and
controlled use. Some progress has been achieved in this regard, for example the work
of Jarvinen and Ravn (4) but further research is solicited. This study indicates the very
nebulous boundaries between recreational and more sustained use. This has important
implications for the prevention of progression to more problematic use, as well as risk
management strategies, i.e., ways in which recreational drug users try to avoid harmful
forms of drug use, loss of control and so on (62, 63). While recreational marijuana users
manage to combine a more or less conventional everyday life with getting high on the
weekend, many escalate their use and develop a drug-focused lifestyle that also often
includes drug-dealing and other illegal activities (37).
Limitations
A number of limitations influence the conclusions that may be drawn from this study.
The most significant of these concern the sample. This was a convenience sample who
self-identified as recreational users. Although there was an equal representation in terms
of gender there was no attempt to diversify in terms of including marginalized or excluded youth in the study. All the young people who participated were social integrated in
their communities. The sample size is also small, not allowing for theoretical saturation.
174
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178
Paul Rompani*
Mentor International, London, UK
L. Edegger
ABSTRACT
During the last 20 years the field of drug prevention has emerged as a credible scientific discipline that has made significant advances.
As a result, practitioners in the field and policy makers have a more complete understanding of the underlying psychosocial risks and
protective factors associated with drug use onset.
More recently, evidence from randomized controlled trials and quasi-experimental studies of theory-based prevention interventions
indicate that a growing number of programmes have demonstrated efficacy in reducing risks and moderating antisocial behaviours of
young people, including drug use and substance abuse.
However, whilst these evidence based outcome evaluated programmes have been implemented in a number of countries it is clear
that in most, if not all countries there is: widespread use of ineffective practices; a lack of awareness of effective practice; limited, or
non-existent, national capacity to develop and implement effective practice and evaluate promising practice developed on the ground.
Furthermore, there are scarce voices arguing for the development, implementation and evaluation of effective prevention practice.
Consequently, governments, NGOs and public health practitioners need to work together within a shared understanding of what we
mean by ‘health’, ‘youth development’ and ‘prevention’ to strengthen the links between science, practice and policy and to develop,
implement and evaluate relevant and appropriate evidence based outcome evaluated prevention strategies. Strategies that are mainstreamed into everyday life that engage and involve families, schools, workplaces, communities and society as a whole.
* Paul Rompani is the Executive Director of Mentor International. Established 20 years ago, in 1994, in collaboration with the WHO at the
UN General Assembly, Mentor International is the leading international youth development NGO working to empower young people and
prevent drug use and substance abuse. It is an international federation with national/regional members in Colombia, Germany, Latvia,
Lebanon, Lithuania, Sweden, the UK and the USA and partners in Estonia and Uganda.
Paul volunteers as Treasurer and Board member of the Vienna NGO Committee on Drugs and represents Mentor International on the
European Commission’s Civil Society Forum on Drugs.
Prior to joining Mentor International, Paul was Chief Executive of international youth development charity Lattitude Global Volunteering, Deputy Chief Executive of the Multiple Sclerosis International Federation and Programme Manager of an international student
exchange programme at the British Council in London.
Paul has an MSc in Voluntary Sector Organisation from the London School of Economics, a Postgraduate Certificate in Charity Management from London South Bank University and a BA in Economics and Social Studies from Royal Holloway, University of London.
Paul lives in Henley on Thames in the UK with his wife and two sons.
179
DRUG PREVENTION ON A GLOBAL LEVEL
Prevention on a Global Level
Introduction
Over the years a number of different perspectives on the prevention (and demand reduction) of drug use and substance abuse have developed, many with valid evidence-based arguments. Debates around harm reduction, decriminalisation and legalisation have
been mostly focused on policy related issues. Whilst some of these perspectives are becoming mainstream, such as the emergence of drug use and substance abuse as a public
health rather than a criminal justice issue, other views, such as those advocating harm
reduction or supporting decriminalisation or legalisation of drugs, are hotly debated.
Prevention remains, for the most part, ‘outside’ of these debates, as there seems to be
consensus that prevention and education are, and will continue to be, relevant irrespective of the position on these other issues. For the purpose of this paper, prevention refers
to the efforts undertaken in stopping the onset of drug abuse among young people (1).
History of prevention
Since prevention measures were first developed the types of intervention approaches
adopted have evolved significantly. The earliest prevention programmes in the 1950s
and 60s concentrated on highlighting the risks of drug use and saying that it was morally
wrong. Prevention initiatives in the 1980s and early 90s strongly focused on scare tactics
and ‘Just say No’ campaigns. The next phase of the prevention effort aimed to provide
unbiased information and education about drug risks. As it became increasingly evident that education alone was not sufficient to change or prevent drug use behaviour
and did not address the contributory factors for drug use a range of new approaches
were suggested as relevant. These included focusing on raising self-esteem, the need to
address peer pressure, the need to build personal and social skills, to focus on attitudes
and values, and to consider other influences that might cause young people to become
involved with drugs.
Scientific Understanding
More recently, the field of drug abuse prevention has emerged as a credible scientific discipline that has made significant advances. As a result, policy makers and practitioners
in the field have developed a more complete understanding of the underlying psychosocial risks and protective factors associated with drug use onset and progression to abuse.
More than just a lack of knowledge about drugs and their consequences, the evidence
points to genetic and biological processes, personality traits, mental health disorders,
180
family neglect and abuse, peer drug usage, drug availability, proximity to trafficking routes, lack of access to quality education, poor attachment to school and the community,
and growing up in marginalised and deprived communities among the most powerful
risk factors.
Conversely, psychological and emotional well-being, a strong attachment to caring and
effective parents and to schools and communities that are well-resourced and organised
are all factors that contribute to individuals being less vulnerable to drug use and other
negative behaviours. Risk and protective factors vary considerably across age, gender,
culture, ethnicities and socioeconomic background and effective prevention programmes should be tailored towards the needs of each group (4).
Researchers have identified specific periods of high-risks in which young people are particularly vulnerable to drug abuse such as transitioning from one school level to the next,
undergoing physical changes in puberty and disruptive social situations (i.e. divorce of
parents). Research has indicated that prevention programmes are particularly beneficial
and supportive during these transition periods (5-6). Gaining a better understanding of
risk and protective factors for drug abuse has subsequently led to the development of
programmes whose aim is to reduce risk factors while enhancing protective factors (7).
Advances in neuroscience, genetics and psychosocial studies have led to a better understanding of the effects of drugs on the adolescent brain and a deeper understanding of
protective and risk factors have filtered into the programmes delivered on the ground.
Brain imaging has revealed that the human brain continues to develop until the early
twenties and that drug use can lead to changes in brain structure, especially in the grey
matter, an area that has been associated with intelligence (8). Genetic studies have led
to insights into why adolescents are more apt to engage in risky behaviour. Geneticists
have been able to identify specific genes that are tied to risky behaviours. Research has
shown that individuals carrying the allele form of 5-HTTLPR are more likely to engage
in impulsive behaviour such as excessive drinking and drug abuse (9).
These developments have informed a broader focus on positive youth development, building of life skills, and addressing issues that will help prevent involvement with drugs or other unhealthy or anti-social behaviours. Consequently, recent thinking points
towards generic programmes aimed broadly at forming good health habits and addressing not just drugs but other anti-social behaviour such as aggressiveness, bullying, gang
violence, and risky sexual and delinquent behaviour. With researchers judging ‘old school programmes’ inefficient and calling for interactive prevention programmes targeting
a small audience (5, 15).
181
Evidence-based Prevention Programmes
More recently, research has proven a growing number of prevention programmes effective in delaying the onset and limiting the extent of drug use by reducing risks and
enhancing protective factors. Research has shown that the odds of abusing drugs are
substantially lower among students who participate in such programmes.
Researchers have also pointed out the need to formulate appropriate responses to different target groups and needs. This has led to the concepts of “universal prevention”
which targets the general population; “selective prevention” targeting those at high risk
of drug use; “indicated prevention” for those already involved in drug use; and “environmental prevention” to target the external factors that affect drug abuse prevention.
Effective or best practice has gained momentum as the science of prevention has developed. There is significant evidence now to inform prevention work, including examples
of programmes that have proven to be effective and a range of principles, standards and
guidelines on how to implement what works best. These include the National Institute on Drug Abuse’s Prevention Principles, the European Monitoring Centre for Drugs
and Drug Addiction’s European Drug Prevention Quality Standards, the United Nations
Office on Drugs and Crime International Standards on Drug Use Prevention and the
Canadian Centre on Substance Abuse’s Canadian Standards for Youth Substance Abuse
Prevention.
Family-Skills Programmes
Recent research has highlighted the importance of parents in prevention. Family-skills
programmes that involve all members of the family in a collaborative way have largely
replaced traditional parenting programmes that focused on parent-only interventions.
Family-skills programmes such as Strengthening Families Programme (SFP), Parents as
Teachers, First Step to Success, PROSPER, Kids and Adults Together Programme (KAT)
and Preparing for the Drug Free Years (PDFY) have proven among the most impactful ones (4, 16-18). Family-skills programmes are often administered in educational or
community settings and can be delivered simultaneously with students’ life-skills training programmes (19). The aim of these programmes is to equip parents/carers with the
tools to create a constructive, understanding, and nurturing environment conducive to
learning and positive development. Family-skills programmes have proven to enhance
parenting skills, strengthen the bond and communication between parents and their offspring and lower family conflicts (20). They have also been effective in reducing impulsive and anti-social behaviour and lowering the odds of drug abuse among young people
by up to 40% (21). Since early drug use is associated with higher rates of addiction later
in life, it is important to target parents as well as children at an early stage, preferably before the onset of drug use and at a time when parents can still exert influence over their
children’s behaviour and decisions (17, 22).
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School-based Programmes
Prevention clearly begins at home, but as suggested in the ancient African proverb that “It
takes a whole village to raise a child” prevention is demonstrably more effective when it
comes from every direction, including schools, youth groups, community and faith-based organisations, sports and social clubs, and the community at large (23). Iceland, for
example, has been running an evidence-based drug prevention programme based upon
a holistic approach to prevention and developed in line with the country’s culture. Drug
and particularly alcohol use by young people has fallen significantly in recent years. It
is thought that actions carried out over many years to build this comprehensive community prevention model have been at the heart of the changes in prevalence. The basic
building blocks of the Icelandic model of prevention are worth exploring. It starts with
good data, an annual survey of young people, the results of which are then presented
in local schools and community centres. Teachers as well as parents are seen as critical
actors in the effort to curb substance abuse and build social capital. Community-wide
partnerships were created with the aim of “reducing the number of unattended parties
in the local community, enforcing curfews and connecting parents with school authorities, sports-club officials, and other youth workers in an organized network of mutual
support (24).”
School-based prevention programmes focusing on building students’ life skills, boosting
their self-esteem and bolstering their resilience have superseded traditional initiatives.
School-based programmes are designed to encourage change in the behaviour of teenagers that are indicative of later drug use. By engaging with the programme, students learn
about the negative consequences of drug use in an interactive way, become familiar with
healthy alternatives, and are equipped with the relevant skills to cope with stressful situations and resist peer pressure. School-based prevention programmes have been found
to produce lasting results when they are complemented by family and community initiatives, target all forms of drug use instead of singling out one particular substance, are administered over an extended period of time and are accompanied by follow-up sessions.
School-based life-skills programmes consistently report positive outcomes in regards to
delaying the onset of drug use and diminishing drug use among young people who have
experimented with drugs prior to the intervention (25-26). Moreover, they have proven
to be beneficial on a much broader scale by means of reducing teenage pregnancy, HIV,
gang violence, bullying, delinquent behaviours and improving overall public health. Studies have shown that students who do not receive school-based prevention programmes
can be twice as likely to misuse drugs and engage in violent behaviour compared to their
peers in prevention programmes (27). Furthermore, evaluations of prevention programmes have proven that prevention efforts do not only provide enormous health and social
benefits, but also economic advantages. Research has shown that prevention can save
governments between US$10 to US$50 for every dollar spent (17, 28-29).
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Mentoring Programmes
In addition to family and life-skills programmes, mentoring programmes have evolved
as an effective tool to curb substance abuse among young people. Mentoring programmes generally involve building a relationship between an adult and a young person based on trust and respect. After careful selection and matching, mentors and mentees
meet at regular intervals often with pre determined structure and some level of facilitation by the organisation managing the programme. Mentoring programmes are delivered
in a variety of settings such as schools, communities and the workplace. The mentor is
usually a trained volunteer who serves as a role model and offers emotional support to
a young person. The relationship between mentor and mentee often goes beyond the
one-year duration of the programme. Mentors can teach young people about different
career options and empower them to make healthy life choices.
Online Programmes
Online programmes, while rendered not as effective as other preventive measures, have
emerged as a useful resource for organisations and practitioners that deliver programmes in remote areas. While their positive impact on reducing substance abuse among
teenagers is limited, online prevention programmes such as Australia’s Climate Schools
programme have proven to decrease truancy, moral disengagement and psychological
distress and are now being tested in other countries such as the United States and the
United Kingdom to measure their effectiveness in other settings (30). Several online
portals and forums, featuring evidence-based programmes and resources have been developed for the drug prevention community. Such portals allow for the exchange of information and best practice and target a wide range of audiences from the drug prevention novice to the veteran. Initiatives such as Mentor International’s Prevention Hub and
local variations, such as Germany’s PrevNet and Australia’s Grog Watch, feature among
Internet-based prevention portals. Other online programmes such as e mentoring and
parenting programmes have also emerged and are likely to become more prominent as
technology becomes more accessible across the globe.
Culturally sensitive programmes
Even though research can contribute significantly to improving prevention programmes, not all the findings might be applicable across the world (31). Due to the intricate
interplay of environmental, individual, social and genetic factors that lead individuals to
or protect them from substance abuse, there is no ‘one-size-fits-all’ solution. A variety
of factors need to be taken into account in the development of effective drug prevention
programmes including cultural sensitivity. Research has shown that programmes that
take local community cultural beliefs and values, generally and regarding substance use,
184
into consideration are more likely to succeed in reducing drug use.
Children growing up in the Andean highlands of Bolivia, in which chewing coca leaves
is culturally accepted, or children raised in North-western India, in which opium ceremonies are a common practice to welcome visitors, share distinctly different views on
drugs than children living in inner city Chicago or suburban Sydney. The same holds
true for alcohol; children growing up in heavy drinking cultures are likely to have different attitudes towards alcohol than children from dry cultures. Drug use and attitudes
can also vary substantially across a country’s socioeconomic and ethnic groups. Street children in Brazil might be tempted to use glue and ‘pasta base’, a highly addictive
by-product of cocaine processing, whereas their peers with money are more likely to be
drawn to cocaine. Understanding the circumstances and needs of the target audience is
key to creating and delivering high-impact prevention programmes. Local governments
in collaboration with community-based organisations and NGOs can create community
profiles that depict rates of drug use among locals, the most commonly used drugs, and
beliefs and motivations behind drug use to better inform the development of prevention
programmes.
Unequal engagement and implementation
The development and implementation of prevention programmes, principles and standards remains dominated by Western practitioners and researchers, with a majority being North American and European-centred. Today, the prevention field includes only
around a dozen evidence-based outcome evaluated programmes that have evidence to
support their efficacy. Research indicates that the majority of practitioners in the world
adopt and deliver approaches that have long been dismissed as out-dated by these Western researchers for their lack of efficacy and cost-inefficiency.
According to the International Youth Foundation “a wealth of knowledge about effective youth development programmes exists, but far too few youth-serving NGOs benefit
from such expertise because of scarce resources and a lack of sustained, coordinated
action (11).”
Often due to lack of funding, resources and personnel, a number of low-impact programmes have seen a revival in countries with developing economies. This is the case for
the Drug Abuse Resistance Education (D.A.R.E.) programme, one of the most widely
used school-based prevention programmes that has been delivered by police officers
across the United States and in 54 countries around the globe for around three decades. Research has consistently proven the programme ineffective in reducing drug abuse
and in some instances even counterproductive (12-14). Whilst the U.S. Department of
Education has banned the programme from its list of effective prevention programmes
and has ordered schools not to spend their funds on the programme, the programme
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continues to be widely used in countries with developing economies.
Other programmes now considered passé in the Western world that continue to be delivered in other countries include the use of scare tactics and profiles of drug users, talks
by ex-addicts, lectures about the dangers of drugs, one-time events and presentations,
and ‘Just say NO’ campaigns. Most of these programmes have been proven inefficient in
preventing teens from abusing drugs and a few of them have even been rendered counterproductive as they might spark young people’s curiosity and interest in drugs.
However, the future of effective drug abuse prevention does not lie merely in the dissemination of a handful of evidence based outcome evaluated programmes around the
world. There is also a significant need for the dissemination of easy to use evaluation
methods as it is possible that ‘home made’, culturally specific initiatives developed by
experienced youth workers adapted from a variety of different programmes may prove
to have a positive impact on young people if they were professionally evaluated.
The Role of NGOs
Non-governmental organisations working in the field of prevention can play a crucial
role in preventing substance abuse on a national as well as an international level. On the
regional and local level they can help forge partnerships that encourage exchange of information and experience in order to avoid the duplication of efforts. Such partnerships
should include an array of community and regional stakeholders such as governmental
and non-governmental agencies, international bodies and think tanks, community and
faith-based organisations, schools and universities, parent and youth groups, local businesses and multi-national corporations, law enforcement and health care. In recent years
several international and regional partnerships such as the Vienna NGO Committee
on Drugs (VNGOC), the Association of Non-Governmental Organisations Working in
Prevention (RIOD), the Inter-American Drug Abuse Control Commission (CICAD),
the EU Civil Society Forum on Drugs and the Middle East and North Africa Harm Reduction Association (MENHARA) and an abundance of smaller national alliances have
been formed to address demand reduction. NGOs can also help connect community-based organisations and volunteer groups to local businesses and multi-national companies that can provide funding, people and the infrastructure to deliver programmes that
keep young people engaged in education, prepare them for adulthood, promote healthy
lifestyles and reduce risky behaviours including drug abuse.
Since examples of best practice are not always readily accessible and available in developing countries, NGOs can inform and guide local prevention initiatives by means of sharing their expertise and knowledge in the field (i.e. sharing best practice, resources and
lessons learnt, and disseminating quality standards). Programmes that are successful in
one region must be carefully adapted and transfer is not always effective. Developing
186
local programmes based on universal principles and standards is often more effective.
In many countries drug prevention is a relatively new area and they have yet to develop
effective policies. NGOs can be at the forefront in providing guidance on how countries
can tackle drug abuse in the political arena, assist them in formulating drug prevention and demand reduction policies and strategies, and establishing a national system
to monitor trends and gauge the impact of programmes. And finally, on a global level,
NGOs can engage in work with policy makers, key agencies and governments to ensure
prevention is kept on the international development agenda.
Conclusion
In recent years drug prevention has transitioned from embracing isolated prevention
efforts to comprehensive initiatives. As shown in this paper, drug prevention has positioned itself within the larger field of prevention, including HIV, suicide, bullying, teen
pregnancy, gang violence and crime prevention. Today, drug prevention is seen as one
area within the broader context of promoting health and the wellbeing of individuals,
especially of youth. Despite the advances in prevention work, drug abuse continues to
pose a major challenge to countries, especially to those with developing economies, in
part because funding and resources are limited or channelled into other areas.
The landscape has changed significantly, there is knowledge about what works, but lack
of funding, resources and political will persist as barriers to the delivery of effective
programmes around the world. This paper has shown that whilst evidence-based outcome-evaluated practice and policy exist, there is significant unmet need in the following
areas:
•
There is widespread use of ineffective practices and a lack of awareness of existing
evidence-based outcome-evaluated prevention practice and policy
•
In many countries there is limited, or non-existent, national capacity to develop
and implement evidence-based outcome-evaluated prevention practice and policy
•
There are insufficient voices arguing for the development and implementation of
effective evidence-based outcome-evaluated prevention practice and policy
•
There is limited research into effective prevention practice and policy
Drug use represents a significant burden to public health, through disease, disability
and social problems, and policy makers are becoming increasingly interested in how
to develop evidence-based drug policy. It is therefore crucial to strengthen the links
between science, practice and policy and develop a new approach to drug policy that
is evidence-based, realistic and coordinated. This paper has highlighted the following
ways in which individuals and organisations can work together to employ the benefits
187
of prevention:
•
Forge coalitions and networks between international and national NGOs, community-based organisations, government officials and other local stakeholders to
advocate for young people’s rights and ensure that they are provided with the skills and opportunities to increase protective factors
•
Encourage collaboration between local community members and organisations
to call on governments to put prevention on the national as well as the regional
political agenda
•
Support effective practice by learning from successful prevention initiatives, engaging with organisations such as UNODC, WHO, CICAD and Mentor International
•
Educate community leaders, teachers and practitioners on the principles of effective prevention
•
Focus on successes and learn from cultural practices which encourage lower levels
of drug use
•
Establish effective outcome evaluation and monitoring mechanisms for programmes
The field of drug abuse prevention has come a long way in the past decades, but has
much further to go in addressing drug abuse in an increasingly interconnected world.
Evidence and further study are needed to ensure the delivery of effective programmes.
Countries have to join forces to ensure that successful prevention programmes spread
across the entire globe rather than being restricted to certain areas. Effective practice
and collaboration between non-governmental and governmental agencies, international
bodies, schools, local businesses, community and faith-based organisations and other
community stakeholders are essential to reduce drug demand around the world.
188
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Peer van der Kreeft*
University College Ghent and Johan Jongbloet, VAD Brussels,
Belgium
ABSTRACT
Unplugged is an evidence based program with twelve sessions to prevent use of tobacco, alcohol and other drugs by children of 10-14
year old. It has been developed and evaluated 2005 in seven European countries. Today it is being applied in more than thirty countries
worldwide. The EU-Dap Drug Abuse Prevention study group revealed that the intervention resulted in 23% reduced risk of using cannabis, 28% reduction of risk to get alcohol intoxicated weekly and 30% reduction of risk to smoke daily. A first part of the paper will
elaborate on the program components and content as well as the study results.
Secondly, the implementation and adaptation processes in different cultures such as the Arabic region, Brazil and Russia have delivered
interesting data on the careful balance between adherence to the proven effective program and needs of the local circumstances and
culture. Finally, the contribution of a recent mediator analysis of Unplugged is proposed, starting from the question “what makes the
intervention effective?”.
* Peer van der Kreeft, social educator, has been the head of prevention at De Sleutel Drug Treatment and Prevention Centre for 25
years until 2011 when he was appointed as a full time lecturer/researcher at the University of College Ghent. His expertise is design of
prevention programs focusing on life skills education and developing training of trainers.
Peer has conducted the Lions-Quest Team 1990-1996, presided the EU Prevnet Network from 2002-2006, and has led the EU-DAP Drug
Abuse Prevention Intervention group and the EU-DAP Faculty project for Program adaptation and training of trainers.
Currently he coordinates the EU Boys and Girls Plus Project. He is on the board of directors of EUSPR, the European Society for Prevention Research and is leading the mapping of prevention science learning programs within the European SPAN project.
Peer is an active contributor to networks such as the UNODC and EMCDDA.
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THE UNPLUGGED DRUG PREVENTION PROGRAM FROM THE EU-DAP NETWORK
The Unplugged Drug Prevention Program
from the EU-Dap Network
Unplugged is an evidence based program with twelve sessions to prevent use of tobacco,
alcohol and other drugs at children 10-14 year old. It has been developed and evaluated 2005 in seven European countries (1). Today it is being applied in more than thirty
countries worldwide. The EU-Dap Drug Abuse Prevention study group revealed that the
intervention resulted in 23% reduced risk of using cannabis, 28% reduction of risk to get
alcohol intoxicated weekly and 30% reduction of risk to smoke daily (2).
International adaptation of unplugged
Since the seven study centers that initiated the intervention (in Sweden, Italy, Spain,
Austria, Greece, Germany, Belgium) have diverse cultural backgrounds, prevention delivery systems and languages, this aroused interest of other European countries. Moreover, materials are public domain, we received several requests for cultural adaptations
in different regions: Arabic speaking countries, Latin-America, South-East Asia, Russia
and Kyrgyzstan (3).
Every time there was the question of fidelity to the program against fit for the target
group. The main reason for cultural adaptation is to increase adoption by the target
group, the prevention delivery system, decision makers and the wider community. Increased adoption leads to better support during implementation and increased sustainability.
Obviously some surface issues can easily be changed. We think of names and places for
instance. They increase identification with the program and are warmly supported. Other proposed changes however are more problematic. We know Unplugged is effective
on different outcomes, but we did not know why it was effective. With preliminary mediation analysis, we now do have an idea of effective mediators. Based on these mediators
we are able to identify core program components. Following, we need to be wary about
any proposed changes in the realm of cultural adaptation that touch on these identified
components.
The process of cultural adaptation is also very informative for the original developers.
First it reveals the components that are most under cultural stress. Secondly, meticulously reviewing the materials time after time yields interesting additions and innovative
ideas for when the materials undergo a facelift.
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Aim and result of alterations
Most prominent reason for cultural adaptation of standardized programs is to improve
program adoption. Program adoption by the institution and wider community is essential for quality implementation and will increase sustainability. The program needs to be
supported by actors in the different phases of the implementation chain (4).
We need decision makers to support the dissemination of the program inside the local
prevention delivery system. Next, trainers and teachers should be intrinsically motivated
by the quality of the materials to implement the program. Finally, pupils should identify
with the content of the materials. Only on this conditions a program can be adopted by
a community, implemented and finally be sustainable.
Even though the process of cultural adaptation is mainly conducted to facilitate adoption of the program in the local context, another beneficial consequence of cultural adaptation is a better understanding of the program itself. Scrutinizing the materials with intermediaries from different professional and cultural backgrounds is utmost informative
and invites original developers to reflect and work the program into the ground. If they
are open for creative alterations and additions it could even lead to improvement of the
mother program.
Corrections
Different adaptation processes lead to the improvement of the original materials through review, discussion, proposed additions and ongoing research. Some proposed alterations make the original program developers critically review and reconsider decisions
made in the past. On every topic under stress during cultural adaptation, developers are
forced to indicate the specific function in the program.
In Unplugged, teacher training is considered a vital element for effectiveness. Certain
concepts inherent to effective prevention are explained in training. Also interactive didactical methods are introduced and practiced. Some proposed adaptations we realize
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are more relevant to the process of training then to the alterations of the written materials.
One quiz card invites pupils to think about cocaine and body weight. It is not clear on
the discussion thread on the back if weight gain is metabolically related to frequent
cocaine use or rather a consequence of emotional fatigue. Even though the result (i.e.
weight gain) is the same, these are two very distinct unwanted consequence processes. Possibly, girls identify more easily with the emotional fatigue and boys identify
more strongly with the biological story. Focusing on this exercise in training, strengthens teachers’ capability for gender sensitive differentiation according to their class
group. Differences in effectiveness related to gender are a hot topic in research.
In another quiz card, a girl is offered an ecstasy pill. Pupils are invited to discuss what
the possible effects are. In the Russian adaptation process it was proposed to explicitly mention ‘if she takes the pill’. We believe however that from the three possible
answers, it is clear she has accepted the pill. In that case, didactically inciting positive
social influence in a group, it is recommended to let pupils come with a possible
fourth answer from their own, i.e. that she could also choose not take the pill. They
discuss reasons why to refuse, correcting perceived positive effects and methods how
to refuse, based on positive social influence.
With this last quiz card, the process of positive influence, decision making skills and
reconsidering perceived positive effects is exercised. Should we thus merely disregard
the proposed change? Or the discussion that rises from former quiz card? Certainly not.
Instead the discussions unveil a training opportunity, characteristic to Unplugged. An
exercise so rich in content marking the distinctive character of the Unplugged prevention program is valuable in the TOT training process.
Adoption
Most propositions for adaptation concern a better adoption by the community. Obviously, the program should be in conformity with national and local law, but equally important in respect to dissemination is sensitiveness to local beliefs, customs, taboos, etc.
Some of the proposed changes do not challenge the theoretical base of the program. The
story of Jacob, who has to deal with moving from one city to another, is changed to a locally more recognizable story in all materials. The aim of exercising coping skills however stays the same. In Arabic materials, all references to flirting, feelings between genders
are substituted by challenges of making friends and general communication issues. Also
here the aim of training relational skills basically stays the same.
In the Arabic materials the word for teacher is translated as someone who forms people.
It includes more sharing than what a lecturer is perceived to do. Seeming unimportant,
this is a vital remark in relation to community adoption. Regionally there are differences
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in learning settings. What we convey as a school based program does not necessarily
mean this is the best setting in other societies. Koran school in Arab societies, grass roots
education settings in Brazil, youth movements in Flanders could all well be settings where a universal prevention program is advisable. Much depends on the local prevention
delivery system. Openness in addressing intermediaries then includes relevant educational settings in the local prevention delivery system which increase uptake in society.
Connected to prevention tradition in a country is terminology. In the introduction, the
Russian language partners (Kyrgyzstan and Russia) point out a need to elaborate on two
key concepts when introducing Unplugged to the teachers. First ‘comprehensive social
influence model’ is a difficult term to understand for teachers and a difficult term to explain for trainers. A more pragmatic term is ‘comprehensive development of social skills’.
However, the focus of the program is positive social influence in the group. This requires
the training of social skills but is does not completely convey the meaning. The term
could be more easily explained focusing on the social influence. In some other versions
‘comprehensive’ is only used once.
Another term found not culturally very sensitive is the word ‘drugs’. It refers to all psychoactive substances, but teachers could convey the term as only covering illicit substances. From the introduction, a teacher needs to realize that this program tries to prevent
onset and abuse of any psychoactive substance. Think about shisha in Arabic speaking
countries, glue in Brazil, etc. The important aspect is not to overlook any psychoactive
substance with the term. In the Belgian materials the term ‘legal and illegal drugs’ is
used. All these are good examples of changes that increase uptake in society but do not
necessarily interfere with theoretical basis of Unplugged.
Other proposed changes do challenge the theoretical grounding of the program. In Arab
societies alcohol does not enjoy the same status as in Western-European societies. Illegal
status of the alcohol drug is stressed in Arabic materials. But we know that focusing on
illegality is not a strong preventive factor with adolescents. Should an adaptation process then refuse this input? No, because this is an important concept for adoption of the
program by the community. Illegality can be mentioned one or two times for this aim.
This does not interfere with the comprehensive social influence approach of Unplugged
but will increase receptivity.
Other proposed changes are more fundamental and interfere with the theoretical foundations of Unplugged. One tension field is between local law and prevention science
base. Russia has had bad experiences with progressive drug prevention programs in the
past. Most notoriously, one universal prevention trial used a program designed for selective prevention. Iatrogenic effects resulted. Afterwards a law was designed to protect kids
from promotion of any illegal psychoactive substances. This conflicts with Unplugged
prevention methodology.
In the theory of reasoned action-attitude, attitudes and subjective norms contribute to
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the model of intentions, the immediate antecedent of behavior. Attitudes and norms are
shaped by perceptions and expectations one has about the effect of a drug. Important
in this process is acknowledging perceived positive/desired effects and correcting these.
Discussing perceived positive effects in Russia however, would come to fall under before mentioned law. Irrespective of this law, we find also other regions struggling with
discussing perceived positive effects with children, while not explicitly mentioned in
codex. Even though in the Russian materials, some explicit perceived positive effects are
deleted, the program stays the same, ensured by training.
There is a difficult tension field between trained facilitators who know how to implement the program and untrained decision makers facilitating dissemination. This program is designed for pupils age 12 – 14. Still enrolment at early age increases effectiveness.
Scientifically sound, but difficult in society. As the target group grows older, resistance
to the program in society fades, but also effectiveness decreases. Scaling up, we are obliged to find a correct crossing point between those two variables. Often we cannot but
compromise on effectiveness to increase adoption, ensure quality implementation and
facilitate dissemination.
Essential to tackle these issues are a good communication strategy, sound training and
gradual implementation. Facilitators should be given time and space to try some lessons,
methodologies, exercises in class without too much pressure for results. Only using this
strategy, the gap between science base and cultural/institutional practices will be narrowed.
Sometimes changes are proposed to take advantage of windows of opportunity that facilitate scaling up the intervention. Binge drinking in Brazil is on the agenda. Introducing
this thematic has benefits in terms of adoption. Introducing a hot issue does not only
increases teacher motivation in implementation of the program, it will also improve pupils’ connectedness to the program and their motivation to interact. Moreover, the wider
community recognizing this problem will be more supportive of the preventive action.
However, this process also works in the other direction. In the Brazilian adaptation it is
questioned to devote an entire lesson on ‘the cigarette drug’. Prevalence for smoking is
very low in Brazil. Moreover, the Brazilian partners conducted a focus group with pre-teens and they link smoking to alcohol addicts and elderly. Not a very sexy image indeed.
It is argued this is a result of national efforts. Isn’t it better to concentrate on illegal drugs
and binge drinking? We believe school based programs are an important contribution to
an integrated approach of tobacco prevention. Moreover the methods have been proved
for teens 12-14 years old. From the perspective of developmental psychology this is a
very distinct target group than the pre-teens in the focus group.
196
Focus of change
Most proposals for change are to increase the cultural fit with the target group. The aim
is a better adoption of the program which should lead to increasing quality of implementation and prolonged sustainability. However we need to be very careful changing
the content of standardized, evidence based programs? Otherwise, how can we ensure
effectiveness?
What are the core components of an evidence based program?
The Unplugged intervention showed fine results in the 3 month follow up study as well
as in the 15 month follow up. But the researchers went further in a mediation analysis to
find out why it is effective: which components or mediators in the program lead to the
desired effect?
The conceptual framework of Unplugged
To determine the effective components first the theoretical model had to be presented
in a schematic model (5).
Of the five theories part of the Unplugged basis we determined which mediators they are
linked to: influencial factors that lead to an intention and thus to the behaviour that we
want to prevent (in the figure ‘use’). These mediators or influence factors are different in
kind. Knowledge on drugs and risk estimation are related to the het health belief model.
Attitude is liaised to the theory of planned behaviour. The social norm theory refers to
normative belief: the perception you have of how many people of your age drink a lot
or smoke, your perception their approval of your behaviour, your supposition of their
expectation that you drink during lunch break or smoke a joint after school hours. The
social and personal skills are based on the theory of problem behaviour and the social
learning theory. The latter is in fact encompassing all mediators.
The theoretical model of Unplugged with the theoretical base in the circles and the
mediators in the middle (Giannotta, 2014)
With this conceptual framework the EU-Dap researchers (eudap.net, the group that
developed Unplugged) could see which mediators were strongest present in the group
where the effect was shown. We needed this analysis to be able making statements on
why the intervention works. Thus we could identify the core components. You need to
know them to be able making smaller or bigger adaptations to the program or to combine it, or parts of it, with other interventions.
197
Theories behind the program
Example how this is present in Unplugged
Social learning theory: you learn observational,
by looking how someone else does something
and which consequences he experiences
In interactive small groups pupils are confronted
with experiences and examples of classmates
Social norms theory: you do what you are suppose that others do and expect from you
Infocards in the drugquiz are mostly about correcting wrong suppositions
Health belief model: your health behaviour is
determined by your estimation of the consequences of it and of the seriousness score you give
to that consequence
The lesson about risks deals with where you get
information and how you estimate your risks
Theory of planned behaviour: your intention to
a certain behaviour is the best predictor of it
An exercise on attitude and belief is about how your
information leads to intention
Theory of problem behaviour: your behaviour
becomes problematic if it is socially undesired
A lesson on alcohol learns the differentation between personal, physical and social risks
Social learning theory (6), Social norms theory (7), Health belief model (8), Theory of planned behavior (9,
10), Theory of problem behaviour (11)
Core components leading to the desired effect
The study group chose eight mediators clearly present in the twelve lessons of Unplugged. Mediators of which the program designers knew that they were a step in the theoretical model between being exposed to the program, the inteniont to use and use (of
cigarettes, alcohol and cannabis).
•
Positive attitude towards drugs
•
Negative attitude
•
Positive beliefs
•
Negative beliefs
•
Knowledge
•
Perception of number of user friends
•
Refusal skills
•
Perception of positive class climate
In the same questionnaire that measured the effect, the researchers could find out how
the young pupils scored on each of those eight factors. EU-Dap compared the scores
on these mediator-questions besides the answers on the questions or and how much
you smoke, drink or use cannabis. In this way the team could make a link between the
underlying mediators and the part of the study population where the prevention had
succeeded.
From the eight factors, three clearly popped up with a significant correlation with effe198
ctiveness:
•
Reduction of a positive attitude,
•
Decrease of the perception on how many peers smoke, drink, or use cannabis,
•
Increase of refusal skills.
Those, EU-Dap concluded, are core components of the program that is being applied
and further disseminated.
REFERENCES:
1. Van der Kreeft P, Wiborg G, Galanti MR, Siliquini R, Bohrn K, Scatigna M, et al. and The
Eu-Dap Study Group ‘’Unplugged’: A new European school program against substance
abuse’ Drugs: education, prevention and policy. 2009 April; vol 16:2, 167 - 181, London.
2. Faggiano F, Galanti MR, Bohrn K, et al. The effectiveness of a school-based substance abuse
prevention program: EU-Dap Cluster Randomised Controlled Trial. Prev Med 2008; 47:
537-543.
3. EU-Dap Consortium. (2010). The EU-Dap 2 Project, Final technical report. Turin, Italy:
Osservatorio Epidemiologico delle Dipendenze (OED).
4. Van der Kreeft, P., Jongbloet, J., Van Havere, T. (2014) Factors Impacting Implementation:
Cultural Adaptation and Training. In Sloboda, Z. and Petras, H. (Ed’s) Advances in Prevention Science: Defining Prevention Science. Vol 1. Springer Publishing & Kluwer (2014).
5. Giannotta, F., Vigna-Taglianti, F., Galanti, M.R. Scatigna, M., Faggiano, F., Journal of Adolescent Health, Volume 54, Issue 5 , Pages 565-573, May 2014.
6. Bandura A. Social Learning Theory. Prentice Hall, Englewood Cliffs New Jersey, 1977.
7. Perkins HW, Berkowitz AD. Perceiving the community norms of alcohol use among students: some research implications for campus alcohol education programming. Int J Addict
1986; 21: 961-976.
8. Rosenstock IM. Why people use health service. Milbank Mem Fund Q 1966; 44: 94-127.
9. Fishbein M, Ajzen I. Belief, attitude, intention, and behavior: An introduction to theory
and research. Addison-Wesley, Reading MA, 1975.
10. Ajzen I, Fishbein M. Understanding Attitudes and Predicting Human Behavior, 1980. Prentice Hall, Englewood New Jersey.
11. Jessor R, Jessor SL. Problem behavior and psychological development: A longitudinal study
of youth. Academic Press, New York NY, 1977.
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200
Savaş Yılmaz*
Director General of the Turkish Green Crescent Society
ABSTRACT
Addiction Prevention Training Program of Turkey (TBM) is developed by the Green Crescent, which aims to reach primarily students,
subsequently the whole population. This program’s goal is to start in kindergarten, continuing with all ages in the target group, enhancing awareness on various addiction types and offering training in these contents.
The program aims to minimize the risk of getting addicted, providing a prevention training service, being a universal grounded training
program for children, teenagers, and adults.
This program has been prepared in order to inform all student groups concerning addiction, information, skill and behavior prevention
possibilities. TBM program has been developed taking the students’ basic needs into consideration on a range of issues including
tobacco addiction, alcohol addiction, drug addiction, technology addiction, and healthy living education in 5 areas, namely preschool,
primary school, secondary school, high school, and adults consisting of a total of 18 modules. This program has been prepared by the
professional Green Crescent Science Committee, composed of a professional education staff, based upon a scientific approach fitting
all age groups, scientific and evidence based modules.
500 school counselors in Turkey will be trained in this program, which has been enhanced by the Green Crescent. Teachers who have
taken this training will establish a teaching plan in their own districts/provinces, bearing in mind the needs of target groups.
Giving training to community leaders such as teachers, imams, and people who are in touch with the society and who will practice these
training on all ages in the society; the implementation and results of the program will be reported to the Green Crescent.
* Savaş Yılmaz graduated from the Faculty of Political Sciences, University of Ankara. He has accomplished his master degree in public
economy at Gazi University, still pursuing his Ph.D. in public economic policy at the Faculty of Political Sciences Department at the
University of Ankara.
He started his career as a supervisor at Dışbank A.Ş., continuing at the World Bank in Turkey as a manager leading big projects, such
as Social Risk Reduction, Istanbul Seismic Risk Mitigation and Emergency Preparedness Project (ISMEP) and finally directing the Health
Transformation and Social Security Reform Project as well as the Social Security Reform Project.
Savaş Yılmaz was a consultant at the Ministry of Labor and Social Security and on the executive board of different organizations, when
he started in August 2013 as the General Manager at the Green Crescent. He has 3 published articles about social politics, a postgraduate
thesis about the pension system and 1 seminar book about the Turkish welfare system.
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ADDICTION TRAINING PROGRAM OF TURKEY
Addiction Prevention Training Program of
Turkey
What is addiction?
Addiction can be defined as the situation where the individual cannot control the physical and psychological need for a substance and forms his/her environment involuntarily
in line with this addiction. As Leshner (1) states, addiction is a chronic and repetitive
disease which changes the individual’s life completely and affects the chemical structure
of the brain. Today, many authorities and sources qualify addiction as a community
health problem.
There are many types of addiction; for the purposes of this article, addiction refers to the
tolerance developed towards the usage of alcohol, tobacco, pleasure-giving substances
and internet.
Combating Addiction
Combating addiction is a complicated field requiring actions to be taken on different
axes. Institute of Medicine determined a combat framework in 1994. According to this
framework, combating addiction was divided into three phases with sub-factors: prevention, treatment and continuation. On the other hand, there are other program applications for combating drugs. For example, the program combating drugs in Portugal was
established on the six axes of coordination, international cooperation, research, review
of legal framework, decreasing demand, and decreasing supply. There are educational
activities within the scope of prevention assessed as a sub-factor of decreasing demand.
Prevention as a Method of Combating Addiction
It is possible to say that addiction is the common problem of all the world countries by
only taking a look at the 2012 World Drug Report of United Nations Office on Drugs
and Crime. Countries try to find solutions for this problem through programs they determine.
In a research conducted in USA, it was found that 1 dollar spent for prevention corresponded to 18 dollars spent for treatment and rehabilitation (2). In other studies, it was
stated that the difference was about 10 times (3). The studies conducted within the scope
of prevention are diversified on the basis of influence area and target audience such as
individual, family, school, etc. 202
Prevention based on individual: The prevention studies in this category are formed
around the individual and depend on the willingness of the individual to participate.
The Snowball Project implemented in various countries is an example of this. The event,
usually organized as 3-day camps, includes conferences, presentations and group discussions to reinforce the information provided. There are also many creative and enjoyable
activities in the camp programs. The meetings and entertainment activities (1-2 times in
a month), far from harmful substances, continue all year round.
Prevention based on school: Research shows that people with addiction start using the
substance causing addiction in adolescence. Within this concept, trainings are organized
in schools to provide information about what addiction is, how it is formed and how to
keep away from the risk of addiction in order to keep the children and adolescent away
from substances and at least to delay the usage. Schools are the preferred place for these
trainings as they are the common meeting point where all the children and adolescents
meet obligatorily and they facilitate access to larger masses. The most current example of
these programs is the Unplugged Project applied in 7 European countries.
Unplugged Project was developed based on the claim in the last researches and publications that drug usage is part of the lifestyle of many adolescents. According to these
researches, social influence has a huge impact on tobacco, alcohol or substance abuse.
The project adopted the social influence education model used in new prevention approaches and aimed the young to adopt behaviors that reinforce the attitudes and skills
contributing to resist the pressures to use drugs. With this purpose, trainings were provided to guidance counselors in secondary schools about addiction and it was ensured that
they shared the information they received with their students, in one lesson per week
during 12 weeks. In the follow-up studies, it was observed that the project contributed to
the reduction of substance usage.
Another tool to prevent addiction among children and adolescents is prevention based
on family. In this project, the objective is to remove or reduce the risk factors in the family that cause children and adolescents to become addicted. Within this scope, parents
are provided with trainings about setting clear expectations and rules against substance
and alcohol abuse, reinforcing positive behaviors, putting into action effective family
management activities and establishing close and caring relations with children (4).
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Addiction and Fight Against Addiction in Turkey
According to the Research of Attitudes and Behaviors for Alcohol and Substance Abuse
in General Population in Turkey (TUBIM GPS Research), conducted for the first time
on country sample by TUBIM in 2011, and to the Research of Attitudes and Behaviors for Alcohol and Substance Abuse in Schools in Turkey; the rate of individuals who
have used any substances including marijuana at least one time -prevalence of lifelong
substance usage- was 2,7% in the group of age 15-64 and it was 1,5% in the group of age
15-16.
When the studies conducted to prevent substance abuse in Turkey are analyzed, it is observed that prevention studies were mostly organized as seminars and that the number
of comprehensive training programs was very few (5). In addition, there is no standardization or integrated approaches in these seminars and trainings. Also, there is lack of
evaluation of the scientific nature and effectiveness of the seminars and training programs.
Researchers performing studies on addiction and addiction prevention have adopted the
model of comprehensive social influence, to develop the life skills, value judgments and
commitments of the youth about not becoming addicted, as well as to include the family,
in order for the prevention programs for children and adolescents to be successful (6).
What is intended by the model of social influence is interactivity, as well as the combination of life skills with value judgments and beliefs.
Combating addiction since 1920, Turkish Green Crescent developed the Addiction Prevention Training Program of Turkey (TBM) to start a socially based combat by combining the methods based on school and family in order to mobilize all levels of the society
in combating addiction starting from the deficiencies in the studies conducted in Turkey
and from the current scientific implementations about prevention studies.
Addiction Prevention Training Program of Turkey (TBM)
Addiction threatens our people of every age with an increasing usage rate and variety.
It is important to raise awareness among the youth by supporting them with preventive
and protective services in schools and on a national basis with the fight against tobacco,
alcohol, drugs, technology and all other addictions.
Turkish Green Crescent develops and applies many projects/programs with the objective to present a scientifically based approach in combating addictions, to develop and
implement scientific modular training programs based on evidence suitable for all age
groups, to raise social awareness about addictions, to expand its activities nationwide
and to become an organization which has a voice on an international level.
One of these programs is “Addiction Prevention Training Program of Turkey” (TBM)
204
started in order to help young people have a safer, happier/healthier life and to raise awareness among our children and adolescents about addiction. This is a universal training
program that will reduce the risk of becoming addicted of individuals who are not addicted and it aims to provide preventive training service to all relevant parties, particularly
children and adolescents.
Turkish Green Crescent came to realize TBM as an action plan effective in combating
addictions by taking into consideration the sociological structure, needs and current
education system in Turkey.
This training program aims to raise awareness among individuals and the society about
various addictions such as tobacco, alcohol, drugs, technology, etc. and to prevent the
use of these substances by providing information and creating awareness.
A program addressing such a large target audience was developed for the first time in
Turkey. This program has been developed with the support of experts, by taking into
consideration the country’s sociological structure, needs and current education system,
so as to be applied all across Turkey.
TBM has been developed by taking into consideration the basic preventative needs of
students and it is composed of a total of 18 modules based on benefit, which were prepared for preschool, primary, secondary and high school students as well as adults in 5
fields, namely tobacco, alcohol, substance, technology addictions and healthy living.All
contents used in the training program were prepared by a professional teaching staff,
including Green Crescent Science Committee, with a scientific approach, as a modular
training program suitable for each age group based on science and proofs. Books and
interactive contents were produced as the trainings will be performed both face to face
and at distance.
TBM training booklets are comprised of 18 booklets designed for different modules.
Each booklet has been written and designed for its target audience. The informative
texts, activities and images used in the books have been meticulously prepared by experts in the field.
In the distance learning phase of TBM, it was aimed to reach all age groups with a training package consisting of 18 modules prepared by changing the activities, videos, etc.
into interactive contents prepared again by experts. The contents prepared by taking
into consideration the characteristics and learning skills of various age groups serve to
attract the attention of the target audience thereby making a positive contribution to the
process of learning.
Also, teachers can rely on activity books prepared for them to realize exemplary activities appropriate for different age groups and enrich the training program in this way.
TBM is a training project to be applied for 3 years from 2013 till 2015. Within the scope
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Target Audience
Healthy
Living
Technology
Addiction
Tobacco
Addiction
Alcohol
Addiction
Substance
Addiction
Preschool
Primary School (1, 2, 3, 4)
Secondary School (5, 6, 7, 8)
High School (9,10,11,12)
Adult
of the project, the application and dissemination process has been designed as 3 phases.
In the first phase, the pilot program is to be applied in the school year of 2013-2014; then
in 2014-2015, the TBM Trainer of Trainers Program and the TBM Trainer Program are
to be realized and lastly the students and the families are to be reached by TBM trainers.
In the last phase, all the syllabus of Ministry of National Education is to be reviewed and
suitable activities are to be prepared accordingly and to be applied in the schools.
Implementation of TBM Training Program in collaboration with Ministry
of National Education
The program started on January 3rd, 2014 within the frame of the protocol signed with
the Ministry of National Education and it was aimed to provide nationwide trainings for
addiction prevention in the schools directly to 20 million students, through 20,000 TBM
trainers trained by 500 trainers of trainers.
In this direction, the pilot program of the project was realized in the high schools in
Istanbul and the program development process was planned so as to follow the pilot
program. The content and dissemination methodology of the program was updated and
reorganized within the framework of the problems confronted, to be applied at the beginning of the school year of 2014-2015.
Within the scope of the pilot program on February 17-22, 2014, combating addictions
and TBM Trainer of Trainer Program were provided to 41 school counselors and participants from other organizations from 39 districts of Istanbul, during 6 days. In these trainings, TBM Implementation Methodology and TBM Program Content trainings were
also provided to ensure that teachers benefit more from the applications in the class, as
well as TBM Trainer Programs including tobacco, alcohol, substance, technology addictions and healthy living contents.
8 groups of 5 people were formed by teachers who successfully completed the trainings.
The groups were formed by teachers from neighboring districts.
The necessary assessments were performed at the end of TBM Trainer Program and a
one-day long workshop was realized on March 19th, 2014 with teachers who completed
206
the trainings successfully.
Within the scope of the workshop, teachers were informed about the implementation
process and they were asked to make evaluations and provide suggestions about the
training programs and the implementation process. The workshop allowed school counselors, who will participate in TBM Trainer Program and convey trainings to the target
audience, to actively participate in the program contents and the implementation process, thereby developing a sense of belonging to TBM. TBM Trainer Programs and the
implementation process were designed to be put into action after the pilot program in
which all target audiences participate.
On April 4-5, 2014 and May 5-6, 2014, 41 TBM trainers provided TBM Trainer Program
training to school counselors in high schools in 2 sessions during 2 days. These trainings
were performed in 8 districts every week during 5 weeks and 830 school counselors from
39 districts were reached in Istanbul.
At the last implementation step of TBM, school counselors who have attended TBM Trainer Program, informed high school students about addiction and types of addiction by
applying the TBM training programs first in their own schools and then in neighboring
schools.
Within this scope, student trainings were performed in 515 high schools in 39 districts.
About 60 thousand students were provided with training in 5 areas. To assess the success
of the trainings performed in the schools, a study of pretest/posttest was performed with
a five point Likert scale.
The pretest/posttest percentages of the scale, prepared based on the wrong beliefs about
addiction believed to be correct in the society, showed that these wrongs were righted
by about 5% to 10% for some issues and that the rate of correct answers exceeded 50%
in some questions.
TBM aims to correct wrong beliefs of addiction known to be true by the target audience
and to popularize correct information especially with the trainings prepared in 5 areas.
The primary objectives of TBM are to prevent the normalization of the usage of addictive substances such as alcohol, cigarettes, etc. and to prevent the youth from having
wrong information about these issues.
In light of the information obtained from the Pilot Program of TBM Trainer of Trainers
Program, TBM Trainer Program, Student Trainings and the Workshop; the necessary
revisions were made by assessing the deficiencies about the training materials, training
programs and implementation process. The pilot program has allowed TBM to remove
beforehand possible problems during the nationwide performance and has contributed
to the creation of an efficacious, reliable and effective training program serving for the
objectives.
207
TBM Trainer of Trainers Program were organized with the support of the Ministry of
National Education and with the participation of 500 teacher candidates nationwide and
12 teacher candidates from TRNC in November 2014, with the purpose of implementing TBM nationwide including TRNC. At the end of these trainings, designed as 4 days
for each addiction area, 102 teachers were trained in substance addiction, 102 teachers
in alcohol addiction, 102 teachers in tobacco addiction, 102 teachers in technology addiction and 98 teachers in healthy living. TBM Trainers are all specialized in their own
fields and they have the required information and skills about the other 4 areas.
TBM Trainer of Trainers groups of 5 people will be formed in each province and the
trainers will be asked to perform a 3-hour TBM Trainer Program in their own area of
expertise. They also will be active as TBM Trainers. A person among the TBM Trainer
of Trainers groups will be determined as the Coordinator Trainer and will manage all
the communication between the groups and Green Crescent and Ministry of National
Education.
An 18-hour training program was prepared for TBM Trainer of Trainers to provide
TBM Trainer Program to all school counselors in their cities. In this scope, 20,000 school
counselors across Turkey will be provided with trainings covering 5 areas and they will
be informed about the skills for combating addiction.
In the third step of TBM, school counselors, who have completed TBM Trainer Program, are asked to apply the trainings prepared in 5 different areas for their students, in
their own schools. Student trainings aim to raise awareness in the target audience about
addiction areas and healthy living and to inform and raise awareness.
TBM and Corporate Cooperation Model
Within the scope of the “Corporate Cooperation Model”, TBM will transfer the TBM
contents to the target audience by providing formation to influential professional groups
in direct relation with the target audience. In this way, the content and the influence area
of the prevention study will be extended with the cooperation of all related establishments and organizations for a nationwide combat.
Other than the cooperation studies to be performed, a media study will also be performed to extend the content and the area of influence of TBM; public service ads special
to TBM will be published on national communication channels; and social participation
and cooperation, which is indispensable for preventive studies, will be realized.
Within the scope of TBM, TBM trainings for the target audiences of the following organizations by implementing TBM Trainer of Trainers Program to train TBM Trainers
within the establishments following the performance of TBM Trainer Program for;
•
208
The specialist personnel and Youth Leaders of Credit and Dormitories Agency
with the cooperation of the Ministry of Youth and Sports
•
The religious officials with the cooperation of the Directorate of Religious Affairs
•
The Work and Professional Consultants with the cooperation of Turkish Employment Agency
•
The specialist personnel of the Ministry with the cooperation of the Ministry of
Internal Affairs
•
The Family Consultants, Psychologists and Social Workers with the cooperation
of the Ministry of Family and Social Policies.
As a result, a multiplier effect will be created by diversifying target audience groups various within TBM and the sustainability of the program in a systematic structure will be
ensured within the relevant establishments and organizations.
Conclusion
The TBM Trainer Program, to be realized within TBM, and the students, who are the
end beneficiaries, will be subject to measurement and evaluation. During the pilot program performed in the school year of 2013-2014, the changes in the level of information
and awareness of the students were measured. An assessment and evaluation study will
be conducted during field trainings which is the phase where the project is disseminated
throughout the country. In the last phase, studies will be conducted in order to evaluate
the behavioral alterations of students, caused by activities prepared on the basis of the
syllabus during one semester.
Turkish Green Crescent will perform the printing and distribution of the training material and the measurement and evaluation tools necessary for all implementation steps
to be realized nationwide. The implementation process will be followed by realizing
continuous information sharing between the Green Crescent and Coordinator Trainers
during all phases of this training organization. Coordinator Trainers will report to the
Green Crescent on a regular basis about the trainings conducted in their provinces.
209
REFERENCES:
1.
2.
3.
4.
5.
Science 3 October 1997:Vol. 278 no. 5335 pp. 45-47 DOI: 10.1126/science.278.5335.45
Miller and Hendrie, 2008
Spoth et al., 2002.
Winters, 2007.
Siyez D, Palabıyık A. Günebakan Madde Bağımlılığını Önleme Eğitim Programının lise
öğrencilerinin madde kullanım sıklığı, uyuşturucu maddeler hakkındaki bilgi düzeyleri ve
yanlış inanışları ile madde reddetme becerileri üzerindeki etkisi. Elektronik Sosyal Bilimler
Dergisi, 8(28); 2009. 56-67.
6. Cuijpers P. Effective ingredients of school‐based drug prevention programs: A systematic
review. Addictive Behaviors [Special Issue: Integration Substance Abuse Treatment and
Prevention in the Community] 27(6); 2002. 1009‐1023.
210
Simona Stankeviciute*
Alcohol Policy Youth Network, Lithuania
ABSTRACT
The term “drug” has very varied use. In medicine drug is a material which can potentially prevent or cure disease or change mental and/
or physical state. Pharmacologist call drug a substance which alters any biochemical or physiological processes of tissues or organs.
In the context of international drug control, “drug” means any of the substances in Schedule I and II of the 1961 Convention, whether
natural or synthetic. Usage of the term “illicit drug” should be avoided, as it is the manufacture, distribution, and use, etc. of a drug
which is illicit, but not the substance itself. However, a lot of people around the world, both laymen and professionals, do not perceive
alcohol as a psychoactive substance with potential to cause dependence. The Gateway Drug Theory suggests that licit drugs, such as
alcohol, may serve as a ‘gateway’ towards the use of other illicit drugs.
Thus society should be very vigilant when it comes to usage of illicit drugs at young age. Even though in many countries it is illegal for
minors to obtain and use alcoholic drinks, it still happens due to decriminalization of such actions. However, this may lead to higher
health problems in the country and, possibly, higher level of use of illegal drugs.
Keywords: Alcohol Use, Youth, Gateway Substance
* Simona Stankeviciute is a recent graduate from Lithuanian University of Health Sciences, currently working as a Medical Doctor in
Lithuanian University of Health Sciences Hospital Kaunas Clinics Department of Pulmonology and Clinical Immunology and as an assistant for Clinical Pharmacology in form Lithuanian University of Health Sciences of Physiology and Pharmacology.
She is also Vice President of Youth Research of Alcohol Policy youth Network and has been involved in both active actions on alcohol
policy and research.
211
LEGAL AND ILLEGAL DRUGS: ALCOHOL AS A GATEWAY SUBSTANCE TO USING OTHER DRUGS
Licit and Illicit Drugs:
Alcohol as a Gateway Substance
The term “drug” has very varied use. In medicine drug is a material, which can potentially prevent or cure disease or change mental and/or physical state. Pharmacologist call
drug a substance, which alters any biochemical or physiological processes of tissues or
organs. In the context of international drug control, “drug” means any of the substances
in Schedule I and II of the 1961 Convention, whether natural or synthetic. Usage of the
term “illicit drug” should be avoided, as it is the manufacture, distribution, use etc. of
a drug which is illicit, but not the substance itself. However, a lot of people around the
world, both layman and professionals, do not perceive alcohol as a psychoactive substance with potential to cause of dependence. Although alcohol has all the features of drug
– it can cause altering of tissue functions, it changes mental and/or physical state of one
who is using it and is addictive. Even more – it is carcinogenic; and is highly dangerous
if used at young age. However, due to many factors, usage of alcohol is decriminalized
in nowadays society. Even though in many countries it is forbidden to use alcohol until
certain age (which varies from 16 to 21 years), we have statistics, which show, that even
twelve year-olds have tried alcohol or even are frequent users. Alcohol consumption
by minors can lead to numerous harmful consequences, including academic problems,
delinquent behavior, and substance use (1).
Some years ago, authors developed so called “Multiple stage progress theory”, which
suggest the stages, during which an individual progresses from a non-user to an illicit
drug user, which are:
•
Nonusers to beer/wine drinkers;
•
From beer/wine drinkers to cigarettes and hard liquor;
•
From cigarettes/hard liquor users to marijuana;
•
From marijuana to other illicit drug use (2).
Other authors later on discussed proposed view and developed so called “gateway theory”. The Gateway Drug Theory suggests that licit drugs, such as alcohol, may serve as a
‘gateway’ toward the use of other, illicit drugs. It says, that one substance is serving as a
gateway substance to other, if there is a clear order whereby drug A is tried before drug
B or the probability of trying drug B is greater for those who have tried drug A when
compared to those who have not tried drug A (3). There is no gateway relation if drug A
precedes the use of drug, but use of drug A at an earlier time does not increase the risk
for use of drug B at a later time.
212
Many studies later on tried to reason the gateway theory, because many of the scientists
and people in general, who are working in the addiction field feels, that there has to be a
logical pattern, in which different substances are started to be used by people, especially
at young age. Unconsciously, many of those people think that alcohol must be serving
as one of the main gate way substance, but suspicion is not something evidence based
practices should rely on. Thus many studies had been carried out to determine, whether
any gateway relationships between alcohol and other substances exist. One of those is
The National Survey on Drug Use and Health (NSDUH) Illicit Drug Use among Lifetime Nondrinkers and Lifetime Alcohol Users. It is being carried out in United States
continuously (4). In 2002 and 2003, an estimated 88.2 percent of persons aged 21 or older (175.6 million) were lifetime alcohol users, whereas an estimated 11.8 percent (23.5
million) were lifetime nondrinkers. Over half of lifetime alcohol users (52.7 percent)
had used one or more illicit drugs at some time in their life, compared to 8.0 percent of
lifetime nondrinkers. Among persons who had used an illicit drug in their lifetime, the
average age at first illicit drug use was 19 years for lifetime alcohol users, versus 23 years
for lifetime nondrinkers (5). In 2009, among the 17.1 million heavy drinkers aged 12 or
older, 33.2 percent were current illicit drug users. Persons who were not current alcohol
users were less likely to have used illicit drugs in the past month (4% percent).
Another study has been carried out in the US in 2012 – it evaluated (5) possible relationship between alcohol, cigarettes and marijuana use among 12th graders in the US. The
study sample was more than 14 000 students and it did establish the relationship between mentioned substances. Alcohol represented the most commonly used substance, with
a majority of students (72.2%) reporting alcohol consumption at some point in their
lifetime. A large percentage of respondents also self-reported the use of tobacco (45.0%)
and marijuana (43.4%). They have concluded that use of alcohol significantly impacts
use of other licit and illicit substances. Among students who had consumed alcohol in
their lifetime, approximately 59 percent had used tobacco, 58 percent had used marijuana, 18 percent had used other narcotics. And these numbers are exceeding usage rates
observed within the overall sample. Other authors (6) tested the same hypothesis and
found out the same results – that alcohol is indeed a gateway substance to using illicit
drugs and not the other way around.
It is curious, that even though it is widely known that alcohol does causes harm and makes huge financial burden, it is still not perceived and not called an illicit drug. Somehow
society keeps on the denial of the nature of the problem and has very ambivalent feelings
about alcohol. On the one hand, the laws on not selling alcohol for minors exist, however, on the other hand, in many countries they are not applied and the authorities are
not taking serious actions in stopping that. In the political arena very great skepticism
about effectiveness of policies exists. Politics often do not agree on starting evidence based alcohol policy, mentioning the contribution it gives to the national budget, however
forgetting, that even more money is often spend on dealing with problems, related to
213
LEGAL AND ILLEGAL DRUGS: ALCOHOL AS A GATEWAY SUBSTANCE TO USING OTHER DRUGS
alcohol and that could have been avoided if alcohol was not used. Surely, all of that often
happens not only due to the short sight of any politics, but also because of influence of
the alcohol industry. It does have very strong relations with government in some countries and in some they have very good lobbyists or both.
Understanding that alcohol servers as a gateway substance to using other drugs poses a
very important task for everyone that is involved with policy and education – it clearly
states, that if we could protect minors from alcohol use, we would have a lot less illicit
drug users later on. For several years now, the best strategies for reducing alcohol use
and related alcohol harm has been know. They consists of strict policy actions towards
increasing alcohol price by increasing taxation, totally banning advertising of alcohol
in media, decreasing alcohol availability by decreasing number of places alcohol is sold,
making sure the licensing systems is working. Other important measures are altering
the drinking context, reducing drink driving, education and if the problems is already
identified – using treatment and early interventions (7, 8).
214
REFERENCES:
1. Ellickson PL, Tucker JS, Klein DJ. Ten-year prospective study of public health problems
associated with early drinking. Pediatrics. 2003; 111(5):949-955.
2. Kandel D. Stages in adolescent involvement in drug use. Science. 1975; 190(4217):912-914.
3. Collins, LM. Using latent transition analysis to examine the gateway hypothesis. In: Kandel,
DB.,editor. Stages and pathways of drug involvement: examining the gateway hypothesis.
University Press; Cambridge: 2002. p. 254-269.
4. Rockville, MD: Substance Abuse and Mental Health Services Administration. Office of
Applied Studies. (2004). Results from the 2003 National Survey on Drug Use and Health:
National findings (DHHS Publication No. SMA 04–3964, NSDUH Series H–25).
5. Kirby T, Barry AE. Alcohol as a gateway drug: a study of US 12th graders. J Sch Health.
2012; 82: 371-379.
6. Mildred M. Maldonado-Molina, A Framework to Examine Gateway Relations in Drug Use:
An Application of Latent Transition Analysis. J Drug Issues. 2010 October; 40(4): 901–924.
doi:10.1177/002204261004000407.
7. Babor et al, 2010, Alcohol – no ordinary commodity, Oxford press.
8. Anderson et al Lancet 2009; 373 : 2234-46, Effectivenes and cost-effectiveness of policies
and programmes to reduce the harm caused by alcohol.
215
216
Intervention,
Recovery and
Rehabilitation
217
218
Ambros Uchtenhagen*
Swiss Research Institute for Public Health and Addiction at
Zurich University
ABSTRACT
Substantial deficits in addiction treatment quality even in well-resourced countries called for improvements at all levels. The quest for
quality standards in addiction treatment, rehabilitation and harm reduction in Europe came from the European Parliament and was
part of the EU Drugs Action Plan 2008-2012. A major research project was mandated by the European Commission, including setting up
inventories of national and international standards from 27 countries, identification of minimum standards and a consensus building
process involving a wide range of experts and other stakeholders, mostly with important positions in their respective organisation
(n=241). A structured concept provided the grid for the various types of standards, including structural, process and outcome standards
on the levels of interventions, services and treatment networks or systems. Proposed lists of standards, extracted from the inventories,
were submitted to stakeholders via on-line surveys and at a European conference with participants from 20 countries. The lists covered
22 minimum standards for treatment/rehabilitation, and 16 harm reduction standards.
Rates of acceptability, effective implementation and expected implementation problems show in general many implementation deficits
in spite of good acceptability of the proposed standards, due to professional, political, ideological or/and financial concerns. For a
number of those, applicability in non-specialist services, including private practice and prison services, was considered to be limited.
Good examples of implementation strategies were discussed, proposals for training opportunities were made. At present, one project
to test implementation at national level is under way.
* Ambros Uchtenhagen was Professor of Social Psychiatry and is President of the Swiss Research Institute for Public Health and Addiction, a WHO Collaborating Centre associated with Zurich University. He is member of the WHO Expert Panel on Drugs and was a board
member of the European Association on Substance Abuse Research. His main research interests are in the epidemiology of addictive
behaviour, implementation and evaluation of preventive and therapeutic interventions, and drug policy. He has more than 280 first
author publications in the fields of social psychiatry and addictions. He was Co-Editor-in-Chief of European Addiction Research. He
published a Handbook on Addiction Medicine (in German).
He set up model services in social psychiatry, for chronic psychotic patients, for young substance abusers and for psychogeriatric patients – wherever he saw a neglected target group. He was involved in numerous research projects and missions for the WHO, the United
Nations Organization on Drugs and Crime, the European Commission, the Council of Europe, the Swiss National Government and others
(he directed the European project “Evaluation of action against drug abuse”, 17 countries participating, and directed the EU project on
“Minimal quality standards in drug demand reduction”, all Member States participating).
219
EUROPEAN QUALITY STANDARD IN ADDICTION TREATMENT AND REHABILITATION
European Quality Standards for Addiction
Treatment and Rehabilitation
On behalf of the treatment and harm reduction standards
partnership
Introduction
Addiction treatment has to meet two major challenges: good coverage of treatment needs in a given population, and good quality of interventions and services. By quality we
understand that treatment should have good results for individuals as well as for society,
and therefore should be based on solid research evidence (1). In spite of considerable
progress in many countries, these goals are far from being reached satisfactorily. According to a recent worldwide WHO survey, both coverage and quality of addiction treatment is deficient, leaving people in need without appropriate care (2). Even in well-resourced countries, such deficits have been documented not so long ago (3, 4).
Great efforts were made for improvements of this problematic situation, on national
(5-7) and also on international (8-11) level. Such efforts include the setting up of evidence-based treatment guidelines and of instruments for capacity building, training and
continued education. This paper describes a recent attempt initiated by the European
Parliament: a project to identify minimum quality standards in drug demand reduction,
mandated by the European Commission in 2010 to an international expert group lead
by the Swiss Research Institute for Public Health and Addiction at Zurich University.
The project aimed at standards in prevention, treatment, rehabilitation and harm reduction, proposed and selected in an extensive consensus-building process. The results are
described in the final project report (12). The prevention part was accomplished in a separate project lead by researchers at the Center of Public Health, John Moore University,
Liverpool, and resulted in a manual published by the European Monitoring Centre on
Drugs and Drug Addiction, EMCDDA (13).
Justification and conceptual framework of the project
While the main justification of treatment for substance abuse problems are good outcomes in terms of health improvements, social integration and a reduction in substance
use, the quality standards have an added value. Credibility and acceptability are enhanced, they help to make best use of available resources and to highlight the role of patient’s
rights. Minimum quality standards can be helpful wherever the financial and human
resources are not available for implementing best practice standards; they also are useful
for identifying priorities for service improvements and evaluation research.
220
Quality standards have to be defined separately for structural properties, for the processes in delivering the various interventions, and for the desired outcomes of interventions. And again they differ on the levels of interventions, of services and of service
networks or systems (1). Benchmarks are the (desired) reference values or ratio by which
quality can be measured. A grid was set up where the type of standards can be entered
according to these differences (see Appendix 1).
Methodology and steps
Separate international expert groups for treatment/rehabilitation and for harm reduction had the task to find the relevant national documents on quality standards via contacts
to national sources. Information from these documents was entered into a structured
template for each document, and on the basis of the 350 collected templates we established national inventories of existing standards for 27 countries. Mandatory standards were listed separately from mere recommendations. From those, a provisional list
of standards was composed and submitted to stakeholders for a consensus about what
should be defined as minimum standard. 241 stakeholders from 20 countries were nominated by our national project partners and participated in two on-line surveys, receiving
information on the source and evidence grade for each of those standard. Stakeholders
were chosen from a large spectrum including research, family members, media etc., but
belonged mostly to governmental organizations (36% health sector, 4% justice sector)
and to NGO’s (29%). A majority held leading positions, coming from many professions.
In the surveys, they reported on the acceptability of each standard, on its implementation status at national level and on expected problems for implementation. Standards
marked as acceptable by at least 80% of responding stakeholders were identified as minimum standards. Finally, this list was submitted at a conference with 128 stakeholders
from 34 countries participating for discussion, eventual modifications and a debate on
implementation perspectives.
The minimum standards
The complete lists of treatment/rehabilitation standards and of harm reduction standards is presented in Annex 2. They are structured according to the grid mentioned above.
Also, they inform on general acceptability for all types of services and on exceptions (the
majority of exceptions concerns non-specialist services, office based and prison based
services).
Another informative part was the identification of missing standards; for treatment/rehabilitation as well as for harm reduction, no standards were found on the ethical and
legal aspects of interventions. Another gap of information exists for any quantitative
benchmarks: what is an acceptable coverage rate, what is an acceptable waiting time for
being served, how much continued training is needed, and eventual limits of cost-effe221
ctiveness ratios – this type of thresholds is not considered and is at stake for future efforts.
Implementation of standards
The rate of standards already implemented at national level never exceeds 60%, but an
important rate of answers in the stakeholder surveys considers implementation to be
feasible without major problems. The rate of standards for which implementation will
not be feasible is in general very low (see details in Appendix 3).
The expected implementation problems as reported in the stakeholder surveys were of a
financial, political, professional, legal or ethical nature (in this order of frequency). The
details for each standard can be seen from Appendix 4.
The stakeholder conference included the presentation of a few examples of how standards can be implemented at national level. The modalities include the introduction of
standards by licensing, mandatory regulations or financial benefits.
Belgium is the first example to launch an implementation project for services at national
level R(14). Others will hopefully follow. An opportunity for a follow-up project on implementation problems and processes is about to be proposed.
222
Appendix 1: Types of quality standards
Level 1: interventions
Level 2: services
Level 3: systems & policies
Structural quality
Type of setting needed for
implementation
Resource standards
Legal & ethical adequacy
standards
Process quality
Implementation standards
Procedural standards
Standards for networking
& cooperation among
services
Outcome quality
Effectivity standards
Effectivity standards
Coverage standards
Benchmarks
Cost-benefit ratio
Cost-utilization ratio
Cost-effectiveness ratio
Appendix 2: Lists of Minimum standards
Treatment/rehabilitation: Structural Standards of Services
1. Accessibility: location (service can easily be reached by public transport)
2. Physical environment: safety (service is equipped for emergencies)
3. Physical environment: space (e.g. service has separate rooms for individual
counselling)
Exception: moderate consensus for non-specialized teams
4. Indication criteria: diagnosis (treatment indication is always made on the basis
of a diagnosis)
Exception: moderate consensus for GP´s office-based services and non-specialized teams
5. Staff composition: education (e.g. at least half of staff has a diploma in medicine,
nursing, social work, or psychology)
Treatment/rehabilitation: Outcome Standards at the System Level
6. Goal: health stabilisation/improvement (treatment must be aimed at improvement or stabilisation of health)
7. Goal: social stabilization/integration (treatment must be aimed at improvement
of social stabilisation or integration)
Exception: moderate consensus for GP´s office-based and prison-based services
and non-specialized teams
8. Goal: reduced substance use (treatment must be aimed at a reduction of substance use e.g. helping the client/patient to reduce the use or to abstain from psy223
chotropic substances)
9. Utilisation monitoring (services must report periodically the occupancy of treatment slots or beds)
10. Discharge monitoring (e.g. ratios of regular vs. irregular discharges and retention rates) Exception: office-based and prison-based services and non-specialized
teams
11. Internal evaluation (services must regularly perform an internal evaluation of
their activities and outcomes)
12. External evaluation (services must regularly allow evaluation by independent external experts)
Exception: office-based and prison-based services and non-specialized teams
Treatment/rehabilitation: Process Standards at the Service /System Level
13. Staff composition: multi-disciplinarity (teams composed by at least 3 professions)
Exceptions: prison-based services and non-specialized teams
14. Assessment procedures: substance use history, diagnosis and treatment history
have to be assessed
Exception: moderate consensus for GP´s office-based and non-specialized teams
15. Assessment procedures: somatic status and social status have to be assessed
Exception: moderate consensus for GP´s office-based and non-specialized teams
16. Assessment procedures: psychiatric status has to be assessed
Exceptions: non-specialized teams
17. Individualised treatment planning (treatment plans are tailored individually to
the needs of the patient)
18. Informed consent (patients must receive information on available treatment options and agree with a proposed regime or plan before starting treatment) Exception: moderate consensus for GP´s office-based and prison-based services and
non-specialized teams
19. Written client records (assessment results, intervention plan, interventions, expected changes and unexpected events are documented complete and up to date
for each patient in a patient record)
224
20. Confidentiality of client data (patient records are confidential and exclusively
accessible to staff involved in a patient’s treatment or regime)
21. Routine cooperation with other agencies (whenever a service is not equipped to
deal with all needs of a given patient, an appropriate other service is at hand for
referral)
Exception: moderate consensus for prison-based services and non-specialized
teams
22. Continued staff training (staff is regularly updated on relevant new knowledge in
their field of action)
Harm Reduction: Outcome Standards at the System Level
1. Goal: reduced risk behaviour (reducing unsafe injections, unsafe drug use and
unprotected sex)
Exception: none
2. Goal: referrals (treatment services must be prepared to refer clients/patients to
other health/social/treatment services if needed and agreed)
Exception: moderate consensus for pill testing
3. Internal evaluation (services must regularly perform an internal evaluation of
their activities and outcomes)
Exception: moderate consensus for pill testing
4. External evaluation (services must regularly allow an evaluation of their activities and outcomes by an independent external evaluator)
Exception: moderate consensus for pill testing, referrals, and sheltered housing
Harm Reduction: Process Standards of Interventions
5. Assessment procedures: risk behaviour assessment (client’s/patient’s risk behaviour is assessed)
Exception: moderate consensus for pill testing, BBV testing and counselling, vaccination, and sheltered housing
6. Assessment procedures: complete needs assessment and priorisation
Valid only for needle-syringe exchange and supervised injection rooms
7. Assessment procedures: client health status has to be assessed
Valid only for needle-syringe exchange, BBV testing and counselling, an vaccination
8. Informed consent (clients/patients must receive information on available service
options and agree with a proposed regime or plan before starting an intervention)
Exception: moderate consensus for needle-syringe exchange, outreach/street
work, pill testing, safer use and safer sex counselling, and sheltered housing
9. Confidentiality of client data (client/patient records are confidential and exclusi225
vely accessible to staff involved in a client’s/patient’s intervention or regime)
Exception: pill testing
10. Individualised treatment planning (tailored to client/patient needs)
Valid for referrals
11. Routine cooperation with other agencies (whenever a service is not equipped to
deal with all needs of a given client/patient, an appropriate other service is at hand
for referral)
12. Continued staff training (staff is regularly updated on relevant new knowledge in
their field of action)
13. Neighbourhood/community consultation (avoiding nuisance and conflict with
other people around service)
Valid for needle-syringe exchange, supervised injection rooms and sheltered housing
226
Appendix 3: acceptability and expected implementation problems (Tables
based on the outcomes of stakeholder surveys.)
3.1 Treatment / rehabilitation: acceptability of proposed quality standards
Structural
standards
services
n
Implemented
(%)
Feasible no Problems Not
No answer
problems
expected feasible (%)
(%)
(%)
(%)
Accessible location
153
22
Safety provisions
150
27
19
Adequate space
149
40
28
Diagnosis mandatory
145
41
Transdisciplinary staff
143
Staff qualifications
142
Drug use assessed
4
6
33
9
11
24
1
7
23
27
1
7
26
21
41
8
4
48
24
17
6
5
84
44/46
38/24
12/29
1/0
5/2
Somatic status
assessed
84
36/40
39/31
16/24
2/4
7/2
Psych. status assessed
84
24/41
32/24
32/36
4/7
8/2
Individual treatment
plan
84
38/40
23/13
29/42
4/2
7/4
Informed consent
84
43/40
39/26
12/29
0/4
6/2
Written records
84
43/36
26/24
19/38
4/0
8/2
Data confidential
84
56/60
26/26
12/13
0/0
3/2
30
39
Process
standards
Services /
interventions
Routine cooperation
84
25/29
26/18
36/49
6/2
6/2
Continued training
staff1
84
30/31
24/16
41/46
0/6
7/2
Goal health improved
142
42
29
22
1
6
Goal social improved
142
29
28
34
4
6
Goal less substance use 142
37
31
25
1
6
Monitor utilisation
142
30
30
29
3
8
Monitor discharge
142
15
25
40
12
9
Internal evaluation
142
23
25
39
9
5
External evaluation
141
8
16
53
17
6
Cost-effectiveness1
140
4
11
51
22
11
Cost-benefit1
139
2
9
42
32
15
1
Outcome
standards at
system level
227
3.2 Treatment / rehabilitation: expected problems for implementation
Structural
standards
services
n
Political Professional Legal
Financial Ethical
Other
problems problems
problems problems problems problems
(%)
(%)
(%)
(%)
(%)
(%)
Accessible location
25
16
16
14
34
4
16
Safety provisions
17
13
16
10
42
10
10
Adequate space
17
12
8
4
52
8
16
Diagnosis mandatory
16
12
32
4
32
4
16
25
9
23
6
53
0
9
11
6
25
0
50
0
19
Process
standards
Services /
interventions
Drug use assessed
4/7
21/29
11/0
29/43
18/11
18/11
Somatic status assessed
5/5
27/27
5/9
50/46
5/5
9/9
Psych. status assessed
4/0
29/34
2/6
39/43
8/6
18/11
plan
6/5
33/30
3/5
39/45
0/3
19/13
Informed consent
13/13
31/32
6/8
13/24
13/11
25/13
Written records
0/0
17/31
4/6
30/34
0/6
30/23
Data confidential
7/0
7/22
21/11
7/22
7/0
50/44
Routine cooperation1
2/9
26/33
13/7
23/38
9/2
26/11
Continued training
staff1
2/0
17/23
0/3
67/71
0/0
15/3
Outcome
standards at
system level
228
Goal health improved
17
22
19
11
24
8
16
Goal social improved
21
14
20
10
37
2
18
16
23
10
26
10
16
Monitor utilisation
17
4
28
4
36
12
16
Monitor discharge
22
2
39
15
27
7
10
Internal evaluation
21
3
43
3
30
5
18
External evaluation
30
5
29
11
38
6
11
Cost-effectiveness1
31
12
30
6
32
10
10
Cost-benefit1
23
14
29
6
33
10
8
3.3 Harm reduction: acceptability of proposed quality standards
Structural
standards
services
n
Implemented
(%)
Feasible no Problems Not
No answer
problems
expected feasible (%)
(%)
(%)
(%)
Accessible location
147
17
23
45
10
5
Opening hours
140
16
24
44
14
1
Low costs for patients
138
23
18
26
22
11
Diagnosis mandatory
137
29
22
23
17
9
Age limits
135
22
21
29
16
13
133
17
20
34
24
5
Staff qualifications1
133
35
27
23
11
5
Indiv. needs assessment 127
14
32
28
13
13
Health status assessed
126
21
33
26
11
10
Risk behavior assessed
125
24
35
25
10
6
plan
125
20
26
33
17
5
Informed consent1
124
40
28
20
7
5
Written records
124
21
26
26
19
8
Data confidential
124
56
27
12
2
3
Routine cooperation
124
35
30
40
4
2
Continued training staff 123
25
28
42
5
1
Neighbourhood consult 123
23
23
33
15
7
Goal less risk behavior 133
40
19
35
4
2
24
21
34
14
8
Goal referrals if
needed
130
42
19
31
5
2
Monitor utilisation1
130
29
31
25
9
6
Internal evaluation
130
24
29
37
8
2
External evaluation
129
9
16
54
16
5
Cost-effectiveness1
129
5
16
40
26
12
Cost-benefit1
128
2
17
38
31
13
1
Process
standards
interventions
Outcome
standards at
system level
229
3.4 Harm reduction: expected problems for implementation
Structural
standards
services
n
Political Professional Legal
Financial Ethical
Other
problems problems
problems problems problems problems
(%)
(%)
(%)
(%)
(%)
(%)
Accessible location
66
23
12
15
31
5
14
Opening hours
61
14
18
9
48
3
9
Low costs for patients
37
24
8
11
35
10
12
Diagnosis mandatory
32
14
19
7
33
7
19
Age limits
39
17
15
24
6
27
11
45
5
24
4
50
1
15
31
4
10
12
51
2
20
Indiv. needs assessment 36
17
15
8
40
5
15
Health status assessed
32
7
22
2
40
9
20
Risk behavior assessed
31
4
21
4
31
13
27
plan
42
8
20
5
37
8
22
Informed consent
25
8
36
13
15
8
21
Written records
32
2
26
17
24
10
21
Data confidential
15
9
18
9
9
14
41
Routine cooperation
49
7
32
10
28
5
17
Continued staff
training
52
5
12
1
66
1
15
Neighbourhood
consult
42
27
21
11
16
11
15
Goal less risk behavior
47
20
16
12
30
11
11
9
21
11
19
16
24
Goal referrals if needed 40
6
26
11
32
3
22
Monitor utilisation
33
4
26
9
30
8
23
Internal evaluation
49
4
24
4
40
3
25
External evaluation
70
9
27
3
45
3
14
Cost-effectiveness
52
11
19
5
29
8
28
Cost-benefit1
48
17
14
4
30
4
32
Process
standards
Outcome
standards at
system level
230
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support the public’s demand for quality care? Subst Abuse Treat 2004; 25:117–121.
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high risk opiate addicts in Europe. Final research report to European Commission. Hamburg, Centre for Interdisciplinary Addiction Research, University of Hamburg, 2004.
5. National Institute on Drug Abuse NIDA (2012). Principles of Drug Addiction Treatment –
a research-based guide. 3rd ed. NIDA Publication No. 12-4180.
6. Gowing L, Ali R, Dunlop A, Farrell M, Lintzeris N (2014). National Guidelines for Medication-Assisted Treatment of Opioid Dependence. Online ISBN: 978-1-74241-945-9Publications approval number: 10253.
7. World Health Organisation (2008). Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence. World Health Organisation, Geneva.
8. United Nations Office on Drugs and Crime & World Health Organisation (2008). Principles of Drug Dependence Treatment. WHO, Geneva.
9. European Monioring Centre for Drugs and Drug Addiction (2011). Guidelines for the
Treatment of Drug Dependence: A European Perspective. EMCDDA, Lisbon.
10. United Nations Office on Drugs and Crime (2010, ongoing). Treatnet: working towards
evidence-based drug dependence treatment and care. UNODC, Vienna.
11. European Monioring Centre for Drugs and Drug Addiction (ongoing). Best practice portal
EMCDDA, Lisbon (www.emcdda.europa.eu/best-practice).
12. Uchtenhagen A, Schaub M (2012): Study on the Development of an EU Framework for
Minimum quality standards and benchmarks in drug demand reduction (EQUS) – Final
Report. Research Institute for Public Health and Addiction, Zurich.
13. Brotherhood A, Sumnall HR and the Prevention Standards Partnership. European drug
prevention quality standards: A manual for prevention professionals. EMCDDA Manuals
No 7. Luxembourg: Publications Office of the European Union; 2011.
14. Vanderplaaschen W (2014). CONSENSUS BUILDING ON MINIMAL QUALITY STANDARDS FOR DRUG DEMAND REDUCTION IN BELGIUM (COMIQS-BE). University
of Gent.
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Boro Goic*
President of NGO Proslavi Oporavak, Sarajevo, Bosnia and
Herzegovina; Chairman of RUN (Recovered Users Network),
Brussels, Belgium
ABSTRACT
Abstinence based recovery is less and less talked about, and there are questions raised in the light of the increased knowledge regarding drug abuse questioning if recovery is a sustainable option or if drug addiction is curable at all.
As the problem of drug abuse is further discussed, many offer various options on a kind of treatment required to answer such and
similar question. This presentation will attempt to offer an option that answers those questions affirmatively. It is a treatment that
approaches the problem through faith and spirituality, focusing on a recovery that goes beyond physical drug abuse, but offers a
holistic approach. Statistics presented show the numbers of addicts who adopted this treatment and found deliverance and were
rehabilitated from the drug abuse, but not only that, but became contributing members of their families and communities, whose
recovery is sustained.
Presentation will discuss the Christian model of rehabilitation, its core principles and methods, specifically in the context of the faith
based rehab centers, in addition to various NGO’s which through their goals and activities decrease number of addicts. It will also
present the impact of this model, or option in the global efforts against drug abuse.
Author will speak as a leader of the organizations that he represents, but also as a recovered addict.
* Boro Goic is the President of the Celebrate Recovery NGO for re-socialization of former addicts and a chairman of RUN (Recovered
Users Network), which was established under EURAD (Europe Against Drugs) in Brussels.
After years in addiction, he recovered from a drug abuse problem and started helping people to come out of addiction. He is a founder
of NGO Celebrate Recovery, which is based in his hometown Sarajevo, Bosnia and Herzegovina. He supported several NGO’s, networks
and conferences in their establishment and is very active in grass root activities in his country and region.
Politically he is active in CSF (Civil Society Forum) in the EU, and several institutions on EU and UN level with a goal to promote a voice
for recovery from addiction.
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CHRISTIAN APPROACH TO SUSTAINABLE RECOVERY OPTIONS
A Christian Approach to Sustainable
Recovery Options
Before getting into my presentation of a Christian approach to sustainable recovery options; I’d like to take a look at a delicate issue that is very current in today’s drug policy
debates. What is recovery?
This chart is presented by the EMCDDA (1) and shows us the following: The term recovery implies a process through which an individual is enabled to move from their
problem drug use towards a life without drugs as an active and contributing member of
society (2).
In this picture we clearly see that this is a process that begins by establishing a stabilization of drug abuse, and ends with complete social integration. This is very important to
keep in mind in whatever part of the process we operate.
Stabilization is the stage where there are attempts to stabilize addicts who are using drugs by putting them on methadone or suboxone replacement therapy. This creates an
opportunity to establish abstinence.
After stabilization different forms of detox are used in the hospital as well as in out-patient institutions in an attempt to bring addicts to the point where they will be able to
establish abstinence. This is the place where they can live without drugs or replacement
therapy.
If we look at it from the standpoint of drug addicts, although it looks like the biggest
problem is to establish abstinence, in the end it seems the easiest. The medical profession
is finding new methods to establish stabilization and abstinence more easily. But what is
being done to help the abstinent addict reach full recovery and integration?
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At times it seems that drug policies in their efforts, measures and programs end with
this stage, but there is more work to be done. Where we stop in our efforts depends on
whether we see addiction as a disease or a disorder. But that’s another debate.
Numbers and statistics show that a person is able to be abstinent with or without replacement therapy. This is the phase where much of the work is done; where the person
recovers. According to the EMCDDA and the chart we saw in the beginning, the process includes one more stage, and that is integration into society. A medical approach
and help is needed in early phases of the process, until stabilization and abstinence are
established. Too often, nothing follows that will deal with and help achieve changes in
behavior and values. As a result, many return to addiction. Because of this we sometimes
have the impression that addiction isn’t curable. This is the phase where the recovering
addict experiences and adopts changes in lifestyle and behavior, becoming an active and
contributing member of society, fully integrated and thus recovered.
No man or woman is born as an addict and no one has to finish their life as one. All of us
involved in this struggle in our respective fields have our own perspectives. It is only by
working together and applying a multidisciplinary approach to the problem that we will
see significant and sustainable results. The common goal should be to see an individual
with the problems of addiction enter the process, finish it, and finish it well in recovery.
Methods and Approaches
There are many programs that lead to desirable changes in behavior, which then continue
on to successful integration and full recovery. Some are based on psychosocial therapy,
some on work therapy or even on peer to peer education. Some of them have integrated
the 12 step process and spiritual aspect of a Higher power, as one stands overwhelmed
at the power of the addiction. My task today is to present a Christian approach to the
question of successful and complete recovery from addiction.
Psycho-social method
• Peer to peer education and work
• 12 Steps
• Christian approach
• Psycho-social method
• Peer to peer education and work
• 12 Steps
• Christian approach
As was mentioned, many recovery programs involve spiritual elements of some kind.
Faith based programs can improve recovery outcomes by offering intervention options
alone or in conjunction with secular programs (3).
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The Christian recovery programs I’m talking about fully integrate the Bible and the teachings of Jesus Christ, making their eternal wisdom constant components of the recovery
process (4).
By connecting the process of recovery to the development of a personal relationship with
Jesus Christ and to a renewed and restored faith in God, a Christian-focused program all
but guarantees that addicts experience a deeper sense of recovery.
This is a recovery that heals the spirit as well as the mind and body, and brings about a
new understanding of life. New attitudes and values lead to desirable changes that don’t
share anything in common with any kind of drug abuse.
History of Christian Approach
The first example of recovery through Christianity was observed in the 1700s when Christian missionaries began to encourage Native American tribes to reject alcohol and
turn back to faith practices. By the late 1700s, Christianity as a tool to combat alcoholism
was found in the medical doctrine of the time. In the century that followed, organizations such as The Salvation Army began to found colonies and homes to house recovering
addicts in the spirit of Christian rescue work.
The early 1900s saw the opening of the first medical facilities specifically created to treat
disorders such as alcoholism, making use of Christianity in their practices. This inspired
secular psychologists of the day to write on and even adopt methodologies being used by
Christian rehabilitation programs.
In the 1950s, grassroots movements and organizations, usually beginning in churches,
became a more local, urban way of fighting addiction problems.
Christian communities against addiction continued to expand from the 1970s to the
1990s, growing in numbers as recovering addicts joined the movement. A new standard
of awareness for how to approach addiction reached Christian communities at the end
of the 20th century, such as modern intervention models and the face of addiction in
different subcultures.
Some Christian residential rehabilitation centers are places where people live together in
therapeutic communities.
Residential rehabilitation centers
• Teen challenge in USA
• Betel
• Remar
• Reto
• Residential rehabilitation centers
• Teen challenge in USA
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• Betel
• Remar
• Reto
here are also many individual programs that can be derived from biblical principles.
Among them are various non-residential 12 step church programs, as well as self-help
groups which are implemented by the non-governmental sector. All share the same goal
and belief that faith in God ultimately can lead to escape from the vicious cycle of addiction.
5 Key Points: How a Christian Approach Can Bring Recovery to an Addict
• Love and Acceptance
Most addicts deal with the problem of rejection. It is a ripple effect caused by their
deviant and criminal behavior. It makes those around them keep their distance, and so
eliminates possible help. Faith brings the understanding that God loves them and has
always loved them –even when they were at their worst. This understanding brings
change. They are not alone nor rejected and such unconditional love can change them in
the sense that they no longer want to be what they were.
• Forgiveness
In the recovery process, every addict has to deal with his or her past. That is not easy,
since during their time as an addict, many have committed a wide range of crimes, from
pickpocketing to prostitution. Addiction is a force that overwhelms the person and shuts
down their conscience. It pushes one over the fence of the law and moral values in order
to satisfy a demanding urge.
While in that phase, addicts have no sense of wrong doing, just glimpses of conscience
here and there. But once abstinence is reached, many of their past violations start to haunt them. They often hold onto feelings of shame, resentment, hurt and guilt. They can’t
embrace their newly found freedom. If addicts are not helped in this stage, it can sometimes become a stumbling block in achieving the goal of sobriety. In order to resolve the
psychological conflict within, they reach for the well-known numbing solution.
The Christian approach introduces God’s grace and forgiveness, presenting acceptance
of that grace and forgiveness as a solution to the conflict within. God sets a clear line
between the past and the future of the individual. Addicts experience the greatness of
God’s unconditional love deep in the core of their being, realizing that this includes them
as well. His love offers forgiveness for everything, regardless of how dark and lawless it
was. There is a profound sense of appreciation and rejection of the old life accompanied
by a deep desire for a fresh new beginning.
Through forgiveness they experience complete acceptance, and the opportunity for a
second chance in life free from the burdens of their past. This is very important for the
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integration of each person. As we mentioned, many who establish abstinence but do not
experience forgiveness, cannot leave the past behind. This may cause a relapse.
Forgiveness is vital to the person’s ability to move forward with their life in a positive and
productive manner.
• Setting New Priorities
If we were to describe the life of an addict in one word, it would be: mess. Everything
that should be a priority is in last place and everything that meets his/her own personal
needs is in first place. Addicts are egocentric, thinking only about themselves. They live
life with no responsibilities whatsoever.
A key thing that brings about a change in thinking and behavior is a biblical priority list
which is totally counter to our own. God is in first place, others are in second place and I
am in third place. This is difficult to understand even when we are not addicts, right? In
a world and in a time when we have needs of our own, how do we deny those needs and
put ourselves in third place? How do I tell myself “no”, when “I” is written with a capital
letter? It’s not necessarily about self-sacrifice, it’s about putting God’s values in first place.
This means putting those around us who are in any kind of need in second place. This
may be our family, friends or some unknown person whom we suddenly want to help
even though their situation doesn’t directly involve us. The point of priority 2 is very
important in the recovery process because God is invisible and abstract, but the people
around us are flesh and blood. By serving and helping them we serve God, too.
Do I still exist? Well, of course. I still have to eat, to drink, to love, to rejoice, but the
important thing is that I’m not always focused on myself. Putting myself out of focus
means living not by my terms and preferences and not always thinking of what I need.
It means thinking about what God wants, and how to be helpful to others. It brings a
totally new way and purpose to life. The result is a change in addictive behavior disorder.
If we maintain these principles this change can cause sustainable value that helps the
person to recover.
• Belonging And Fellowship
A very important thing that can enable changes is the sense of belonging and fellowship.
Man was created as a social being and therefore he is searching for groups where he will
feel that he belongs. Let us consider the period of addiction. These people had a problem
in that they were members of a group that did not have a positive effect on them. There
was no larger goal or intention and they felt a lack of support because everything was
based on the addictive substance. Of course it is clear that if we were part of a group that
met every day to consume drugs, as much as we lied and deceived ourselves at the time,
we knew very well this was a group that didn’t push us forward. Instead, it made us fail.
It is important for people in the recovery process to be surrounded by those who have a
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goal and purpose and who are working for the benefit of themselves and others. When
this happens in community character traits and values are changed. The basic human
need to be part of something that is positive is satisfied. In that situation people function
not at 100% but at 200%.
Support from understanding people is also very important. Those in recovery find people who believe that they are not rejected, to whom they can be accountable, and that
can give support to them in any situation in life. Whatever you are doing in life, you must
agree that we all need support.
• Influence of Example
Have you ever been in a public place where addicts are injecting drugs; perhaps in Karachi, the junkyards in Madrid, or at the railway station in Frankfurt? The picture is
startling. When we see these kinds of things we often come to the conclusion that there
is no way out, the above examples show us that.
But there is another part of the story. We need to look at the end of those arrows from the
first part of the presentation. Examples of recovered addicts show us that victory over
addiction is possible.
A Christian-focused approach helps addicts not only to recover; it also finds ways to
help them serve and work within the community. Addicts who undertake recovery in a
Christian setting will likely be invited to participate in various volunteer service activities, providing opportunities to engage with the community in a positive and constructive way. Such opportunities can strengthen the self-esteem of the recovering addict and
help show them that they can be valuable members of society. In fact, many recovering
addicts go on to become active participants in Christian service organizations that try to
help other addicts through the recovery process.
These positive examples can help those who are still addicted take steps towards recovery. Recovery is not self-centered. I have recovered, but I am there for others. Let’s not
forget that we have the opportunity for influence in everything we do. Through my experience in the Balkans and RUN, I could tell you about many recovered people whose
recovery is not only for them; with their positive example they also contribute to the
community.
Their family members are no longer afraid of what will happen tomorrow. Their neighbors live in peace and they see that there is someone who protects and sustains them;
not someone who will rob them. Employers are happy because these people are a living
example of trying to justify that before-mentioned second chance.
Moreover, recovered people are examples of winning in life and we all need these examples, they are the best fuel for society, no matter in what field. A lot of time we think of
addicts as a problem, but society needs winners.
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These key points have a potential for increasing understanding of the role of the Christian approach in substance-use recovery, developing research-based interventions to
manage addiction and uncovering important constructs about addiction recovery for a
future study.
Balkan Miracle
I left the story about the region where I live for last. This is a region that has spent the
end of the last century experiencing and recovering from war and where transition is
still ongoing.
In the 1990s people began to go to Christian rehab centers after seeing examples of positive things happening there. Many were grasping for straws. In finding a means to
become free from addiction they also found faith. Rehab centers were free and self-sustaining, with no restrictions on how long one could stay there. There were no obstacles
that could cause a termination of rehabilitation.
People who had resolved their problems left rehab with new values and returned to their
communities to begin their lives again. They started with nothing but with a view to the
future and a resolved past because of the forgiveness they had experienced. Thanks to
their new priorities (where God is in first place and others in second) they could impact
those who were still in trouble, encouraging them to take steps towards victory.
The result was the opening of even more rehab centers and the emergence of NGOs
that dealt with the integration of former addicts into society. More and more churches
decided to devote attention to this population. A culmination of this collaboration is the
annual conference which is organized by an NGO in Sarajevo. Its purpose is to strengthen and encourage recovered addicts. Another important aspect to the conference
is networking between Christian organizations. Attendance at the conference and the
resulting relationships grow from year to year and can only strengthen the argument
that a Christian approach is a solid and effective one. It can lead to the desired result of
appropriate behavior and integration of the person as an active and contributing member of society.
Statistics show that 5,500 people have passed through Christian rehab centers in this region. About 20% (1,100 people) completed various programs ranging from 18-24 months. Of those 1,100, 80% (about 900) are still abstinent and have been integrated into
society (5).
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Conclusion
A Christian approach in the Balkan region
While the results in other regions may differ, I would like to conclude by emphasizing
what is happening in the Balkans.
Achievements:
• Very good results in the fight against drug abuse,
• Huge influence on recovered drug addicts,
• Good response from the professional community to minimize marginalization
and skepticism regarding the cure of addiction,
• Satisfactory cooperation with institutional treatment programs.
Challenges:
• Little impact of Christian rehab centers and NGOs on drug policy issues in
these countries,
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• Huge rate of unemployment among recovered addicts (because of the economic situation in the region).
Finally, I would ask the question “Is it worth believing even when it seems there is no
hope?” Statistics and the pictures we see of addiction can keep us from saying to the
addict, “You deserve a chance. We will support you. We will develop programs using a
holistic approach to bring you to a place of victory.”
Let us not get stuck in the stabilization phase which can create a surreal world where
addiction still plays the primary role. Let us not think that reaching a fragile abstinence
is the end. We must all work together in this process of leading the addict all the way to
the tip of the arrow which is complete recovery and integration.
In this way we will see those examples which show that overcoming addiction is possible. Our society and the world in which we live need this.
‘Love the Lord your God with all your heart and with all your soul and with all your
mind.’
‘Love others as you love yourself.’
‘All the Law hangs on these two commandments.’
Holy Bible
REFERENCES
(1) Available at www.EMCDDA.europa.eu
(2) “Scottish Government 2008 Road to Recovery: A New Approach to Tackling Scotland’s
Drug Problem”.
(3) Magura, S. The Combined effects of treatment intensity, self-help groups and patent attributes on drinking outcomes. Journal of Psychoactive drugs. 2005; 371 (1), 85-92.
(4) Stephen R. Honaker, LMHC, is a Christian Program Counselor for Recovery Associates.
(5) Statistics were collected from 3 rehab centers. Reto (Split, Croatia), Remar (Belgrade, Serbia)
and Duga (Novi Sad, Serbia).
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Bronwyn Jane Myers*
Alcohol, Tobacco and Other Drug Research Unit, South African
Medical Research Council
Katherine Sorsdahl
Centre for Public Mental Health, University of Cape Town
ABSTRACT
Traditionally, substance use services have not been provided at South African primary health care facilities, limiting access to treatment. A lack of mental health workers has slowed plans to integrate these services into the primary health system. This has prompted
calls for the task-shifting of some treatment responsibilities from mental health specialists to non-specialty health workers.
We present findings from three projects that used a task-shifting approach to integrate brief interventions (BI) for substance use into
primary care. The first involved the horizontal integration of nurse-led BI services. In our 3 month evaluation, we found significant
reductions in substance use (p<0.001). The second involved the vertical integration of a community health worker-delivered BI within
emergency services. In a randomised controlled trial, participants were assigned to a session of motivational interviewing (MI), a
5-session blended MI and problem-solving therapy (PST) intervention, or a control group. At 3 months, ASSIST scores were significantly
lower in the MI-PST group than in the other groups (p<0.001). Third, we horizontally integrated a nurse-delivered BI intervention into
an antenatal clinic. There was low detection of alcohol use, however tobacco use decreased significantly following the intervention
(p<0.001). Through task-shifting, substance use services are feasible to provide in primary health care within low-and-middle-income
countries. It remains unclear whether it is more feasible, acceptable and effective to integrate these services into primary care using
horizontally or vertically integrated approaches.
These questions need to be answered in order to guide the implementation of these new health services.
Keywords: substance use, primary care, task shifting, integration, South Africa.
* Dr. Myers is a Chief Specialist Scientist in the Alcohol and Drug Abuse Research Unit of the South African Medical Research Council,
where she heads up the treatment and other interventions sub-stream.
Dr. Myers has more than ten years research experience. Her recent work includes a trial of a women-focused intervention to reduce
drug-related sexual risk and violence, a trial of an intervention to reduce sexual risk for HIV among couples who drink alcohol, a trial of
problem solving therapy for patients in emergency department settings and ongoing efforts to develop and implement a performance
measurement system for South African substance abuse treatment services.
Dr. Myers also has considerable experience as an addictions clinician and her experience includes working with service providers to
implement evidence-based practices and address barriers to care. She has an honorary appointment at the level of associate professor
with the University of Cape Town’s Department of Psychiatry and Mental Health where she maintains teaching and supervision duties.
Dr. Myers has published prolifically on the topics of substance use disorders, vulnerable populations, HIV, access to treatment and
provision of evidence-based practices for substance use disorders.
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ADDRESSING SUBSTANCE USE WITHIN PRIMARY HEALTH CARE SETTINGS IN SOUTH AFRICA:
OPPORTUNITIES AND CHALLENGES
Addressing Substance Use within Primary
Health Care Settings in South Africa:
Opportunities and Challenges
Background
Substance use disorders represent a major public health problem, both globally and
in South Africa. Data from a recent, nationally representative community sample, the
South African Stress & Health study (SASH), indicate a high lifetime prevalence (13.3%)
and early onset (21 years) of substance use disorders (1). Compared to the other provinces in the country, the Western Cape appears particularly affected by substance use
disorders. For example, the SASH study found significantly higher lifetime prevalence
rates for substance use disorders in the Western Cape compared to the other provinces.
This is concerning given evidence that the availability of substance abuse treatment services is limited in the Western Cape (with existing services largely overwhelmed by the
demand for treatment) (2).
One way of improving access to treatment in South Africa is to increase the range of
treatment services available to ensure that services cover the full continuum of care (2).
The existing substance abuse treatment system relies heavily on the provision of high
threshold treatment services offered by specialist service providers, with few low-threshold early intervention services available at a primary health care level. This limits access
to care as high threshold services are costly to provide. Apart from limited availability of
these services (with only about 16,000 treatment slots available annually), there are also
well-documented structural issues to accessing these services including affordability and
geographic access barriers (3, 5). Other barriers to treatment utilization include low rates of perceived need for treatment among people who may benefit from these services;
often people only seek out treatment when their problems have become very severe and
require intensive services (5, 6). Increasing the repertoire of substance use services to
include lower threshold intervention services that focus on providing screening to facilitate early case detection, brief interventions and (where needed) referral to more intensive treatment may be a cost-effective way of expanding access to care.
Evidence from high-income countries suggests that screening, brief intervention, and
referral to treatment (SBIRT) for substance use disorders is effective for addressing mild
to moderate substance-related problems and is feasible to implement in health services
(7, 8). To date, there has been little evidence from South Africa about the effectiveness
or feasibility of implementing SBIRT for substance use problems in health services. Providing SBIRT in primary health care settings is a widely supported strategy for incre244
asing the detection of substance-related problems among people who may present for
primary care services but who would not ordinarily seek out substance use or mental
health services (9). Proponents argue that SBIRT would not only improve patient’s lives
by preventing the progression of their substance us disorder but would also result in
cost-savings to the health system. As substance use often contributes to risk for injury,
and poorer chronic communicable and non-communicable disease outcomes, and because these health problems increase health service utilization and costs, the detection
and treatment of substance use disorder is critical to an effective and functioning health
system (10).
Despite the potential benefits of integrating SBIRT services for substance use into the
primary health care system, such services have been absent from primary health care
services in South Africa (11). This is partly because of limited capacity to deliver additional mental health services in low-resourced and chronically overburdened health services and the limited availability of specialist mental health staff in LMICs (12, 13). Task
shifting SBIRT for common mental disorders (including substance use disorders) from
specialty to non-specialty health workers has been widely proposed as a strategy for
expanding access to substance use and mental health care in countries with few mental
health specialists (12, 13). The World Health Organization has identified four levels of
task shifting in which mental health care tasks previously undertaken by mental health
specialists are shifted to non-specialist doctors (level 1), nurses (level 2), community
health workers (CHW, level 3), and people living with these disorders (level 4); with specialists providing supervision and training to non-specialized cadres (12, 13). South Africa’s non-communicable disease policy framework (2013-2017) embraces task shifting
from senior cadres to level 2 and level 3 staff (who comprise the bulk of health workers)
as a strategy for expanding access to and the integration of substance use services into
primary care settings (14). However this integration has been hampered by unanswered
questions about how to include SBIRT for substance use into primary care services so
that these services are acceptable to patients and providers, and feasible to implement
with few additional resources.
In this paper, we reflect upon the lessons learned from three pilot studies that attempted
to integrate SBIRT for substance use into primary health care services. We will present
an overview of each study; evidence of its feasibility, acceptability and impact on substance use outcomes; and the challenges to implementing these programmes as planned.
245
Methods
We present three case studies of efforts to implement SBIRT programmes for substance
use into primary health care settings within the Western Cape Province of South Africa.
• The Jooste day hospital project
This SBIRT programme emerged from the realization that for one day hospital in the
Western Cape, at least 80% of the 250 patients seeking psychiatric services on a monthly
basis had a substance-related psychosis. This led to the creation of a SBIRT programme
delivered at a substance use center located within the hospital and staffed by a social
worker, an auxiliary social worker and an administrative/research assistant. At this hospital, the process of delivering SBIRT was as follows. All patients presenting for services
at this hospital were screened for potential substance use by nurses and any suspected cases of substance use were referred to the substance use center for further follow
up. Patients referred to the center were provided with verbal and written information
about the programme. The auxiliary social worker then re-screened the patient using
a modified version of the ASSIST (Alcohol, Smoking, and Substance Involvement Screening Test) (15) to screen for the presence of problematic substance use. For patients
with moderate or high ASSIST scores, the social worker delivered a brief intervention
(based on motivational interviewing), conducted by the social worker, was provided to
the patient immediately following the screening. As participants in the high-risk group
were more likely to have a substance-related health condition or suspected substance
dependence, they were referred for further care to specialist substance abuse treatment
centers following the brief intervention. An independent external evaluator conducted
the outcomes evaluation of this programme (16). This evaluation used an uncontrolled
one-group pre-test post-test design. All participants who were enrolled into the programme participated in the evaluation. At the three month follow-up, the ASSIST was
re-administered by the administration clerk to all patients and a feedback questionnaire
about the services was completed.
• Substance Use and Trauma Intervention (Project STRIVE)
Most primary care clinics in South Africa have level 1 emergency departments that are
open 24 hours and deal with injuries and other serious medical conditions requiring
emergency medical interventions. In low income communities in the Western Cape,
more than 50% of the cases presenting for these services are related in some way to alcohol or drug misuse. Incidents of violence and injury increase over weekends. The goal
of this project was to help reduce high levels of substance-related violence and traumatic
injury seen in these settings through providing patients presenting for emergency services with SBIRT for substance use. The SBIRT programme went through a thorough
development process that included an epidemiological study to assess the coping strategies and problem-solving styles of people who use substances (17), in-depth interviews
246
with health care workers to assess what would be feasible and acceptable to implement in
their context (18), expert interviews with stakeholders, and a pilot–test of the intervention with patients to examine initial outcomes and responses to the intervention (20).
We then adapted the SBIRT package prior to testing it in a small randomized controlled
trial.
In this trial, the process of care was as follows: Community Health Workers (CHWs)
especially employed to provide this new service approached patients for screening after
they had been triaged for illness or injury severity and while they were waiting for a
consultation with the attending doctor. Patients were eligible if they were ≥ 18 years of
age and if they were at moderate to high risk for substance use problems, as measured
by the ASSIST (15). Exclusion criteria included a severely altered mental status, being
physically incapable of participating due to severe illness, and being without any detailed
locator information. Patients were screened and recruited at varying times during the
day and during at least one 12-hour night shift on the weekend (7pm–7am) in order to
reflect the busiest periods of the selected departments. Patients who consented to participate in the programme were asked to complete an interviewer-administered baseline
questionnaire which included questions on substance use, injury and other health risks
that took approximately 45 minutes to complete. After this assessment, participants were
randomly assigned to one of three conditions.
The three conditions comprised of one session of motivational interviewing (MI), 5 sessions of a blended MI-problem solving therapy (PST) intervention, and an information
only control arm. The 4 session intervention focused on building motivation to change
and developing and practicing skills to address life problems. These sessions were spaced
approximately one week apart and were between 45 and 60 minutes in duration. During
these sessions, the counsellor and the participant collaborated to identify problems occurring in the participant’s life, and focused on exploring one or more of these problems
while the counsellor taught the participant a structured PST approach to addressing
problems (20). The baseline assessment was re-administered three months after the initial assessment.
• Antenatal Personal Support Project
The goal of this project was to help improve maternal and infant health outcomes by integrating SBIRT for common mental disorders into free midwife-led antenatal services.
This pilot programme was offered at a maternal obstetric unit located within a large impoverished community in Cape Town. As part of their initial first contact with antenatal
care, all pregnant women attending the MOU were screened for depression by the nurse
responsible for recording their medical history. Women who scored at risk for depression were referred to psychiatric services for further assessment and care. Following this
initial screening, women were referred to the HIV counsellors based at the MOU who
were responsible for conducting HIV testing and counselling (HCT). These community
247
health workers (CHW) were trained to screen all pregnant women for alcohol, tobacco
and other drug (ATOD) use using the ASSIST (15). If the women screened positive for
any alcohol, tobacco or drug use, these CHWs provided them with a brief intervention.
This brief intervention is based on the ‘5 As’ Smoking Cessation Clinical Practice Guideline, an intervention specifically adapted for use with South African pregnant women
(21). The 5A’s for tobacco cessation consists of the provision of a 10–15 minute counselling session by a trained provider that consists of five steps: asking the patient about
their tobacco use, advising every tobacco user to quit; assessing the patient’s readiness
to change; assisting willing patients to quit, and arranging a follow up visit to assess the
patient’s success in quitting. It also includes the provision of pregnancy-specific self-help
education materials. Not only is the 5As intervention regarded as the best practice for
brief tobacco cessation counselling, but has been shown to be effective in the South African context (21). This intervention was adapted to address alcohol and other drug use in
addition to tobacco use. Following the brief intervention, patients who screened at high
risk for substance-related health problems and who were likely to have a substance use
disorder were referred for further care to specialist substance abuse treatment centers.
We evaluated the feasibility, acceptability and initial outcomes of this programme by extracting data from clinical records, assessing patient’s responses to the intervention and
exploring providers’ views of the feasibility and acceptability of the programme.
Results
1. The Jooste day hospital project
Universal screening was not implemented, rather there was “case-finding” by nurses
Overall, 127 patients using substances received an intervention from the GF Jooste
Hospital. Among these participants, the most frequently reported primary substance
of abuse was methamphetamine (30%), followed by alcohol (26%) and cannabis (26%).
Poly-substance use was reported by 44% of participants.
Response to the intervention
Of these 127 patients, 68% received screening, a brief intervention and referral for specialist substance abuse treatment, while 32% received screening and a brief intervention
without referral for further treatment. Overall substance use involvement scores decreased significantly following the intervention (pre-intervention: M=37.60, SD=8.433;
post-intervention: M=17.02, SD=17.19, t (72)=10.89, p<0.001). Reductions in the use of
all classes of drugs were found.
Referral to care was poor
Uptake of referrals to specialized treatment was poor with less than 50% of those who
were referred utilising these services. Patients reported attitudinal and structural bar248
riers as reasons for not attending further care. Of those that did attend treatment services, only 55% felt that the facility met their needs.
• Substance Use and Trauma Intervention (Project STRIVE)
Feasibility of universal screening
In the implementation period we screened more than 2700 patients, of whom 19% met
inclusion criteria. Of these, 74% were willing to participate in the programme indicating
high levels of acceptability to patients. Providers however suggested that approaching
intoxicated, injured and aggressive patients was sometimes challenging and reported
using active case detection methods rather than universal screening.
Feasibility and acceptability of intervention
Only 58% of patients completed all five sessions. Patient feedback revealed that 3 to 4
sessions was the preferred duration of the intervention. Patients found the intervention
materials and content highly acceptable. Providers thought that a CHW rather than a
nurse-delivered intervention was more feasible to implement in a busy emergency department setting. They noted that for the programme to be implemented properly they
would require additional CHWs dedicated to the delivery of this programme (19, 20).
Initial outcomes of Project STRIVE
There was a significant effect of intervention type on substance use outcomes, with Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) scores significantly
lower in the MI-PST condition relative to the combined MI and CG control groups (adjusted mean difference of -1.7, 95% CI: -3.36 to -0.08) at 3 month follow-up. There were
no significant differences in substance use outcomes among participants randomized to
the MI condition and those allocated to the CG. In addition, there was a significant effect of intervention type on depression outcomes, as measured by the Centre for Epidemiological Studies Depression (CES-D) scale. Participants in the MI-PST group reported
less depressed mood at three months compared with those in the combined MI and CG
conditions (adjusted mean difference of -3.33, 95% CI: -6.24 to -0.42). Further a linked
cost-effectiveness analysis suggested that the targeting of MI-PST to high need services
would be the most efficient use of limited resources.
• Antenatal Personal Support Project
Feasibility of conducting universal screening for substance use
Over a period of 6 months (August- January 2013) a total of 3,407 women presented at
the MOU for their first antenatal visit. Of these, only 1,468 (43%) women were screened
for maternal mental disorders. In addition, we found lower than expected rates of ATOD
use disclosure for this population. Of the 1,468 women who were screened, 302 (21.4%)
met criteria for depression, 388 (26.4%) disclosed smoking tobacco, and 29 (2%) disclo249
sed alcohol and other drug use. Of the 302 who met criteria for depression, only 15 (5%)
were referred for further treatment.
Women’s preliminary responses to the intervention
Results from the three-month evaluation indicated that participants significantly decreased their tobacco use following receipt of the 5A’s intervention and psycho-educational materials (pre-intervention mean 18.16±2.5, post-intervention mean 4.24±1.75, t
(73)=3.45, p<0.001). Of the 29 women who disclosed alcohol and drug use, 15 completed the follow-up interview. Among these women, there was no significant reduction in
alcohol and drug use following receipt of the intervention.
Health care workers’ perceptions of barriers to delivering SBIRT
All of the healthcare workers interviewed were in favour of the continuation of this pilot
SBIRT programme, however they did identify areas of concern. First, they reported an
increase in their workload following the implementation of SBIRT into the antenatal
services due to additional responsibilities associated with screening, providing the brief
intervention and/or referral to specialized services. They also reported a lack of consultation regarding the expectations of them and their expanded responsibilities under
this new programme. Third they reported that women were not willing to disclose their
ATOD use and this hindered the uptake of the programme. They also noted that SBIRT
was very challenging to implement without a sustainable referral pathway in place. According to respondents, the main reasons for this was a lack of specialist psychiatric
services in the area, including within nongovernment organizations (NGOs) serving the
local community.
Discussion
South Africa is overwhelmed by a high prevalence of untreated substance use disorders
coupled with limited availability of treatment facilities to reduce the burden of these
disorders. SBIRT in primary health care settings has been proposed as a strategy for expanding access to care and improving the early detection of people with potential substance use disorders. This paper presents an overview of three pilot studies that attempt
to introduce SBIRT into primary care settings within a task-shifting framework. All of
these studies demonstrated that when using evidence-based interventions that are implemented with fidelity, SBIRT approaches can lead to clinically significant reductions in
substance use involvement and also have secondary benefits in terms of improving other
indicators of poor mental health (for example, depression) that are often associated with
greater substance use involvement. This is among the first evidence for the effectiveness
of SBIRT for substance use from low and middle income countries. These findings hold
even when the delivery of these interventions is task-shifted away from mental health
specialists to nurses without mental health training (tier 2) and even community health
workers (tier 3).This suggests that SBIRT can be effectively implemented and has the po250
tential to have a positive effect on substance use outcomes in low-resourced health care
settings, with relatively little additional investment in costly human resources.
Apart from emerging evidence of the effectiveness of these approaches in a low and
middle income country setting, these three studies also demonstrate the acceptability
of introducing SBIRT within a task-shifting framework to both patients and providers.
In all studies, providers reported that they thought the SBIRT model was important and
added value to their clinical practice. Patients demonstrated that this was acceptable
by having high numbers of patients who were potentially eligible for participation in
the programme actually enrolling in the service and by having relatively high rates of
retention in the services (even for the longest intervention). Together these findings
demonstrate that introducing SBIRT into primary health care settings may provide an
opportunity to expand access to care and reduce the negative health outcomes associated
within continued substance use involvement for a cohort of patients who are unlikely to
access stand-alone substance use services.
However there are some lessons we learned through implementing these programmes
that require careful consideration before rolling out SBIRT more widely in primary care
settings. First, in all three pilot programmes, health workers failed to conduct universal
screening of patients for substance use disorders. We found that nurses were too busy
with routine care to universally screen all patients presenting for services. Instead they
conducted their own case-finding in which they only screened patients where they had a
high degree of clinical suspicion that the person may be using substances. This finding is
not altogether surprising as other studies in this low-resourced and over-subscribed health care system have also reported that health care workers tend to case-find rather than
universally screen patients for mental health difficulties (22). Future iterations of SBIRT
in primary care settings may wish to consider two alternative approaches to universal
screening. In populations where any substance use is considered dangerous and needs to
be intervened with (such as pregnant women or patients with traumatic injuries), health
service planners may want to consider using technology-based screening tools such as
quick biological screens or self-administered computerized assessments that occur at the
point of care to ensure that universal screening occurs and does not rely on busy clinic
staff to implement it. In populations where any substance use is highly stigmatized, this
might also improve substance use disclosure rates. Second, while SBIRT for substance
use disorders has been advocated for all chronic disease patients (e.g., for HIV, TB, hypertension )in resource rich settings, it is probably not feasible to conduct SBIRT for all
chronic disease patients in less resourced settings due to the additional staffing resources
and time needed. It may be a more efficient use of scarce health resources in chronic
disease care services to only screen patients for substance use involvement if they are
not adhering optimally to their health regimen or have unexplained poorer responses
to treatment.
251
The second lesson we learned relates to the continuum of care. In all three pilot programmes, the “referral to treatment” arm of the SBIRT programme was problematic. In
some instances, health workers did not know or have any local resources to which they
could refer patients for further specialist care. In other instances, referral uptake was limited due to structural barriers to accessing care. More concerning were reports among
the small proportion of patients who did take up their referrals that the care they received was not completely to their liking. Together, all of these findings highlight the need
to strengthen referral to treatment. It is probably not feasible to create a whole set of new
resources to which to refer patients to care. To address this barrier, we have proposed
utilizing brief interventions (BI) that are slightly longer than the one session BI that
is commonly implemented in primary care settings. In our earlier feasibility work we
found that patients actually wanted more counselling sessions than we provided and said
that they would be willing to attend 3 to 4 intervention sessions (19). While this is still
within the definition of a brief intervention it is more than what is traditionally provided and in psychotherapy terms can be defined as a short treatment. This would partly
bridge the gap between BI and referral to more specialized care. These BI may also need
to be supplemented with case management strategies to help effectively link patients to
more specialized care when this is indicated. Case management strategies (23) can be an
effective tool for helping overcome some of the structural barriers to accessing specialist
care that many patients with substance use disorders experience. Finally, to successfully
link patients to specialist treatment, more work needs to be done to ensure that available
services are a good fit for this population. Several studies have reported patient dissatisfaction with substance use treatment services in South Africa, highlighting the need
to work with organizations providing these services to improve the quality of care they
provide and ensure that it meets the needs of the patients they serve (2, 5).
We also identified several gaps in our knowledge of how to integrate SBIRT into primary
care settings that need to be addressed prior to implementing this programme more broadly in South African health care services. First, while we have demonstrated positive
outcomes for these SBIRT programmes, we need more information on the durability
of these outcomes and whether patients were able to maintain the reductions to their
substance use over at least a 12 month follow up period. We also need more evidence of
the cost-effectiveness of these approaches so that we can build a business case for why
the health care system should move to implement this new programme. Further, we
need more certainty about whether the health care system should adopt a horizontally
integrated (HI) approach to delivering substance use services within primary health care
services or a vertically integrated (VI) service. In a HI approach, level 2 staff (such as
nurses) without specialty mental health training would be designated to provide additional mental health care and support to patients in addition to their usual chronic disease
duties. In contrast, in a VI model where task-shifting is adopted, mental health care
would be delivered by level 3 staff (such as CHWs) who are part of the collaborative care
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team but whose sole responsibility is the provision of SBIRT for mental disorders (24-5).
While the merits of both models of integrated care have been outlined for other types of
health services, (24-5) there has been no studies comparing the relative effectiveness of
VI or HI models on substance use outcomes. On one hand, level 2 cadres in a VI approach would have more health training and exposure to mental health issues than level 3
staff, and these differences in training could impact on mental health outcomes. In contrast, nurses in a HI approach would have many other responsibilities that may limit their
ability to practice and develop substance use intervention skills and the amount of time
they have to provide SBIRT which could impact on the effectiveness of an HI approach.
More research on the relative impact and cost-effectiveness of each model of integrated
service delivery is needed so that these questions can be answered.
In conclusion we have shown that SBIRT is a promising approach to reducing substance
use among patients presenting for primary health care services in a low resourced setting, however more work needs to be done to improve screening detection rates and referral to care. Also, evidence on whether VI or HI models of service integration are more
effective and cost-effective for improving substance use outcomes is needed before the
health system can proceed with integrating this service package in primary health care.
253
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256
Cenk Yancar*
Oya Bahadır Yüksel Center for Youth, Gaziantep
ABSTRACT
People with drug-related problems often have multiple treatment needs across a range of personal, social and economic areas. Oya
Bahadır Yüksel Treatment and Rehabilitation Centre was founded to meet those different needs of addicted kids and youngster, help
them to stop using drugs and cure the drug-related illnesses, to provide a healthy life and help them to be self-sufficient in their life.
Oya Bahadır Yüksel Treatment and Rehabilitation Centre plays an essential role in the purification of youngsters, providing a healthy
life and support them to realize their strengths and build self-confidence. The treatment process in Oya Bahadır Yüksel Treatment
and Rehabilitation Centre is diversified for individual needs. Basically the process is made up of psychiatric assessment, treatment of
withdrawal syndrome, treatment of other drug-related illnesses, individual therapy programs (motivational therapy, cognitive-behavioral therapy), family therapy and group therapy, psycho-educational workshops, 12 Steps Programs, NA meetings. Together with these
treatment processes it also has rehabilitative activities to keep them away from drugs and help their reintegration to society.
During their treatment process also educational and occupational life is planned for their future, at the end of the treatment they either
attend educational institutions or they get a job for a self-sufficient life. After treatment process, municipality provides them half-way
homes for their follow-up process so that they can have still protection to stay away from drugs.
Treatment process also involves parent and families in which way we can also see the family-related problems and solve the malfunction dynamics of family.
Local governments have the responsibility to create a healthy environment for society and protect kids and youngster the legislative
framework and provisions of Oya Bahadır Yüksel Treatment and Rehabilitation Centre relies on that responsibility of Gaziantep Metropolitan Municipality.
Keywords: Drug Abuse, Treatment, Rehabilitation, Legislation
* Dr. Cenk Yancar was born in 1975 in Istanbul. He graduated from Istanbul University Çapa Faculty of Medicine, worked as the Psychiatry
Specialist of Amatem Clinic at Bakırköy Psychiatry Hospital in 2006. He has been working as the general and clinic director at Gaziantep
Metropolitan Municipality Oya Bahadır Yüksel 50 bedded Adolescent Addiction Treatment and Rehabilitation Center since 2008. He
received Certified Addiction Professional 3 (the education and power to make treatment, educating training and supervision in the field
of addiction) by the Middle East Certification Board Certified Addiction Professional 3 between 2011 and 2013. He attended trainings at
several centers in the field of adolescent addiction treatment and rehabilitation.
2009 Mountain Manor Treatment Center, Baltimore/USA Adolescent Addiction Treatment
2009 Caron Addiction Treatment Center, Pennsylvania/USA Adolescent Addiction Treatment and Rehabilitation
2010 Tactus Addiction Treatment Organization, Nijmegen/Netherlands Addiction Rehabilitation Models
2011 Tactus Addiction Treatment Organization, Nijmegen/Netherlands Treatment Approaches for Drug Addiction
257
OYA BAHADIR YUKSEL TREATMENT AND REHABILITATION CENTRE
Treatment and Rehabilitation Model for
Children and Adolescents in Gaziantep
Metropolitan Municipality
Recent industrial growth, immigration and increase in population in Gaziantep resulted in economic and social problems. This affects families, especially young people and
children, and substance abuse increases together with the number of children living on
streets and the child labor problem gets more severe.
According to Tubim report in 2013, in Gaziantep where there is no AMATEM, it is ranked in the 5th place regarding the place of residence of the inpatient treatment patients
and in the 4th place in direct death cases due to drug use (1).
In our city, approximately 1,000 children and adolescents are estimated to be living or
working on streets.
Our municipality is serving to solve substance abuse in children and adolescents who
live and work on the streets through 3 centers, namely Münir Onat Center for Children
and Youth, Akınal Center for Children-Youth and Families and Oya Bahadır Yüksel
Center for Children and Youth.
Metropolitan Municipality’s activities regarding this issue date back to 1997. Children
determined to have been working on the streets, brought in by families or other official
institutions are evaluated first before being accepted to the suitable centers or referred
to outpatient treatment program.
If the children or adolescents under risk don’t use drugs or have just started using them,
they are accepted to Münir Onat Center for Children and Youth to continue active education if they don’t have a healthy environment in which they can live with their families. Children who will be referred to working or obtaining a profession are accepted to
Akınal Center for Children-Youth and Family Center. Two centers have a total capacity
of 33 beds and children older than 12 years are also accepted.
In 2013, Münir Onat Center for Children and Youth provided 35 children with boarding care services. They continue their education and are supported by voluntary teachers in the subjects of English, Turkish, History, Geography, Physics, Chemistry, Math
and Geometry. Children were provided consultancy and counselling services and their
families were periodically met to offer consultancy and they were guided in terms of
how to access social resources based on their needs. Five of the boarding students went
to university. In addition, many young students benefited from the center’s facilities
(internet, library, and study sessions) during daytime.
258
In 2013, a total of 32 children were offered boarding care services in Akınal Center for
Children, Youth and Families. The Center helps children learn professions in the workshops and referred to vocational schools and young people who are too old for formal
education are ensured to continue their education via open learning education system.
In workshops, jewelry design, mosaic, candle-making, wood painting, watering art,
glass painting, wood works and carpenter services are offered. Activities to contribute
to the personal and social development of children are carried out during the year with
specialized teachers. Families of children working on streets are trained to raise their
awareness and these trainings are focused on dangers on the street, substance addiction,
effective communication, conflict resolution, and children-adolescent psychology.
In 2013, both centers admitted 67 boarding children. In addition, 24 children were determined as in need of protection and all of them were referred to Provincial Directorate of Family and Social Policies. With a Project that we conducted, we provided education support to 175 young individuals with limited finances. Various social, cultural and
sportive activities are organized for young individuals living in the centers.
Majority of street adolescents (up to 78%) use drugs (2-4). High levels of substance
abuse and the need for a different approach for children using drugs called for the establishment of Oya Bahadır Yüksel Center for Youth.
Adolescence is a phase where the risk of starting substance abuse is very high. Using
drugs during adolescence have adverse permanent and long-term effects on individuals’
brain developments. For example, 60% of adolescent addicts have a long-term abuse
story, 66% are involved in physical violence, 83% in other illegal activities, and 83% have
social, emotional and medical problems (2, 5). When the criminal adolescent profile
is examined, it is observed that 60 to 71% of them use drugs and using drugs is more
acceptable among those who commit crimes (6).
Oya Bahadır Yüksel Center for Youth
Based on these needs, our center has been offering its services since April 2008, with
the social responsibility awareness of Gaziantep Metropolitan Municipality, in shelter,
treatment, rehabilitation, education services, preparation to return to family and social
life for children and young people between the ages of 13 and 19 in Gaziantep who live
on the streets or with their parents, and who use drugs.
The center was built on a land of 15 decares (2,500 m2 closed space) allocated by Gaziantep Metropolitan Municipality, by Hüsnü Özyeğin Foundation using contemporary
architecture elements mixed with Seljukian architecture elements.
Treatment program and staff training were also organized and financed by Hüsnü Özyeğin Foundation. Dr. David J. Powell, deceased last year, who established programs and
built centers in China, Singapore, USA, Poland, Antigua and was lastly working in psyc259
hiatry clinic at Yale and his team created the program and training at the center. He had
contributed to creating the program at the center starting from June 2008 and provided
staff trainings and consultancy services at the center until he passed away. Programs
implemented in other centers were developed and implemented within 2 years by evaluating the results obtained at the centers by considering Turkish family characteristics,
culture, our traditions and our country’s specifications. Dr. David J. Powell was the president of International Center for Health Concerns and founding member of International Center for Drug Addiction Studies. He had been working on drug addiction since
1965. His books include: Clinical Supervision in Alcohol and Drug Abuse Counseling:
Principles, Models, Methods (2004), Playing Life’s Second Half: A Man’s Guide for Turning Success into Significance (2003), Clinical Supervision: Skills for Substance Abuse
Counselors (1980).
Our center aims to keep children and adolescents who are under social risk, inclined to
crime and who use volatile substances and drugs; and to reintegrate them in the society
by helping them improve physically, spiritually, mentally and educationally. To that end,
our center integrates treatment, education and vocational trainings.
The program is focused on children whose life experiences are failure, punishment and
disappointment and they are shown that there are many aspects of life in which they can
achieve by building a relationship based on trust and sincerity and they are given the
message of change instead of punishment. Instead of highlighting past events, we focus
on the present moment and we consider the troubles as an opportunity, not a problem.
In addition, treatment focuses on positive peer culture, compassion, kindness, family
and standards of judgment in the society.
Treatment Content
•
Psychiatric and medical evaluation,
•
Family structure evaluation and social investigation,
•
Treatment of deprivation and continuance of substances (for patients experiencing severe deprivation symptoms bound to the substance (especially alcohol and
heroin) are referred to the university for detoxification treatment and then taken
to the treatment program),
•
Treatment of comorbid medical and psychiatric disorders,
•
Individual therapy (motivational interviewing, cognitive behavioral therapy),
problem-focused family therapy, group therapy;
•
Psycho-training works,
•
12-step program and NA (Narcotics Anonymous) Meetings.
260
In group therapies the Safety Model (9) is adopted at the early phases of the treatment and
Matrix Model (10) is adopted in later phases. Early phase treatment model is configured
by evaluating life experiences of children living on streets, elements such as abuse and
crime; while long-term model is focused on relapse prevention and behavior changes.
Treatment requires therapy which maximizes long-term healing; establishing a healthy,
safe, supportive and companioning environment in which patients can be with their
peers; and supporting healing goals with family, education, job and lifestyle in order to
maximize the healing potential.
Patient Admission
Patient admission to the center is usually realized by mobile teams. This enables us to reach children who don’t apply to the treatment themselves, don’t seek any treatment and
whose drug abuse isn’t known to their families or considered a problem by them. These
street patients can be detected before experiencing serious legal and health problems in
early phases of substance abuse. In addition, children can be admitted via referral from
Police, mukhtars, universities, state hospitals, other official and civil institutions and organization as well as application of families.
Medical, psychiatric, legal, educational, social and family evaluation of determined
children and adolescents are performed before making a decision whether the patient
will be outpatient or inpatient; in case where the addiction is not the major element, they
are referred to other centers following short-term treatments. Patients are not treated or
admitted without their willingness to treatment as well as approval and participation of
their families.
Admitted patients are taken to a 6-month treatment program which consists of 3 phases
depending on the patient’s conditions. In each phase, possibility of patient’s returning to
their families and social life is evaluated.
1- Acute Phase (1 Month)
In this phase, substance influence is removed, patient orientation to the center is performed, and comorbid health and psychiatric problems begin to be treated. For each
patient, a treatment plan for their personal problems is also prepared along with the
continuing program. In every phase of the treatment, psycho-education, group and oneto-one therapies and 12-step program are implemented. In addition, class education
start and pre-evaluations are made for professional and artistic education in this phase.
Patients’ contact with the outside world is completely blocked. Center’s lawyer evaluates
the patient’s legal problems, if any, and intervenes. If addiction is not the major problem
in patient, they are usually referred to other centers by the treatment team at the end of
this phase.
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2- Primary Phase (2 months)
Influences of substances on patient’s life, reasons to use substance, coping with the desire
of taking substance, anger management and problem solving skills are reviewed during
this period. Damaged relationships with the family are tackled in this phase. Patient’s family is more actively involved in the process. Controlled contact with the outside world
and family visits begin. The patient is referred to outside activities through the rewarding system. Individual treatment plan is reviewed based on the patient’s behavior at
the center as well as within family and society. Moreover, trainings and skill enhancing
classes are focused on in this period.
3- Extended Period (3 months)
In this longest period of the treatment, the focus is on the patient’s adaptation to social
life, and patients are prepared for work life, family and social life. NA meetings start at
this phase. Directorate of National Education or Public Education Directorate is contacted for the patient’s incomplete education. Especially children who will continue active
education life restart their incomplete education within the treatment program. In the
extended period, patients who are too old for active education are also referred to vocational trainings in cooperation with İŞKUR. For children who go to school during
treatment and for those who go to İŞKUR trainings, separate programs are conducted
within the extended period. In addition, patients completing the 6-month program are
referred to a job according to their vocational education based on the plan created with
them and their parents. Evaluating patients’ living environment, families and psychiatric state in this phase, patients with good social support and can return to their families
are discharged at the end of this phase. Their treatment continues with follow-up through outpatient treatment program. Majority of the patients are discharged at the end of
this period.
Yarıyol Evi (House of Halfway)
It is one of the major legs of the treatment supported by two institutions in Gaziantep
together with the Children Police. Our patients living in the house located in downtown
Gaziantep meet their own needs and continue to look for a job by paying a symbolic
amount of rent. In the House of Halfway, patients with poor family conditions (decomposed family, family members using drugs, sexual abuse etc.), patients without a family
and patients with severe social problems can be accommodated. They are expected to
participate in weekly group therapies and NA meetings. Family therapies continue in
this period. As the patients start to work regularly, their responsibilities are expected to
increase during the treatment period. House representatives are selected among patients
with long-term treatment. They can live in these houses until they join the army at the
longest.
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Outpatient Treatment Program and Follow-Up
Patients completing the treatment program or who don’t require inpatient treatment are
referred to outpatient treatment program which is configured based on the patient’s needs. Regular psychiatric meetings are held with outpatient patients and their treatment
is planned. Group therapies are held once a week. Their families are referred to family
meetings organized once in every 15 days. NA meetings are held for patients 3 times a
week. For patients completing the treatment program, regular job and family follow-ups,
lab examinations for substance abuse and health problems are added to the outpatient
follow-up program.
Prevention Activities
Especially children under risk and who haven’t started or have just started using drugs
are referred to Münir Onat Center for Children and Youth and Akınal Center for Children and Youth to participate the programs. This enables children with the potential of
becoming an addict to be reintegrated in the society. In addition, Psychological Counselors and Guidance Counselors working in Gaziantep are given training seminars regarding addiction issues in association with the Counsellorship Research Center. Training
meetings on substance abuse and addiction are periodically held in neighborhoods with
high-levels of substance abuse.
Education Content
• Classroom trainings
• Skills and vocational trainings
• Handicraft trainings
• Physical education
• Art trainings
• Music education
• Theater trainings
• Computer trainings
• Folk dances trainings
• Religion and ethics
• Family education
• Photography trainings
• Mosaic making
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• Textile trainings
• Stone workshops
• Shoe workshops
• Copper workshops
The Center also provides a pet-care facility; vegetable and fruit gardens that are fully
under the patients’ responsibility in order to allow them to experience the concept of
love and take responsibility.
Our center works on a 24 hours basis with 65 specialized personnel and it has a capacity
of 40 patients. Halfway houses have a capacity of 10 patients after treatment. Since April
2008, we have reached 1,045 people and 846 of them are evaluated as troubled substance
abusers.
When we examine characteristics of the patients who referred to our center, we determined that age range of the applicants is 9 to 21 years old. 846 out of applicants are
male (98%) and 11 are female (2%). Female patients are taken to outpatient treatment
program.
59 out of 846 adolescents (7%) are illiterate, 152 (18%) are primary school drop-outs,
439 (52%) are middle school drop-outs, 186 (22%) are middle school graduates and high
school drop-outs and only 7 of the applicants are high school graduates.
516 of the patients (61%) started using substance during school period while it is determined that 329 (39%) of them started after they left the school.
Treatment applicant average age is 15.6.
46.3% of the families have drug abuse history; most frequently a cousin, father or brother.
74.2% of the patients live with their own parents.
Average number of siblings is 4.85.
91.4% of the patients have working experience under the age of 16. These children are
referred to various jobs.
It is determined that 490 patients (58%) have experienced legal difficulties while 109
(13%) of them went to prison.
Majority of the patients (87%) use multiple drugs (Volatile, diluent, heroin etc.). 90% of
the multiple substance abusers use 3 or more substances. 118 (14%) patients were determined to be heroin users. Average age of the patients using heroin is 16.17.
99% of the adolescents who applied for treatment do smoke. Average age of starting
smoking is 9.95. Average age of starting substance is 11.26.
Our center working on 24 hours basis, with a capacity of 40 patients, has a Psychiatrist,
264
2 nurses, 4 Psychologists, 2 Social Workers, 4 Sociologists, 2 Addiction Counselors and
12 Teachers.
624 adolescents have been admitted to Oya Bahadır Yüksel Center for Children and
Youth so far. In 2013, a total of 117 patients were admitted to the center. 416 out of 846
patients are followed-up after treatment and 131 patients are employed in a regular job.
There are currently 29 patients in the center and 8 patients in the halfway house who
receive treatment services.
REFERENCES:
1. Turkish Monitoring Center for Drugs and Drug Addiction (TUBİM) 2013 Turkey Drug
Report. p: 21,83.
2. Aksoy A, Ögel K. Self-damaging behavior and substance abuse in street youths. Anadolu
Journal of Psychiatry. 2005; 6:163-169.
3. Slesnick N, Meade M. System youth: a subgroup of substance-abusing homeless adolescents. J Subst Abuse. 2001; 13(3): 367-84.
4. Adlaf EM, Zdanowicz YM. A cluster-analytic study of substance problems and mental
health among street youths. Am J Drug Alcohol Abuse. 1999; 25(4): 639-60.
5. Tims FM, Dennis ML, Hamilton N, J Buchan B, Diamond G, Funk R, Brantley LB. Characteristics and problems of 600 adolescent cannabis abusers in outpatient treatment. Addiction. 2002 Dec; 97 Suppl 1: 46-57.
6. Kinlock TW, Battjes RJ, Gordon MS. Factors associated with criminal severity among adolescents entering substance abuse treatment. Journal of Drug Issues. 2004; 34(2): 293-318.
7. Lisa M. Najavits. Seeking Safety: A Treatment Manual for PTSD and Substance Abuse. New
York: The Guildford Press; 2002.
8. SAMSAH, Matrix Intensive Outpatient Treatment Manual. Washington D.C: SAMSAH;
2006.
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266
Cüneyt Evren*
Bakırköy Training and Research Hospital for Psychiatry
Neurology and Neurosurgery, Alcohol and Drug Research,
Treatment and Training Center (AMATEM), Istanbul, Turkey
ABSTRACT
Although rates of opioid abuse found in Turkey is lower than North America and Europe, opioid abuse is an increasing public health
problem in Turkey, both due to the use of heroin and to an increasing number of individuals developing dependence on prescription
opioids. Opioid maintenance treatment (OMT) for opioid dependence is effective in reducing mortality, HIV transmission, crime, and
use of other drugs. Buprenorphine (BUP) maintenance is effective in treating opioid dependence, but problems with the misuse and
diversion of BUP may limit its acceptability and dissemination. Abstinence-oriented symptomatic treatment was the most commonly
offered treatment option in Turkey until the end of 2009. Agonist treatments, including methadone, a single form of buprenorphine or
a combined form of buprenorphine and naloxone (BNX) were not available. Starting in April 2010, BNX was approved for opioid dependence treatment as a detoxification or maintenance treatment by the Turkish Ministry of Health. The prescription of BNX was, however,
restricted to hospitals that included a state-approved specialized clinic for the treatment of substance dependency.
In Istanbul, with a population exceeding 13 million inhabitants, only 2 centers provide a BNX maintenance treatment program. At the
beginning of 2010 the Alcohol and Drug Research Treatment and Training Centre (AMATEM) in Istanbul started providing BNX, but only
to patients who were hospitalized. At the beginning of 2011 AMATEM published a guideline and extended the implementation of BNX OMT
to make it available on an outpatient basis. During this time we conducted some studies considering BNX OMT.
Keywords: Opioid Maintenance Treatment; Buprenorphine; Guideline; Harm Reduction
* Assoc. Prof. Cüneyt Evren graduated from Istanbul University, Istanbul Faculty of Medicine in 1991. He completed his psychiatry
specialization in Bakırkoy Training and Research Hospital for Psychiatry, Neurology and Neurosurgery in 1996.
In the same year, he started working as the head assistant in Alcohol Drug Research, Treatment and Education Centre (AMATEM), and
he became Assoc. Prof. Dr. in 2006.
In 2010, he took over the position of clinic director of AMATEM. He has up to 200 national and international scientific publications and
book chapters in the field of alcohol and drug addiction.
He is still in charge of for AMATEM Alcohol Department, Editor of Duşunen Adam: Journal of Psychiatry and Neurological Sciences,
President of Bakırkoy Research and Advanced Education Centre (BARİLEM) and a Member of Scientific Meeting Arrangement Board of
Turkish Psychiatry Association.
267
OPIOID MAINTENANCE TREATMENT IN ISTANBUL AND RELATED OUTCOME
Buprenorphine/Naloxone Maintenance
Treatment in Turkey and Guideline
Introduction
Although rates of opioid abuse found in Turkey is lower than North America and Europe (1), opioid abuse is an increasing public health problem in Turkey, both due to the
use of heroin and to an increasing number of individuals developing dependence on
prescription opioids (2, 3). Illicit use of opioids has been associated with considerable
societal costs, including increased rates of emergency department visits, drug overdoses, criminal activity, lost work days and general medical and psychiatric consequences
(4-7). As the similar trend in North America and Europe (2), treatment admissions for
opioid abuse and dependence in Turkey have increased dramatically in recent years.
Buprenorphine is a partial opioid agonist of the mu receptor, with antagonistic properties at the kappa receptor (8). To prevent buprenorphine abuse, buprenorphine is
typically packaged with naloxone (buprenorphine/naloxone - BN, Suboxone®), which
yields no effect when administered sublingually but exerts antagonist properties when
injected (8, 9). Opioid maintanence treatment (OMT) for opioid dependence, such as
BN, is effective in reducing mortality, HIV transmission, crime, and other drug use (10,
11). BN has also been shown to be a safe and effective treatment of opioid dependence
in non-specialized, outpatient, office-based settings (12-14).
Abstinence-oriented symptomatic treatment was the most commonly offered treatment
option in Turkey until the end of 2009. Agonist treatments, including methadone, a
single form of buprenorphine or a combined form of BNX were not available. Starting
from beginning of the 2010, BNX combination was approved for opioid dependence
treatment as a detoxification or a maintenance treatment by Turkish Ministry of Health
(15) which served as an opportunity to increase the number of patients with opioid
dependence receiving treatment. The number of prescriptions for BN has increased steadily since its approval and BN has been associated with bringing new users into treatment. The prescription of BNX was, however, restricted to hospitals that included a state-approved specialized clinic for treatment of substance dependency. Consistent with
this, physician adoption has been primarily among addiction specialists who make up
all the prescribers in Turkey. After its’ approval, Alcohol and Drug Research, Treatment
and Training Center (AMATEM) in Istanbul started BNX OMT only to the patients who
were hospitalized. In Istanbul, with a population exceeding 13 million inhabitants, only
2 centres provide a BNX maintenance treatment (BMT) programme. Thus due to limited resources, there is a long waiting list to get into this maintenance programs. At the
268
beginning of 2011, AMATEM has written a guideline (16) and started implementation
of BNX maintenance treatment also as an outpatient basis.
The central problem in the treatment of heroin dependency is high rates of relapse to
drug use after periods of forced or self-imposed abstinence (17). Retention in OMT has
been associated with improved outcomes in adults (18-20), and discontinuation with
relapse (21), overdose death (22), and worse HIV treatment outcomes (23). Retention
rates for BN maintenance treatment at 6 months ranged from 35% to 59% (12, 14, 24),
and a 38% retention was reported in one study that followed patients for 2 years (25).
Another study found the overall retention rate as 56.9% (64.7% of their months were
opioid-negative) for 1 year, with about half of the dropouts occurring in the first month
(26). Pinto et al. (27) reported that among 134 opioid dependent patients 61.2% retained
in treatment at 3 months and 42.5% retained in treatment at 6 months. Finally in a recent
study Schwarz et al. (28) reported that over one third (37.2%) of the sample discontinued
BN maintenance treatment within the first month following induction, while 25% of the
sample stayed for at least 43 months in treatment (28).
There are few studies of OMT outcome that considers what factors might be associated
with treatment dropout or what might be done to improve it. Pre-treatment characteristics most consistently associated with poorer outcome among heroin dependent patients
in BNX maintenance treatment include; male gender, lack of employment, younger age
at onset of opioid use, more continuous and longer opioid use, use of heroin rather than
other opioids as the primary drug, higher levels of psychiatric symptoms, lower levels of
general functioning, poorer psychosocial functioning and more severe legal problems
(14, 29-36). However, depression was associated with treatment retention in two studies
(34, 37). During treatment, predictors of negative outcome in heroin dependents included lower doses, greater severity of withdrawal, side effects, more positive urine tests
for opioids and other drugs, opioid positive drug screens at week 1, and fewer addiction
counseling sessions (10, 14, 35, 38).
Treatment in AMATEM Istanbul
Decision for treatment type, whether it is going to be outpatient or inpatient, mainly depends on the guideline AMATEM has written (16). According to this guideline, patients
who has a diagnose of opioid dependence for at least two years, who abuse depressants
such as alcohol or benzodiazepine, who use polysubstances and those who dropped-out
from outpatient OMT twice in a year are implemented for BNX maintenance treatment
as an inpatient.
Induction and stabilization phase ends at the end of one to two weeks. Baseline interviews with the patients were done before induction of the BN. Both outpatients and
inpatients (after being discharged from the hospital) are advised to participate to the
Outpatient Treatment Program (OTP) once a week for at least one year, whereas they
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were obligated to come to the outpatient treatment unit every month to get BN prescribed. BN doses prescribed range from 2 to 24 mg per day, with most patients receiving 8
to 12 mg per day.
Predictors of outcome within 6 month follow-up among heroin dependent
patients in buprenorphine/naloxone maintenance treatment
The aim of our first study was to evaluate the predictors of outcome within a 6 month
follow-up among heroin dependent patients in buprenorphine/naloxone (BNX) maintenance treatment, which is the only agent that is used for maintenance treatment in
Turkey (39). A total of 392 heroin dependent patients who were consecutively admitted
to the clinic (n=106, 27.04%) or were taken as an outpatient for BNX maintenance treatment (n=286, 72.96%) were included in the study. Patients were investigated with the Bakırköy Opioid Withdrawal Scale (BOWS), the Substance Craving Scale (SCS), the Drug
Use Disorders Identification Test (DUDIT), the Drug Abuse Screening Test (DAST-10)
and the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) at
baseline evaluation. Among 392 heroin dependent patients 287 (73.21%) were considered as relapsed to substance use or dropout from treatment, whereas 105 (26.79%) were
considered as compliant to the BNX maintenance treatment. Rates of having first degree
relative with substance abuse, being under probation and having a history of suicide
attempt were higher in relapsed/dropout group (RDG). Other than these, sociodemographic variables did not differ between these two groups. Mean scores of BOWS and SCS
were higher in the RDG than the maintenance group at first month, whereas DUDIT,
DAST-10, SOCRATES scores and mean dose of BN did not differ between the groups.
Severity of craving predicted negative outcome together with history of suicide attempt
and being under probation at the end of sixth month. Among items of SCS, “severity
of craving” predicted negative outcome. When type of treatment was included in these
regression analyses as an independent variable, outpatient treatment predicted negative
outcome together with history of suicide attempt and being under probation (39).
In bivariate analyses, patients that relapsed to substance use or those considered as dropout from treatment (a) had higher rates of substance abuse among first degree relatives,
(b) were more likely to be under probation, (c) had a history of suicide attempt, (d)
higher severity of withdrawal, and (e) craving. In regression analysis, craving was associated with negative outcome (relapse/dropout) together with history of suicide attempt
and being under probation. When the type of treatment (inpatient/outpatient) was also
taken as an independent variable, outpatient treatment predicted negative outcome instead of craving, together with history of suicide attempt and being under probation. This
suggests that although the severity of craving is an important risk factor to drop-out
from treatment, two weeks of supervized treatment with additional educational program in stabilization phaze may be helpful to these patients to continue maintenance treatment. Finally history of suicide attempt and being under probation are two risk factors
270
for negative outcome, independent from both craving and the type of the treatment (39).
Since the dose of BNX did not differ between the RDG and those retained in maintenance treatment, the present study suggests that those with high withdrawal symptoms or
craving, particulary those with high severity of craving may need a higher dose of BNX.
History of suicide attempt and being under probation are high risks for negative outcome, particularly among those in outpatient treatment. Thus, more observed (supervised)
use of BNX in first two weeks, which is more available during inpatient treatment, may
improve outcome in outpatient maintenance treatment (39).
At minimum findings of the present study may suggest that clinics should review their
dosing and monitoring methods. A re-assessment of the treatment efficacy through a
possible dosage increase or supportive psychosocial implementations could potentially
increase adherence to BN maintenance treatment (40, 41).
Illicit use and diversion of buprenorphine/naloxone among patients in
buprenorphine/naloxone maintenance treatment in Istanbul, Turkey
Opioid maintenance treatment (OMT) for opioid dependence is effective in reducing
mortality, HIV transmission, crime, and the use of other drugs (42). Buprenorphine
(BUP) maintenance is effective in treating opioid dependence, but problems with the
misuse and diversion of BUP may limit its acceptability and dissemination (43). Thus,
the buprenorphine/naloxone combination tablet (BNX) was developed to reduce potential problems with misuse and diversion (44-47). Two qualitative, ethnographic studies based on interviews with people who abused opioids in Baltimore and throughout
New England suggest that the avoidance of withdrawal symptoms is the primary motive
for the use of diverted BUP (48, 49). Previous studies exploring factors related to BUP
injection have shown that the perception of inadequate BUP dosage prescription can
influence BUP injection (50, 51), as well as the severity of drug dependence and suicide
ideation or attempts, even in HIV-infected injection drug users (IDUs) receiving BUP
treatment (50). The prevalence of recent diversion was over 10 times higher among those
receiving supervised BUP compared with methadone (MET), with 23.8% of BUP-maintained participants reporting that they had diverted their dose in the preceding 12
months in Australia (52). In France, individuals perceiving their prescribed dosage as
inadequate and feeling dissatisfaction with BUP treatment ran a higher risk of sniffing
(53) and injection (54). The previous studies demonstrated that the illicit use of BUP is
associated with attempted self-treatment rather than being an attempt to “misuse” it (54,
55). Consistently with these data, in a previous study the percentage of BUP diversion
was reported as 46.5% (9.6% daily and 50.6% sporadically) within 6-month follow-up,
and the inability to access BUP treatment was reported as the main predictor (AOR:
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7.31); as a result, the authors suggested that improving –rather than limiting– access to
good quality, affordable BUP treatment may be an effective public health strategy to mitigate the illicit use of BUP (56). Seven published studies have documented the diversion
and/or injection of BNX (57-63). Three of these studies found BNX to have a lower street
value than BPN in the period immediately following the medication’s introduction (57,
59, 62), although it is not clear whether this has been sustained over time. Other studies
found that the street price of BNX increased over time to a price that was equivalent to
that for BUP (58, 60). Although 80% of drug users who tried injecting BNX had a bad
experience in Finland (57), a number of studies suggest that, while BNX may have lower
abuse liability than BUP, the inclusion of naloxone may not completely eliminate its potential misuse (47, 62, 64). A Malaysian study found that the introduction of BNX did
not reduce injection-related risk behaviours among participants who had previously injected BUP, and even if withdrawal symptoms were reported, they did not result in a decrease in the self-administered BNX dose (58). A two-wave survey of BUP among IDUs
was conducted shortly before BUP withdrawal from the Malaysian market (n=276) and
then again six months after BNX was introduced (n=204). The results suggest that the
introduction of BNX and withdrawal of BUP may have helped to reduce, but did not eliminate, the problems experienced with diversion and abuse in Kuala Lumpur, Malaysia
(63). In 2009, while BNX was less commonly and less frequently injected than BUP, both
sublingual medications were diverted more than liquid MET (60).
Besides noting the measures taken in Turkey against the BNX combination to suppress
the misuse of therapeutic opiates, a detailed study on the illicit use of BNX has become
a compelling priority. The aim of this study is, in fact, to evaluate the extent of the illicit
use and diversion of BNX by patients in BNX maintenance treatment (BMT) (65).
Methods: 281 heroin-dependent patients were included in the study. These patients had
consecutively attended the Alcohol and Drug Research treatment and Training Center
(AMATEM) polyclinic as BMT outpatients, and had reached the end of the stabilization
phase at least 2 weeks after induction.
Results: Of these 281 heroin-dependent subjects in BMT, 110 (39.1%) were considered
as belonging to the group that had used illicit (i.e. unprescribed) BNX. This group presented higher current doses, a higher use of BNX before treatment, a shorter period of
BNX treatment and a lower frequency of remission of drug use. There was no difference
between the two groups in estimates of dose adequacy, receiving education for BNX use,
having a legal problem and/or probation, using different routes for BNX other than the
sublingual route of administration, or giving away BNX doses. Those in the group that
did use illicit BNX showed higher percentages both for the more frequent use of BNX or
higher doses of it, and its less frequent use or for lower doses, besides the more frequent
use of other substances during BMT, compared with the group unaffected by illicit BNX.
Conclusions: Most of the patients that used illicit BNX had done this before their moni272
tored use of BNX and had used it to relieve withdrawal symptoms, which suggests that
the main difficulty for those seeking illicit BNX in Istanbul is how to access treatment
(65).
Motor impulsivity discriminated relapsed male heroin dependents from
those who were still in buprenorphine maintenance treatment at the
12-month follow-up
Impulsivity has been shown to be related to risk taking, lack of planning, and quick decision-making (66). Definitions of impulsivity suggest that such behaviours tend to be
committed without forethought or conscious judgment, and are characterized by acting
on the spur of the moment, an inability to focus on a specific task, and a lack of adequate
planning (67, 68). Some authors include temperamental traits, such as sensation seeking
and risk taking, in their definition of impulsivity (66). There is accumulating evidence
from preclinical laboratory animal and clinical studies indicating that impulsive behaviour may be causally linked to several distinct processes in drug addiction, including
its onset, maintenance, related problems and relapse into drug use (69-73). Impulsivity
has also been found to be a high-risk factor in early substance use, and to be related to
the severity of drug abuse and treatment retention (74, 75). In a review of Acton (76),
it was argued that impulsivity is a temperamental risk factor for substance use. It has
been suggested that impulsivity may be a fundamental mechanism both in the onset of
excessive substance use (77) and in relapse into substance use (78). Impulsivity may also
serve to moderate the relationship between substance-use behaviour and substance-use
outcomes, such as substance use-related problems (79-80). High relative comorbidity
is observed between alcohol use disorders and Axis I and Axis II psychiatric disorders
found within the impulse control spectrum; i.e. antisocial personality disorder (81). Impulsivity may also serve to moderate the relationship between substance-use behaviour
and substance-use outcomes, such as substance use-related problems (79-80). Moreover,
previous evidence suggests impulsivity as a mediator of the genetic basis for SUD (82).
The existing literature suggests that impulsivity may be a multidimensional construct,
and individual differences may exist across the different dimensions of impulsiveness,
which may be related to different patterns and severities of substance use (83). Impulsivity may interfere with the outpatient or inpatient treatment of substance dependence
(84).
The aim of this third study was to evaluate whether impulsivity was able to discriminate
relapsed male heroin dependents from those who were still in buprenorphine maintenance treatment at 12-month follow-up, while checking the effects of depression, and
state and trait anxieties (85). Of 78 consecutively admitted male heroin dependents, 52
were examined during a face-to-face interview 12 months after discharge from hospital.
Patients were investigated by applying the Barratt Impulsiveness Scale, version 11 (BIS11), Beck Depression Inventory (BDI) and State and Trait Anxiety Inventory (STAI) at
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the end of 12 months.
Results: Of 52 heroin-dependent inpatients, 23 (44.2%) were considered as having relapsed into heroin use during the previous twelve months, whereas 29 (55.8%) were
still in the maintenance treatment. Demographic variables did not differ between the
two groups. Mean scores on the impulsivity subscales (motor, attentional and non-planning) and total BIS-11 were higher in the relapsed group than in the maintenance group
at follow-up. So too, depression and anxiety scores were higher in the relapsed group.
Impulsivity, particularly motor impulsiveness, discriminated the relapsed group from
the maintenance group, together with state anxiety. Although motor impulsiveness was
able to discriminate the relapsed group from the maintenance group, together with state
anxiety, this cross-sectional study did not evaluate the causal relationship. Despite the
limitations, our results suggest that motor impulsiveness and state anxiety may be the
areas to focus on in the treatment of relapsed heroin dependents (85).
Conclusion
Addiction is a disease of a lifetime.
Remission and relapse natural.
Treatment should always include a psychosocial program. Brief counseling, therapeutic individual counseling, outpatient groups, inpatient therapy, rehabilitation programs,
self-help groups.
Patient-specific strategies should be planned.
Target should be to determine the appropriate model (full sobriety-harm reduction),
according to the patient’s needs and opportunities.
Supervision of the program is important in maintenance treatment with Suboxone.
There must be information network between treatment centers that apply maintenance
treatment, which may decrease both evaluation time and abuse risk of the drug.
Treatment centers that have maintenance treatment programs must reconsider their
programs according to results of the treatment.
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Elisa Rubini*
International Relations, San Patrignano
ABSTRACT
San Patrignano will present its recovery model. Since 1978 the community has welcomed more than 25,000 individuals suffering from
drug addiction without any religious, ideological of social discrimination and completely free of charge. The drug rehabilitation program of San Patrignano is drug-free, long term and residential.
Our approach is totally based on individuals, providing a place and space for their personal and professional growth building a drug
free life and assisting also in the social reinsertion upon completion of the program. We invest in education and job trainings as viable
ways to self-support the residents in their future life as productive members of the society.
In the San Patrignano community are hosted also people with special needs. Among them there are minors, pregnant women and
mothers with kids. Special housings have been created for them to be able to better respond to their needs.
According to the Italian Drug Law, San Patrignano also welcome offenders in an alternative setting from prison, offering a real option
for treatment, recovery and social integration, providing support, education, job trainings and life skills.
* Ms. Rubini has been working for the San Patrignano Foundation since 2009 and currently leads the International Relations Team.
Since 2013, Ms. Rubini is Member of Board of the Vienna NGO Committee on Narcotic Drugs (VNGOC), Board Member of European Action
on Drugs (EURAD) and Drug Expert for the Civil Society Forum of the EU. Ms. Rubini is among the founding members of the following
international networks: Recovered Users Network (RUN) and Drug Policy Futures (DPF).
Ms. Rubini holds a Master Degree in Philosophy from the Catholic University of Milan (2003), a Master in International Relations from
the Vienna Diplomatic Academy MAIS (2006), an Executive International Master on Drug Addition, Prevention, Enforcement and Social
Integration from IULM University of Milan (2008), and a Post Graduate Degree in Philosophical Counseling from Gesellschaft fur
Philosophische Praxis e.V. Dr. Gerd Achenbach, Cologne (2011).
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SAN PATRIGNANO: A COMMUNITY FOR LIFE. A MODEL FOR DRUG REHABILITATION, RECOVERY AND SOCIAL REINTEGRATION
San Patrignano: A Community for Life. A Model
for Drug Rehabilitation, Recovery and Social
Reintegration
Brief history and description of the San Patrignano community
The San Patrignano community started in 1978. It was a private initiative of a single
person, Vincenzo Muccioli who noticed how socially marginalized and abandoned the
drug addicted used to be. In late 1970s and early 1980s drug addiction was highly stigmatized, heroin addiction was epidemic and the youngsters were left alone with their
habit. Vincenzo wanted to do something and opened up the door of his house and family
to welcome the first girl and then boys, providing them with a safe and lovely environment to start their path towards recovery. After a while, a house was not large enough
to welcome all the people who asked for and needed help. Along with a group of friends
and volunteers, motivated to produce a social change, Vincenzo moved up to his country
house and piece of land in the Rimini hills and the community started, throughout the
years and gradually, to grow until reaching the current dimension.
At the beginning there was no structured model or treatment, the San Patrignano approach developed progressively, starting as an enlarged family and providing counselling
and examples. The practical approach of assistance and care along with job training in a
friendly and healthy environment produced the conditions for a behavioral change. The
community is currently home of more than 1,300 individuals and has welcomed more
than 25,000 people since 1978. Recalling Vincenzo’s word on drug addiction and the
drug problem, the following description summarizes the philosophy of the community
(1):
“Among the problems that affect the drug addict, drug use is the least relevant. The core
problems is not drugs, nor the abstinence crisis: it is the human being with his fears and
the black holes that threaten to suck him in. That is why I do not like to say nor hear that
ours is a community for drug addicts. Ours is a community for life, where you can restart
after years spent as a social outcast. Ours, if we really need a definition, is a community
against social marginalization”.
The San Patrignano recovery model
Drug users who decide to enter in the community are considered as human beings who
asked for and need help and deserve an opportunity to change their life. Each person is
considered a unique individual and therefore the recovery program is tailored on each
person’s need. In San Patrignano nobody is judged for his or her past nor stigmatized.
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The residents are not considered patients and treated with pharmacological substitution
treatment. The community follows a drug-free approach, promoting abstinence from
drug use and preparing residents with a detox period before entering in the program.
People who have been taking methadone or other substitution treatments are required
to scale down the prescription drugs before being admitted. In exceptional cases, such
as for example pregnant women, where the decreasing might be delayed and the need
to welcome the mother is a priority, the resident might enter while is still scaling down
the substitution therapy. San Patrignano believes that it is possible to overcome drug
addiction, and proved that getting rid of addiction is achievable and that recovery is a
viable and preferable alternative to life-long treatment. The entire community is also a
smoke-free zone, since healthy lifestyle is highly encouraged as well as a life free from
any form of addiction.
Care is one of the fundamental pillars for the community which is based on peer to
peer education. The new comers are inserted into the community life from day one and
matched with a tutor, which is a resident with more experience who is more advanced
in his recovery, but still in the program. This initial relation is crucial in providing support, room for growth and fostering dialogue and listening among peers. In addition
to the peer-to- peer approach there is also the strong living example of recovered drug
users who completed the program and decided to live in the community and become
coordinators of the vocational and professional trainings. They represent the value of the
example and the living proof that coming out of addiction is achievable.
Another important aspect of the recovery program is education. The community invests and strongly supports education and vocational trainings. Learning a profession,
earning a degree is a key component for increasing self-esteem and fostering the future
chances of a successful social reintegration upon completion of the program. Among
the possibilities and the study curricula available in San Patrignano to choose from are
secondary high schools, professional degrees in technical fields as well as university careers. Part of the educational offer is also associated to internships in the community
in the field of study, such as hostelry, dental technology, graphic design and nursing.
The community offers vocational trainings in a broad range of disciplines from green maintenance to agriculture and greenhouses to handicraft and hand-made work in
the furniture, home decoration and fashion accessories, from animal breeding to food
processing and catering industry, just to mention a few among the fifty professional trainings available in the community. Job training and education also provide a structure
to former addicts’ life, teach the importance of commitment to achieve results and boast
self-motivation. Furthermore, it exemplifies the necessity of respecting time and deadlines and offers personal fulfillment and gratification to individuals who have generally
experienced little praise and encouragement in life. The professional trainings and work
inside the community also help in interpersonal relations by providing a concrete tool
to obtain independence and autonomy from relatives and means to support themselves
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and eventually a family in the future. The products and services coming out of the professional trainings also financially support the community in its strive for sustainability,
generating a valuable income to self-sustain the independence of San Patrignano from
State contributions and tax-payers money.
In terms of structure the recovery program is residential and long term. The fact of living
and staying in the community is functional to creating the interpersonal relation and the
environmental therapeutic effect (2) that the community offers reproducing in a small
scale the complexity of life outside. This phenomenon has been called life city effect.
The average length of the program is three to four years, since this is the time needed to
overcome the addiction and establishing robust bases to build a new life and future and
to plan the social reintegration.
In the community are also offered recreational activities to the residents such as sports
(football, basketball, running, etc.), music, movies, reading, cultural entertainment and
theater. The football teams of the community participate in local competition; the San
Patrignano running team takes part in the major marathons around the world such as
the New York and London Marathons. The SanPatrignano theatre company plays in
renowned theaters in Italy featuring classic pieces and experimenting choral and innovative versions of masterpieces by Shakespeare and Pirandello so far.
People with special needs: mothers, fathers, children and minors
San Patrignano also takes care of people with special needs, in particular mothers and
children as well as minors both female and male, and offers support in fatherhood.
Since 1978 the community has welcomed around 3,200 women and one third of them
were mothers. 70% of the mothers are in the age range 19-30 (half of them are aged
19-25 and half 26-50), 10% are minors (namely under 18) and 20% are over 30. Many
women decide to enter in the community while they are pregnant and more than 250
children have been born in the community since 1978. Admission procedures are simplified and pregnant women have priority access in the community because it is taken
into consideration the interest and the health of the child as major concern. Regarding
the mothers who have already a baby or a child, it is possible for them to bring the son or
daughter with her in the community. Nearly 70% of the mothers are entering the program with the child, only 30% leave them outside with family members or foster care, and
it normally depends on regional law and social services. San Patrignano believes that the
most adequate place for the children is with their mothers and supports the parents in
re-obtaining custody of the children also when that was taken over by third parties when
the mother was incapable of perform her duties due to drug addiction.
Since the very beginning the community felt the need to take care of mother and children creating ad hoc spaces and interventions. Dedicated housings to create a family kind
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of environment responding to baby and children needs, where the mothers are supported by professional educators who are taking care of the kids, while they focus on
overcoming addiction and learning a job. To provide additional support a kindergarten
has been built in the community offering care for babies up to 3 years. From the age of
3, continuing with primary and secondary education the children attend public schools
outside of the community to foster their social integration with peers in the local communities. Afterschool services are available in the afternoon, offering the mothers the
opportunity to continue their professional trainings and earning professional qualification and diplomas.
San Patrignano also fosters parenting skills for those among the residents of the community who are fathers. In case both of the parents are living in the community, special time
and space will be allocated to them to assist them in rebuilding their family and to take
joint care of their children. Professional psychological support and counselling might be
provided in case of need, as well as counselling and legal representation to solve questions related to custody. Children might suffer from consequences related to early abandonment and separation from the mother or social marginalization and harm created
by the drug abuse and special intervention might be needed. The mothers are also facing
the double and complex challenge of overcoming the addiction and at the same time
learning to be a good parent. Social reinsertion is sensibly planned in case of mother and
child, and the options are considered carefully and sometime it takes longer than that
of a single person because the wellbeing of both is absolute priority. When possible and
advisable it is encouraged to resume ties with the family of origin and with the partner, if
he is also recovered from addiction (because the 99% of the mothers experiencing drug
addiction have had also a drug addict partner), to support them in starting their new life.
The other group with special needs is the minors. The community welcomes both male
and female minors. Since early 80s a separate facility has been created to host male teenagers. More than 409 minors have entered the community throughout the years (248
male and 161 female). A special house has been usually dedicated to the male minors
and recently a new facility has been built for female teenagers which have been previously hosted with adult women. The new house for girls counts at present with 9 residents,
while around 20 youngsters are hosted in the minor house for male. Most of the teenagers are aged 15 to 17, some of them are sent on probation by the juvenile courts around
Italy, having a past of abuses, degradation, violence and marginalization. The houses
meant for minors are small communities within the community. Daily interaction with
the broader community is undertaken and a daily structure of study, sport, leisure and
vocational trainings are planned. Strong emphasis is placed on education. Youngsters
are encouraged to restart interrupted studies and to attend schools at the Community
Study Centre. Literary courses are regularly available and they can obtain high school
degrees and even continuing to university education while they undertake the recovery
program.
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Persons in conflict with law: alternatives to incarceration
San Patrignano welcomes people in conflict with law, supporting ex-offenders in their
rehabilitation and furthermore contributing to the development of life skills, education
and job training fostering their social reinsertion opportunities upon completion of the
program and having paid the full length of the sentence.
According to Italian Law, Art.94 del DPR 309/90, drug addicts and alcoholics have the
option to seek treatment and exit prison on probation with the purpose of solving their
addiction problem. The time they spend on probation, fully substitutes the period of
detention and the ex-addicts and ex-offenders upon completion of the total length of the
due period could start their social reintegration. The subject entitled to this provision
should not have more than four remaining years of convictions ahead of him, at the moment of submitting the request to the judge. A joint effort of the social, health services
and treatment centers or communities is requested to produce evidence of the addiction, and support the judge in allowing the probation upon request and consensus of the
addict. Drug consumption or addiction is not considered a crime in Italy, but referred
as administrative offence, giving the fact that the drugs are illegal. Drug dealing and the
offences committed under the effect of drugs are subject to trial as crime.
Italian data on alternative sentencing (3) show that from 2007 to 2010 there was an increase in the number of people asking for alternative sentencing to prison. Since 2011 a
small decrease has been registered due to the disrupting effects of the amnesty in 2006
which have been extinguishing the crimes with a detention period of a maximum of
three years of sentencing to be left to pay. In the biennium 2012-2013, the number of people exiting prison on probation has been stabilized. In 2013 2,530 drug addicts entered
on probation implementing the Art.94 DPR 309/90, which constitute 28% of the total of
those getting into probation. The large majority is male (94.8%), Italian citizens (91.7%)
and belonging mainly to the age range 35-44 (39.1%). Regarding the cases closed in
2013, 56% of the files of people on probation for drug treatment have received a positive feedback, while 23.9% received a suspension of the probation due to bad behavior.
According to the monitoring research on the prison situation in Italy, started in 2012,
analyzing up to 90% of the prison population, there is a population with drug addiction
according to the diagnosis of the DSM IV and the ICD-IX-CM of about 12,897 individuals. Just a small part of them (2,383) have filed a request for alternative sentencing according to the Art.94 DPR 309/90 and 71.5% of them have been recognized as fulfilling
the conditions for accessing the probation.
In May 2014, due to prison overcrowding in Italy and related pending EU sanctions,
recent developments brought the Parliament to reconsider the current drug legislation
and adopt a new law on drugs and drugs related offences. As a result of this process the
new law rescheduled cannabis as less harmful substance, while under the previous law
all narcotic drugs had been considered equally dangerous for health. Furthermore the
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length of the punishment for small drug dealing has been reduced and sanctions softened with the results that less people are likely to get convicted for drug smuggling and
dealing. It is too soon to measure the effects of the new law, but it reasonable to expect
that with regulations that are more permissive of drug dealing, consequent drug use will
be flourishing.
Notwithstanding the possible negative effects of the new law, the provision of Art.94 del
DPR 309/90 remains in place and also if the beneficiaries might be diminished in term
of absolute numbers, the law still secures the right of drug addicts to go to treatment and
rehabilitation instead of being in prison.
There might also be the case of residents of the community, who entered voluntarily
with the purpose of recovering might face trials while they are already in the community for offences previously committed. In these cases, the San Patrignano legal office is
assisting and counselling them and will support in the process of obtaining alternative
sentencing to prison and continuing the rehabilitation in the community as allowed by
the Italian law and by the judge. The Legal Office of San Patrignano takes care of both
cases and provides council and assistance to its residents during their trials and also
after the sentence to secure they receive proper advice and also liaises with offenders in
prison who want to enter in the community undertaking a recovery program instead of
staying in detention. Since 1980, San Patrignano took care of 3,800 people in conflict
with law, substituting more than 3,600 years of jail and converting them in rehabilitation
programs.
In the last year (2013 data), San Patrignano followed 458 court trials and took care of 49
residents in house arrest, 123 people on probation, and 18 residents in house detention.
All in all in 2013 substituted 114 years of prison thanks to its work and save 4 million
euro for the Italian state.
San Patrignano is currently undertaking an EU Project STREAM targeting evaluation
on reducing recidivism in cooperation with the National Offenders Management Service UK and the De Montfort University in Leicester, UK. San Patrignano is currently
implementing a pilot project refining the European guidelines on evaluation of program
working with offenders. Final results of the project and evaluation report on the value of
the recovery program in San Patrignano in reducing crime recidivism along with drug
addiction will be available in autumn 2014.
Self-sustainability and rentable activities
San Patrignano believes in the principle of gratuity, wherefore none of the residents or
their families are asked for a payment. The program is offered for free. In order to run
its day to day work, the community believes in and pursues a policy of self-sustainability. Since the very beginning San Patrignano did not asked for public funds to run the
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community. That was a precise choice to guarantee the independence of the community
from any political and financial ties. Throughout the years a range of workshops and
vocational trainings have been created to serve the needs of the community and respond
to the first logistical and functional activities. The kitchen, the carpentry, agriculture and
animal breading were among the first activities in early 80s. Nowadays San Patrignano
offers more than 50 branches, some of them rental activities, which are providing 50%
of the funding needed for keeping the community running, while 50% of the costs are
coming from fundraising supporting San Patrignano’s work in the field of recovery. All
the products and services of San Patrignano are inspired by excellence of quality and
handicraft. They are successfully placed in the niche market because they are good and
customers are choosing them and buying them for their actual value and in addition to
it, they are also contributing to the social cause of the community. The importance of
producing excellent goods has also a therapeutic value for the residents, who can measure themselves with professionals and masters in different disciplines, learning their
expertise in producing high quality goods, which will boost their self-esteem and contribute to their recovery. The excellence of the products reflects the excellence of the people
who have been producing them. Some examples of the productive vocational trainings
of the community are presented in the following paragraphs:
Graphics design and printing workshop
The graphics sector has always had the goal of keeping up with technological innovations, providing the full cycle of production: from the graphic idea to the realization,
going through quality and color control, to digital printing. The San Patrignano Magazine is produced monthly in the graphics workshop. Furthermore, the Creative Graphics
Agency offers the residents internships in the design sectors providing the opportunity
to work with professional designers and clients measuring themselves with the outside
job market. The websites and e-commerce of the community are managed and maintained by the residents under professional supervision. The San Patrignano Audiovisual is
producing all the videos of the community and also works with external clients.
Home decoration, interior design and fashion accessories
Counting on more than 20 years of expertise the decoration workshop offers home
accessorize in leather, decorated fabrics and wallpapers made with herbal and natural
colors as well as fashion accessories such as leather and fabric bags, belts and leather
sandals. The textile sector produces hand-made woven accessories in cashmere and precious yarns, patchwork, hand-knitted and crochet design to wear and home-decoration.
All pieces are luxury and unique, reflecting the hand-made philosophy.
The San Patrignano carpentry presents furniture and home decoration collections pro288
duced with wood and eco-sustainable and recycled materials. In particular the Barrique
the third like of wood project, build on a cooperation with exclusive international designers, presents a limited edition of design items manufactured by community residents
using the recycled wood with the dismissed barrels from the wine cellars.
Agriculture and food production
Food and wine play an important role in the Italian culture, therefore some of the more
rental activities of the community are related to agricultural and food production. The
winery of San Patrignano, which counts on hundred hectares of vineyard in the community premises, produces more than 500,000 bottles a year. Many of the San Patrignano
wines have been receiving national awards and are sold in Italy and abroad, with success.
The fact that a recovery community produces and sells wine does not represent in our
view a conflict of interest, because wine in Italian tradition, is mainly considered and
consumed as a food, in moderate quantity. We support a sober consumption, as used in
the Mediterranean culture, with the aim of tasting and enjoying a glass of wine during
the meal and not for social consumption with the only purpose of getting high, binge
drinking, which is more culturally common in Nordic countries. Moreover, wine harvesting is a moment of unity and sharing; the entire community contributes and actually
participates in the activities. The meat production (cow, pork and rabbits) is meant for
internal consumption and also for food processing of cured meet to be sold outside the
community. The dairy products and cheeses are also contributing to the community
income. Some of the sheep-pecorino cheeses as well as fresh cheeses like squacquerone
received national awards in recent years. Beekeeping activities offer a superb variety of
honey. Two different kinds of extra-virgin olive oils, Evo and Paratino, are also produced
by San Patrignano. The community bakery primarily provides for internal needs, but
also presents a selection of cookies and seasonal baking products to be sold outside.
Dog and Horse breading for pet therapy or services
The kennels and the stables at San Patrignano were set up in the late 70s out of the passion of the founder Vincenzo Muccioli who believed in the therapeutic value, for drug
recovering addicts, of working with animals anticipating the later work of the pet therapy. The kennels in San Patrignano focuses on Labrador breeding, since these dogs have
been identified as the most suitable for pet therapy. Pet therapy trainings are regularly
offered to residents. Among the rental activities of the kennels are breading of puppies
for selling purpose, dog pension for external clients and pet therapy services for children
and people with physical disabilities. San Patrignano is also breeding horses and taking
care of horses for external clients. Currently there are almost 100 horses, including active jumpers, stallions and ponies. Some of them are used in the San Patrignano Riding
School, offering courses for children, teenagers and grown up riders who want to get
trained in horsemanship.
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Floriculture and green maintenance
Floriculture is particularly indicated for people facing the problem of drug addiction
and social exclusion. Natural growing and respect for nature and the seasonal changes,
are able to teach patience and serenity. Gardening and green maintenance are also providing important professional skills that can lead to a career in either landscaping or
organic farming.
Hospital and Health care
Although San Patrignano does not have a medical approach towards treating drug addiction in itself, nevertheless, drug use can lead to serious illnesses which require appropriate treatment. The medical center of the community was built to provide care, research
and to prevent these diseases. Inaugurated in 1994, when the AIDS epidemic reached
its peak, the Medical Center became a point of reference for pathologies related to drug
addiction: HIV, hepatitis, sexually transmitted diseases, psychiatric conditions, dental
problems, just to mention a few. The community has made no distinction with regards
to those suffering from illnesses, either mental or physical, which are often subject of
stigmatization. Since 2014 the hospital has been inserted into the list of the recognized
health system centers, offering treatment also for locals living outside the community
who might want to receive assistance in San Patrignano.
Upon entering the community, each resident undergoes a complete checkup (blood test,
x-ray, ultrasounds, ECG etc.) to confirm that they are not suffering from contagious
diseases and to allow them the permission to practice sport. The residents who require
dental care can count on a team of specialized dentists, hygienists, and orthodontists.
Specialized visits (for example for infectious diseases, or with gastroenterologists, psychiatrists, endocrinologists, etc.) are scheduled in case of need for the residents, during
their entire stay in the Community. Furthermore, in the hospital, psychotherapy support
is offered if needed, a laboratory for blood testing, a gym and facilities for physiotherapy
are also available. The hospital is equipped with fifty beds over two floors, dedicated to
those who need long term care. Besides Community residents, people referred from
other hospitals, who may not have a family or relatives to support them, or who are
unable to care of themselves, are also welcomed to be treated. Along with the nurses
and doctors, community residents also assist the patients on a daily basis, strengthening
the spirit of service that is acquired during the recovery program. Their work is of vital
importance to help the patients feeling less isolated, and it may sometimes also lead to a
career in healthcare, whether in the medical or dental field. Thanks to their experience
in the Medical Center, many residents have resumed their study and later on become
doctors, nurses, or orthodontists.
San Patrignano undertakes important research projects in the medical field in coopera290
tion with Italian and international researchers and published in some of the most prestigious scientific publications in the world. A key component of the research is the huge
amount of data acquired over the years, with over 25,000 people (3,800 of whom HIV
positive) followed over the period of thirty years, including a comprehensive clinical
data on drug addiction.
Admission and preadmission
In the community there is a dedicated office dealing with admission. The fundamental
requisites to start the admission process are the willingness and commitment to quit addiction and start a new life. Getting admitted into the community program might happen either through direct contact with the community or via the network of voluntary
associations in Italy and abroad providing family support, counselling and referrals to
the community. These associations are constituted by volunteers, parents, relatives and
recovered addicts. They are liaising with the San Patrignano admission office, collecting
the requests for help from their geographical area, supporting addicts in their desire to
change. They are also assisting the families of the residents and advising them on how
they could support the recovery of their beloved ones. These voluntary associations also
operate within the prison system, raising awareness among those convicted because of
crime connected or committed under the influence of drugs, about alternative sentencing to incarceration and access to treatment outside prison. We currently have more
than twenty associations around Italy and three abroad in London (UK), Split (Croatia)
and Santa Monica (USA).
The second way to gaining admission in the community program is through direct contact with the San Patrignano Admission Office. Regular contacts are encouraged to assess motivation and progress, via regular mail, e-mail and Skype video-call, especially
for inquiries and motivational interviews from abroad.
During the years, a half-way which is a pre-admission house was also developed, providing immediate help and assistance to the drug addicts who need to go through the
detox phase in a serene environment, testing also their motivation to enter in the program and familiarizing with the values and work of the community. Two pre-admission
centers are available in Salerno and in Botticella, both are in a beautiful environmental
landscape with a farm setting offering housing, meals and full board of activities for the
residents. The process of preparing people for entering in the community normally lasts
a couple of months, which is the time needed to complete the detox phase and testing the
real motivation and commitment to start a recovery program in San Patrignano.
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Follow up research and current research projects
The more systematic research to date regarding the results obtained by the San Patrignano community has been undertaken in the “Beyond the community” project (4). The
aim of the research was to assess the long term results of the residents of the community.
Evaluations were undertaken during their recovery program and in the following two to
four years after they left San Patrignano. “Beyond the community” was a joint independent evaluation project of three Italian Universities: Bologna, Pavia and Urbino.
The first aspect of the study dealt with the retention factor namely the percentage of
people remaining in treatment for a predetermined amount of time. The retention factor
has been evaluated to be around 70% after one year, dropping to 52% and 45% respectively after two and three years. The second part of the research consisted in toxicological
analysis combined with the sociological questionnaire, for subjects who have left the
community for at least three years. The hair strand analysis allowed for the detection
of exposure and consumption of drugs back to one month per centimeter of hair analyzed. The average results for residents who have left with consent upon completion of
the program and remained drug free was 72%. The percentage still remains high for the
people who left without consent, but completing the program, which is about 50%.
San Patrignano is currently undertaking another research in cooperation with Bologna
University and the Italian Anti-Drug Department, which will monitor residents during
the recovery path from the entrance in the community until the completion of the program, the social reintegration and the follow up. The project has been running for six
months already and will continue for an overall duration of four years.
Conclusions: The importance of recovery: general considerations and opportunities to
learn more in practice
San Patrignano believes in the importance of recovery as an answer to drug addiction for
those individuals who are really motivated to change their life, and as a viable alternative
to a life of pharmacological maintenance treatment or a life spent in prison or in criminal activities to support the habit.
Recovery is also a social investment for the society as a whole because it will result in
the long run as a mayor saving to both individual and society in particular by reducing
interpersonal and/or family conflicts, increasing work productivity, diminishing drug
related incidents as well as overdoses and/or drug related deaths. The actual amount of
savings to the welfare and health system thanks to recovery has not been measured, but
governments and members states should further analyze the costs of addiction in their
country to better assess their drug policy, action plan and interventions.
According to the Italian data (3) the social costs of addiction estimated for 2012 in Italy
are 15.65 million euros, about 1% of the GDP. Among them 4.12 million euros derived
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from lack of productivity, including also premature deaths and mortality caused by drugged driving. Health care costs are around 1.55 million euros summing up drug treatment services and health care for drug related diseases. The cost of the criminal justice
involved in drug issues is 1.33 million euros including the expenditures of the detention
system and services provided by tribunals and courts.
Moreover, San Patrignano is a founding member and supporter of the Recovered User
Networks, RUN. The vision of RUN is to contribute to constructive and respectful drug
policies, for individuals, families and communities, by raising the voice of the recovery
movement and including its principles in major international political forums.
Furthermore San Patrignano stands available to share its expertise maturated in more
than 30 years of work at the grass roots level with governments, civil society and social
workers interested in the drug field. The community regularly welcomes visits to the
community and is in contact with dozens of delegations, most of whom have been visiting San Patrignano over the years. San Patrignano hosted delegates from Qatar, Indonesia, China, Croatia, Mexico, Sweden, Norway, Finland, Estonia, Canada, UK, Scotland,
Brazil, France, Latvia, Georgia, Russia, USA, Guatemala, Colombia, Denmark, Lebanon,
Germany, Turkey, Romania, Argentina, Peru, Maldives, Dominican Republic, The Netherlands, Antilles, Australia, New Zeeland, Spain, Austria, Republic of Seychelles, just
to mention a few.
Another option San Patrignano offers to individuals or organization interested in learning the recovery model more in depth is the International workshop. The workshop is
available twice a year in July and November and it is a special format of one week, combining lectures and experiential labs in the vocational trainings on site in San Patrignano,
which allows for living all the aspects of the community with a team of tutors and staff
from San Patrignano, accompanying the guests during their stay.
In line with the mission of San Patrignano, which is to provide a heartfelt welcome to
people in need and to accompany them in their rehabilitation, the community reiterates
with the words of its founder, Vincenzo Muccioli, that “San Patrignano is one way to deal
with drug addiction, and not the way” and that the leading principle is not to teach drug
addicts what they have to do, but doing it together in the spirit of the community. Therefore whoever feels an interest in finding solutions to drug addiction might come to visit,
getting inspired by San Patrignano, and then continuing in his own and personal way,
adapting their ideas and intervention to different contexts and nations, but following the
same goal of a recovered life.
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REFERENCES
1. Catrignanò M. A Drug Free Approach to Treatment-Cultural/Social Aspects and Follow-up
Studies: the case of San Patrignano Therapeutic Community. Journal of Global Drug Policy
and Practice. Spring 2012; Volume 6 (Issue 1) pages 64-75. Available at HYPERLINK
“http://www.globaldrugpolicy.org/Issues/Vol%206%20Issue%201/Journal%20Vol%206%20
Issue%201%20sm.pdf ” http://www.globaldrugpolicy.org/Issues/Vol%206%20Issue%201/
Journal%20Vol%206%20Issue%201%20sm.pdf
2. Guidicini P, Pieretti G, San Patrignano. Environmental Therapy and City Effect. A study of
Biographic Paths conducted on Community residents. Milano: Franco Angeli; 1996.
3. Presidenza del consiglio dei Ministri Dipartimento Politiche Antidroga. Relazione annuale
al parlamento 2014. Uso di sostanze e tossicodipendenze in Italia sulle tossicodipendenze
2013. Roma: Dipartimento Politiche Antidroga 2014.
4. Manfré G, Piazzi G, Pollettini A, editors. Beyond the Community. A Follow Up study on
San Patrignano formers guests. Milano: Franco Angeli 2005.
ADDITIONAL REFERENCES
Baraldi C, Piazzi G. The Community Seen from the Bottom. Children at San Patrignano. Milano: Franco Angeli; 1998.
Guidicini P, Pieretti G. San Patrignano Between Community and Society. A research on the
Biographic Routes of 711 San Patrignano Former Guests. Milano: Franco Angeli; 1995.
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Janusz Sieroslawski*
Institute of Psychiatry and Neurology, Warsaw, Poland
ABSTRACT
Social re-adaptation and re-integration are the big challenge in assistance to drug addicts. The paper presents two models of rehabilitation of drug addicts and discusses advantages and disadvantages of each of them.
The first model is rehabilitation in a residential center applying therapeutic community approach. Patients together with therapeutic
staff constitute community isolated from the society. Availability of drugs is low if any as therapeutic communities are located far away
from patient’s original community. In such artificial total institution the psychosocial interactions are very intensive. The patients try
to change their attitudes, internalize norms and learn social roles. The community assures sense of security reinforcing therapeutic
impact. The problems appear when patients leave the therapeutic community and try adopt to normal life in society.
The second model in contrast to the first one doesn’t isolate drug addicts from the broader society. The rehabilitation is provided in the
context of natural environment on the basis of out-patient clinics, sometimes with support of maintenance therapy. Various services
like welfare agencies or employment agencies are also involved. The psychosocial therapeutic activities are not so intensive, but all the
time are provided in a natural context of everyday life. The special focus is on vocational rehabilitation, employment and improvement
of social relationships. Nevertheless, remaining in the environment where drugs were taken can constitute threats for the patients.
On the basis of Polish experiences, the feasibility of both approaches is discussed.
Keywords: Rehabilitation, Therapeutic Community, Community-Based Program, Drug Addicts, Recovery from Addiction
* Study supported by National Bureau for Drug Prevention in the scope of Grant Agreement with European Monitoring Center for Drugs
and Drug Addiction (EMCDDA).
Researcher, sociologist, for 32 years working in the Institute of Psychiatry and Neurology in Warsaw, conducting research focused on
epidemiological monitoring in the area of alcohol and drug problems, as well as, evaluation of social response to substance use related
problems including alcohol and drug policy.
Involved in many international research projects and drug policy implementation practices. Polish Permanent Correspondent to
Pompidou Group (Council of Europe). Expert of the Polish National Focal Point for EMCDDA. Trainer in numerous training initiatives
organized by EMCDDA, UNODC, WHO, and Pompidou Group.
Expert in numerous twinning drug policy programs supported by European Commission. Expert in Central Asia Drug Action Program
commissioned by European Commission. Author of about 120 scientific publications in Polish, English, German, and Russian.
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TWO MODELS OF REHABILITATION- THERAPEUTIC COMMUNITY VERSUS COMMUNITY-BASED PROGRAM
Two Models of Rehabilitation – Therapeutic
Community versus Community Based
Program
Introduction
Drug dependence is not only medical problem but also psychological and social problem
The profile of drug addict usually includes:
•
social exclusion
•
psychological disorders
•
dysfunctionality in playing social roles
•
incorrect interpersonal relationships
All these problems usually aroused as an effect of addiction or constituted background
for addiction or most frequently both of them.
Rehabilitation is a process aimed at returning drug addicts to society by compensating
these disorders and dysfunctionalities. Rehabilitation of drug addicts is defined in the
field of substance use as “the process by which an individual with a substance use disorder achieves an optimal state of health, psychological functioning, and social well-being” (1).
Various models of rehabilitation founded on various concepts of addiction with different traditions were developed.
Comparison of two following models is a subject of this paper:
•
Therapeutic community model
•
Community based program model
Therapeutic Community Model
Therapeutic community concept as a treatment option for drug addicts was developed
in USA in 1950s (2).
Addiction concept behind this model is more psychological and moral problem (personality disorder) but also social dysfunctionality caused by drug use. The model applies
psychological and pedagogical approach.
The treatment goals are as follows:
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•
abstinence
•
personality change, reorientation of attitudes
•
social re-adaptation, internalization of social norms
Therapeutic community concept is usually implemented in residential treatment facility
isolated from the rest of society. This is a long-term therapy, which last 1-2 years (3).
Patients with therapeutic staff constitute community which plays the fundamental role
in the therapy. The community constitutes the basic reference group for clients. The
identification with group is very strong, hence group processes are very influential. Especially in condition of isolation group impact can change a lot. Intensive psychological
influence involving various therapeutic methods, but always group process is most important one. Therapeutic community assures sense of security of patients and reinforces
therapeutic impact.
Therapeutic communities in Poland have long tradition going back to late 1970’s. The
first therapeutic community was initiated in our country in 1978 (3). The majority of
rehabilitation centers are run by nongovernmental organizations (NGO). Recently there existed about 90 therapeutic communities in Poland (3). Majority of them is run by
nongovernmental organizations (NGOs). Therapeutic communities were long time a
heart of the treatment system in Poland. Out-patients clinics played the role an entry to
the system of residential treatment. The next step were detoxification units in hospitals
whence patients were directed to long term residential rehabilitation centers. After-care
offer like hostels or outpatient services were underdeveloped. Such system was quite
functional for socially deprived opiate addicts.
Residential rehabilitation centers applying therapeutic community concept are usually
located in rural area, separated from surrounding. The “own territory” provides bases
for group self-identification and supports sense of security for clients. Each community
defines common philosophy and rules. The structure in terms of hierarchy and steps in
achieving the rehabilitation goals is also defined.
There could be identified four therapeutic areas in the therapeutic community approach:
•
Modeling of behavior pattern (correctional actions)
•
Work with mental and emotional development
•
Work with intellectual and spiritual development
•
Shaping and developing life skills including vocational skills
Therapeutic community approach is mentioned in UNODC Drug Abuse Treatment Toolkit as one of evidence based rehabilitation option (4).
Effectives of therapeutic communities was confirmed by several studies (5).
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In Poland the study focused on assessment of Polish treatment and rehabilitation system
revealed that completion rate in average was 27% (6). The biggest dropout is observed in
the first several days of admission – 17%. There are not outcome studies in Poland but
anecdotal data suggests positive outcomes for heavy opiates addicts.
According to findings of American Drug Abuse Treatment Outcome Study (DATOS) (7,
8, 9) dropout amounts 30-40% in the first 30 days of admission and declines thereafter.
Completion rates are in average 10-20%, and one-year retention rate range 15% to 30%.
More than 50% clients experience positive outcome (improve: social functioning, employment, decreased: criminality, substance use). Multivariate analysis confirmed that 6
months or more in long term residential rehabilitation programs was associated with the
reductions by 50% weekly or daily cocaine use in the follow-up year than in the preadmission year (9).
Community Based Treatment
International Network of Drug Dependence Treatment and Rehabilitation Resource
Centers (Treatnet) in the good practice document on Community Based Treatment
proposes: “The biopsychosocial model is used here as a basis for service and treatment
planning. This is a holistic approach that takes into account the complex variety of factors such as genetic, psychological, social, economical, political factors to explain drug
use problems and drug dependence. The biopsychological model proposes that the best
way to treat drug use problems or dependence is through a multidisciplinary team.” (10)
According to this approach the treatment is aimed at social readaptation and reintegration, improvement of interpersonal relationships and internalization of social norms.
Abstinence is necessary in some programs, but is not the most important one.
Therapeutic program implemented in the context of natural patient’s environment usually on the basis of out-patient facility. Various services like welfare agencies or employment agencies are also involved – close multi-sectorial collaboration is important factor
of success.
The special focus is on vocational rehabilitation and improvement of social relationships. Rehabilitation can be supported by substitution therapy.
Community-Based Drug rehabilitation responds to the needs and resources of community. The first step is careful assessment. This type of program is based on a vision of the
multifactorial range of drug related problems that may affect drug addicts, their families
and whole community. Such perspective encourages the use of a variety of paths to treatment, recovery and increased quality of life (10).
The patient needs are on first place in this approach, so service providers reoriented own
approach (11).
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Community-based rehabilitation compared to other type of treatment (e.g. residential rehabilitation):
•
is less invasive
•
facilitates patient access to service
•
is less disrupting of family, working and social life
•
is focuses on social integration from the beginning
•
is more flexible
•
promotes patient’s independence in natural environment (10)
Moreover community-based approach is affordable for community, supports stigma reduction and empowers community (10).
First comprehensive community-based drug prevention program in two local communities in Poland was implemented in 1994-1995 in the scope of European Commission
Grant (12). The program activities consisted of universal prevention measures aimed at
youth, work with youth at risk, as well as rehabilitation and harm reduction measures
addressed to drug users. The program was implemented in close collaboration of researchers and local community. The planning was preceded by initial assessment. On
each stage of program implementation representatives of local institutions and nongovernmental organizations were involved. The program was based on close multiagency
collaboration.
Rehabilitation offers developed for drug addicts included:
•
counseling and support,
•
psychotherapy (individual and group),
•
family therapy,
•
support in employment,
•
social welfare,
•
maintenance therapy.
After two years of program implementation outcome evaluation was conducted using
qualitative and quantitative methods. The results of initial assessment were taken as a
baseline. The data were collected applying school and population surveys, in-depth interviews with stakeholders as well as representatives of target population. The statistical
data and program documentations were also analyzed.
The evaluation exercise revealed positive outcomes on both levels client and community.
Outcomes identified on the client level were as follows:
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•
all identified drug addicts were covered and no any dropout was noted
•
legal and administrative status of several clients was clarified and stabilized
•
all clients able to work found employment
•
for all unable to work welfare assistance was assured
•
majority of clients improved relationships with family
Most of drug addicts taking part in the program notice opening new life perspectives for
them by participation.
Outcomes identified on the community level were as follows:
•
illicit drug local production and market collapsed
•
stigma decreased
•
inter-institutional cooperation improved
Comparison of two models
Comparison of two models is summarized in the table below:
Therapeutic community seems to be more suitable for drug addicts with broken all social relationships and without any social support. Homelessness and sever life conditions
could be also factors for choosing this option.
Drug addicts not totally isolated from their social environment with chance for family
support probably could be better clients for community base program.
Conclusions
Both, therapeutic community and community based programs are evidence-based. Both
approaches have advantages and disadvantages. There is no simply answer, which approach is better – all is dependent on cultural context, local circumstances and drug addict
profile.
Service planers should develop both models to provide drug addicts with differentiated
rehabilitation offer. For same clients therapeutic community would be effective, for other
the community based program would better. Potential clients should select option which
seems to you more suitable for his/her life situation and nature of the problem.
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REFERENCES:
1. Demand Reduction. A Glossary of Terms. UN ODCCP, New York, 2000.
2. De Leon, G. (2003). Społeczność terapeutyczna. Teoria, Model, Metoda. Warszawa:
Krajowe Biuro ds. Przeciwdziałania Narkomanii.
3. Koczurowska J. (2012). Społeczność terapeutyczna w rehabilitacji uzależnień. In: P. Jabłoński, B. Bukowska, J. C. Czabała (2012) Uzależnienie od narkotyków, Krajowe Biuro ds.
Przeciwdziałania Narkomanii.
4. UNODC (2003) Drug Abuse Treatment and Rehabilitation: a Practical Planning and Implementation Guide. New York 2003.
5. Lees J., Manning N., and Rawlings B. (1999) Therapeutic Community Effectiveness: A
Systematic International Review of Therapeutic Community Treatment for People with
Personality Disorders and Mentally Disordered Offenders. CRD Report 17. The University
of York.
6. Mosklewicz J., Langiewicz W., Sierosławski J., Świątkiewicz G. (2005).Optymalny model
zaspakajania potrzeb leczniczych osób uzależnionych od nielegalnych substancji psychoaktywnych w Polsce. Raport dostępny na stronie Krajowego Biura ds. Przeciwdziałania
Narkomanii www.narkomania.gov.pl
7. Hubbard, R. L., Craddock, S. G., Flynn, P. M., Anderson, J., & Etheridge, R. M. (1997).
Overview of 1-year follow-up outcomes in the Drug Abuse Treatment Outcome Study
(DATOS). Psychology of Addictive Behaviors, 11(4), 261-278.
8. Hughes P., H., Coletti S.,D., Neri R.L., Urmann C.,F., Stahl S., Sicilian D.,M& Anthony J.C.
(1995). Retaining cocaine-abusing women in therapeutic community: The effect of a child
live-in program. American Journal of Public Health, 85, 1149-1152.
9. Hubbard R., L., Craddock S.,G., Flynn P.,M., Anderson J., Etheridge R., M. (1997) Overview of 1-year follow up outcomes in the Drug Abuse Treatment Outcome Study (DATOS).
Psychology of Addictive Behaviors, 11(4), str. 261-278.
10. UNODC (2008) Community Based Treatment Good Practice. Treatnet: International Network of Drug Dependence Treatment and Rehabilitation Resource Centres.
Good practice document. Vienna, 2008. http://www.unodc.org/docs/treatment/CBTS_
AB_24_01_09_accepted.pdf
11. Kunze, H., Becker, Th, Priebe, S. (2004). Reform of psychiatric services in Germany:
hospital staffing directive and commissioning of community care. Psychiatric Bulletin. 28:
218-221.
12. Moskalewicz J., Sieroslawski J. Swiatkiewicz G., Zamecki K. Zieliński A. (1999) Prevention
and Management of Drug Abuse in Poland. Summary of Final Report. Institute of Psychiatry and Neurology, Warsaw 1999.
13. UNODC (2009) Principle of Drug Dependence Treatment. Discussion Paper. United
Nations Office on Drugs and Crime. Vienna. http://www.unodc.org/docs/treatment/Principles_of_Drug_Dependence_Treatment_and_Care.pdf
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Jean Kissell*
Executive Director, WADAN
Mohammad Nasib**
Chairman of WADAN
ABSTRACT
Drug addiction is a major problem in Afghanistan and its treatment is an ongoing challenge. WADAN addresses this with our treatment
centers that provide a holistic approach to rehabilitation of those afflicted with drug addiction that includes family counseling and
re-integration into society.
Our paper and our presentation will each focus on the history of the Welfare Association for the Development of Afghanistan’s work
to alleviate those suffering from drug addiction through treatment and rehabilitation as well as our efforts to educate people of both
genders, of all ages and from all societal groups about the dangers of drug addiction as well as discouraging participation in any
stage of the illegal poppy industry from production to trafficking. We use our treatment centers, outreach centers, and our work with
teachers, community leaders, religious figures and all others that can be reached through WADAN’s nationwide projects to address the
problem and educate the Afghans.
Rule of law is not practiced in Afghanistan, peace and good governance eludes Afghanistan and poverty and hopelessness are widespread and in some areas tradition regards homemade poppy products as medicinal. Even among those who are supposed to uphold
the law, the police and military, drug addiction is a problem. Tiny children and elderly women suffer from drug addiction as well as
entire families. Sisters sometimes bring their brothers to seek treatment. WADAN promotes holistic wellness-body, mind and, spirit and
compassionate religious counseling is a mainstay in our treatment procedures.
* Born and educated in the State of Vermont, Jean Kissell left home in 1987 to organize, coordinate and teach the first International
Rescue Committee (IRC) journalism course for Afghan refugees in Peshawar, Pakistan. Following that she has lived in Saudi Arabia,
Oman, and the UAE as well as in the USA.
In 2003, she went to Kabul to help WADAN for a few weeks to fulfill a promise made in 1987 to her Afghan students.
In 2014, as Executive Director of the Welfare Association for the Development of Afghanistan, which is an Afghan NGO. She is focused on
WADAN’s work of building people through civic education, formal and community based education and drug control through residential
treatment centers, drop in centers and outreach education efforts.
** Mohammad Nasib was born in Nangarhar Province, Afghanistan. After the Soviet invasion he migrated to Peshawar, Pakistan. He went
to the USA for higher education and upon his return from 1993 to mid-2002 he worked for UNODC, UNDP and the World Bank.
He is a founder of the Welfare Association for the Development of Afghanistan (WADAN) and was its Managing Director from August
2002-October 2008, when he joined the Center for International Private Enterprise (CIPE) as its Country Director for Afghanistan. Currently he serves WADAN as the Chairman of the Board of Directors.
WADAN has three major focus areas of work: civic education, education and drug control that reflect major needs for the development
of the people and institutions in Afghanistan. Mr. Nasib is also currently the Chairman of the Board of Directors of the Afghan NGOs
Coordination Bureau. ANCB is an umbrella organization with more than 200 Afghan NGOs.
He is a strong believer and an advocate for an organized, aware, educated and active civil society in Afghanistan.
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WADAN AFGHANISTAN: WADAN’S APPROACH TO DRUG CONTROL, 2002-2014
Wadan Afghanistan: WADAN’s Approach to
Drug Control 2002 -2014
Wadan is a Pashto language word, both a noun and a verb, meaning innovation, blossoming, life, prosperity, progress, success, stability, joy and enlightenment. WADAN is
also the acronym for our non-governmental organization, the Welfare Association for
the Development of Afghanistan.
Established in August 2002, our WADAN is an indigenous NGO that envisions a peaceful, educated, drug free, democratic, developed and prosperous Afghanistan. We work
in coordination with line ministries, civil society organizations and others in grassroots
community and institutional development, civic education, and education in addition
to drug control initiatives. We maintain national coverage.
Today with over 2,000 full time staff members, WADAN is one of the largest and most
active of the Afghan NGOs. However, our very first project was the United Nations
Drug Awareness Day in Kabul in 2003. Its budget was $1,200.00.
As part of the modest multinational efforts to treat drug-addicted Afghan men, women
and children, WADAN currently runs 16 treatment and rehabilitation centers throughout Afghanistan. Our funding is provided by the UNODC and INL through the
Colombo Plan.
Kabul City, with its population of millions, is home to three WADAN residential treatment centers that have 180 beds for men, one with 20 beds for women and one with 40
beds for both children and women. The men’s centers are equipped to provide home-based treatment for 180 women per 90-day treatment cycle.
Also in Kabul, we have an outpatient clinic which can see up to 30 patients a day, additionally it provides follow-up for recovering addicts, public awareness, social, medical
and referral services. Four other outpatient centers offering the same services are located in the provinces of Logar, Ghazni, Zabul and Kandahar.
Gardez, in Paktia Province, is where our first residential treatment and rehabilitation
center opened in 2004 with 20 beds for men and home based treatment for women. We
also operate 20-bed centers for men in Maidan-Wardak, Khost, Helmand, Kandahar,
Herat, and Badakhshan Provinces, as well as a 15-bed center in Farah Province. With
the exception of Farah, these centers offer home based treatment for women.
Residential treatment for women is available in Farah City, Farah Province in the west
of Afghanistan where we have 20 beds for women and home based care as well. In Jalalabad City, Nangarhar Province in the eastern part of the country, WADAN has two
304
facilities for women, one with 15-beds for women, adolescent girls and children and a
separate 20-bed center for women, which offers home-based treatment.
In the year ending August 31, 2014, WADAN discharged 1,046 men, 249 women and
471 adolescents and children following treatment and rehabilitation. In the same time
period, 1,483 people received home-based care. Of these only 29 were men. In the
conservative atmosphere of Afghanistan most women simply do not have the option
of traveling to residential treatment centers. Men’s primary reason for choosing home
based treatment could be to avoid social stigma, particularly if their position in society
is a high one. Nonetheless, at the end of August 2014, there were 973 on the waiting lists
for treatment at our residential centers. Fifty-two of them are women or children.
The UNODC 2009 Drug Use in Afghanistan Survey, which admittedly is out of date
today, estimated there were around one million drug addicts who used mostly opium
with heroin addicts being the next most numerous (1). The INL Drug Demand Reduction Program Research Brief in December 2012 presented the results of The Afghanistan
National Urban Drug Use Survey 2012 (ANDUS) that showed 1.6 million addicts including 0.03 million children who were passive child addicts (2).
After the Taliban Era, when drug addiction was a crime and addicts went to jail, there
was a great need for awareness education, and this remains true today. Each of WADAN’s civic education and education projects address drug control issues, addiction,
rehabilitation, surviving the social stigma of seeking addiction treatment, and also not
cultivating poppies, trafficking or manufacturing illegal drugs.
Psychosocial counseling and religion are important parts of our programming; ensuring that recovering addicts have welcoming environments when they go home is addressed in family counseling sessions while their family member is under treatment and
later through the aftercare process. Basic Education is also an important component of
WADAN’s treatment programs at all our residential treatment centers.
WADAN focuses intensively on post treatment follow-up and social reintegration. We
have found that it is evident that recovering addicts, when encouraged, become role
models for others who are still addicted. The backbone of WADAN’s addiction treatment is to stress rehabilitation and reintegration. This approach aids in reducing the
social stigma of drug addiction, encourages addicts to seek treatment, and benefits those who have successfully completed treatment.
WADAN has also provided treatment for drug addicts who are jailed; we have worked in the prison in Kandahar, where detoxification and rehabilitation was offered to
prisoners and basic health care was available for both prisoners and guards. We have
also provided drug education, detoxification, and rehabilitation services to the Afghan
National Police in Kandahar and Herat.
Now that we have presented some basic facts about WADAN and WADAN’s drug tre305
atment and rehabilitation programming, we would like to look more closely at the life
of one individual. While Anwar’s story has the ingredients of lost love, youthful folly,
failure and redemption that are found in literature, Anwar’s story is true:
From Drug Addict to Role Model
In many ways, Mohammad Anwar’s tale is a typical, if tragic, chronicle of war, displacement, alienation, and drug addiction.
What makes Anwar so different is the ending: the former mujahidin commander, political activist and heroin addict worked as a counselor in WADAN’s Khushal Khan Drug
Treatment Center in Kabul.
“I come from an educated family,” said Anwar. “My father was an influential figure in the
Islamic Revolutionary Council; when the Communists took over, we had to flee to Iran.”
As a high school student, he excelled; he gained admittance to university, a rarity for
Afghan refugees in Iran.
“I had the highest grades of any student in the country,” he said.
Anwar majored in Farsi literature, and dreamed of becoming a writer. His future looked
bright.
But then his life took a dark turn, and all because of love.
“I had a girlfriend,” he recalled. “She was Iranian, and her father was a writer. He was
also an addict.”
Anwar had wanted to marry her, but his parents refused to allow the marriage.
Without his parents’ permission, he could do nothing. He broke the news to his girlfriend, who helped him gain access to drugs from her father.
“I wanted to get revenge against my family,” laughed Anwar, a bit sadly. “So I took the
drugs and ran away.”
Thus began Anwar’s descent into violence and addiction. As he was becoming more
seriously involved with drugs, Anwar was also forging a reputation as a fierce mujahidin
commander. He would go over the border from Iran into Afghanistan and then retreat
back to Iran. Most of the time he was fighting, he confessed, he was high on drugs.
“I took heroin, crack cocaine, crystal meth,” he said. “That was when I was in Iran. In
Afghanistan I took opium, or injected heroin.”
The Soviets left Afghanistan in 1989.
“I returned in 2000,” he said.
But life was difficult for the young man. The eldest son of a wealthy family, he did not
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have to worry about money. But his family eventually disowned him, because they could
not accept his drug use.
“One day I was standing on the street next to a beggar,” he recalled. “My clothes were
clean enough, and expensive. But the beggar could tell by my face what I was.
“’Go away’, hissed the beggar. “With you here, people are afraid to come close enough to
give me money.’”
That was a wake-up call for Anwar.
He decided he had to get clean.
“There was a drug treatment center,” he said. “I got on the waiting list.”
“The detox period was very, very difficult; I had a very strong temptation to relapse. But
I considered it an ordeal sent by God.”
“The WADAN center helped me through it,” he said. “If not for them, I do not know
what would have happened to me.”
“My counselor first asked me to work as a volunteer,” he said. “And I was keen to keep
his trust, so I agreed.”
Anwar was so successful in working with the patients that he soon became a full-time
counselor. He studied social work, and was employed by WADAN for years.
“It makes a big difference when the patients see me with the doctor,” said Anwar. “They
may dismiss the doctor as being too bookish. But with me they know it is the real thing.
I went through it all myself.”
Anwar was happy in his new profession, and even found an outlet for his political activism.
“I have found a new cause,” he smiled. “We are taking revenge on the drug mafia by reducing the demand for their product. I am a warrior again – but it is the war against drugs.”
Mohammad Anwar died awaiting surgery in August 2014.
Insurgents have never targeted WADAN’s treatment centers. However, On November
11, 2012, there was a huge explosion in Maidan-Wardak, an improvised explosive device, an IED, exploded near the treatment center. Thirty people were present at the time
and the WADAN facility suffered what is termed ‘collateral damage’.
Immediately after hearing about the incident, WADAN doctors and social workers from
Kabul rushed to the scene, where they surveyed the damage, visited those hospitalized
and took ambulatory patients and staff back to Kabul. Of the eighteen men under treatment, nine were placed at one of our treatment centers in Kabul, eight remained hospitalized and three decided to go home.
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Our compassionate and hardworking technical field staffs provide services under difficult circumstances that are the reality in Afghanistan and they remain committed, long
serving and dedicated, and they persevere. These are brave men and women. This is
Wadan.
In conclusion, even while we educate Afghan people about the evils of poppy cultivation
and manufacturing and trafficking drugs and though we have treated thousands of Afghan drug addicts over the years, and will continue serving them for as long as we can, we
must also consider the way forward. Our efforts must include working to solve the drug
problem that spreads throughout the world from opium poppies grown in Afghanistan
and is an enormous problem at home that destroys the lives of thousands and thousands
of Afghans – the current services that we provide are limited and cannot address the
need, service must be increased at all levels. A comprehensive approach to drug addiction and poppy cultivation is necessary. The Afghans believe these are problems the
international community should solve and the international community believes this is
the Afghan problem.
There should be political will and the rule of law and good governance in Afghanistan
and there should be coordination between the Afghan government and the international
community regarding this problem.
There should be sustainable economic development in Afghanistan where farmers
would be able to generate sufficient income to meet their needs without resorting to
growing poppies.
Law enforcement must target the drug mafias within Afghanistan; crop eradication punishes the farmers but it does not necessarily work, it has not worked in Afghanistan.
Regional and international cooperation and sustained support are necessary for Afghanistan to cease being known as the world’s largest producer of opium products and for
Afghan society to stay on the road to recovery.
REFERENCES
1. UNODC. Drug Use in Afghanistan: 2009 Survey. Executive Summary. UNODC. 2009.
2. INL. Afghanistan National Urban Drug Use Survey (ANDUS) 2012, International Narcotics and Law Enforcement Affairs (INL), Demand Reduction Program Research Brief.
December 2012.
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Jose Angel Prado*
Deputy Director General of Operations in the Centers for Youth
Integration in Mexico
ABSTRACT
The treatment of substance-related disorders, both induced by substances and use disorders, like other chronic diseases should be
addressed by health and transdisciplinary teams supported by self-help groups and patients in rehabilitation, to help patients stay
motivated to keep total and sustained abstinence.
We have often sought for the best models for the treatment of these patients, however we must not forget that what we treat are “patients and not diseases”, and therefore the diagnosis is the most important point in the beginning of the treatment and management
for those who suffer from substance disorders and their families.
The cognitive behavioral model, the motivational interviewing, and other models, have been successful; however do not work for all
patients. The treatments provided for an alcohol-dependent patient with antisocial personality disorder, whose consumption is usually
playful, and for an alcohol dependent patient with compulsive personality traits and whose consumption is a form of a self-medication
against a concomitant anxiety disorder are not the same.
At the Centers for Youth Integration in Mexico, we offer outpatient treatment, intensive outpatient and professional residential treatment. For a population of about 103,000 people, all with alcohol, tobacco and other substance use disorders.
* Dr. Jose Angel Prado was born in Mexico City on January 12, 1958; he studied medicine at the Universidad Anahuac and later Psychiatry in the University of Mexican Army and Air Force, where he graduated with honors.
He studied Psychoanalytic Group Psychotherapy at the Mexican Psychoanalytic Association and subsequently traveled to the city of
Baltimore in Maryland USA, as Hubert Humphrey Fellow to study a specialty in prevention and treatment of substance use disorders
in the School of Public Health, at the Johns Hopkins University.
Later he was invited to Israel to attend a course on prevention and treatment of drug abuse at the Ophri Institute in Jerusalem. He is
currently Deputy Director General of Operations in the Centers for Youth Integration in Mexico.
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RECOVERY AND REHABILITATION IN MEXICO
Recovery and Rehabilitation in México
Mexico, like many other developing countries in Latin America, is experiencing two
major transitions, on the one side a demographic transition due to the change in the
population pyramid, that it had a large base of children and adolescents in the recent
past, and now is going upside down, and most of the population is concentrated in the
so-called “economically active population”(1). On the other hand an epidemiological
transition type as the main causes of mortality and burden of disease is associated with
non-communicable chronic diseases, when no more than 50 years this association was
with infectious diseases (2).
Among the diseases and social determinants linked with non-communicable chronic
conditions are obesity, diabetes mellitus, lack of exercise of the population, stress associated with violence, unemployment, lack of opportunities for development and of course,
within a leading spot, substance use and related disorders; therefore the phenomena of
the substance use disorders is considered a serious public health problem that requires
priority attention.
According to the National Survey on Addictions, it is reported that alcohol consumption
in 2011 was observed a lifetime prevalence of 71.3%, the last year of 51.4% and 31.6% in
last month. Regarding the high consumption of alcohol (4 drinks or more per occasion),
it was reported to be 47.2% among men and 19.3% among women (3). In the adolescent
population, it was found that alcohol consumption has increased significantly in all three kinds of prevalence. Such that consumption increased from 35.6% in 2008 to 42.9%
in 2011, the last year of 25.7% and 30.0% in the last month from 7.1% to 14.5%. This
same trend was observed in men and women, especially in the consumption of the last
month as it increased their case from 11.5% to 17.4% and 2.7% of them 11.6%.
It was also observed that the dependent rate recorded a significant increase from 2002
to 2011, rising from 2.1% to 4.1%. Regarding the use of any illegal or prescription psychotropic drugs in the past year, the prevalence was 1.8% in the consumption of illegal
drugs, very similar to the 1.5% found in 2008. Moreover, the prevalence of dependence
of illicit drug use in this population during the last year was 0.7%, which is very similar
to what was reported in 2008 it is currently estimated that 550,000 presents a dependence disorder on illegal substances.
To address the phenomenon requires comprehensive policies covering mental health
promotion, prevention, early identification of consumption, treatment, rehabilitation
and social reintegration of consumers and their families(4). For the specific case of the
treatment and rehabilitation we have tried several models based on a philosophy or way
of understanding addiction to psychoactive substances. There are those who understand
310
addiction as a weakness of character and therefore propose disciplinary measures to
their attention, some others sees it as a moral problem and proposed penalties, which is
widespread in Mexico, others understand it as a spiritual problem and there are those
who argue that there is a genetic vulnerability or as the result of adaptation of the brain
pathways of stress and reward circuit.
A common assumption is that of self-medication and suggests that the substance is used
to deal with emotional distress, (theory of self-medication), example of this is the possible tendency of subjects with low dopamine activity in the prefrontal cortex and therefore prone to anhedonia, apathy and dysphoria that motivates them to consume cocaine
and amphetamine-type stimulants (5). Others like us who understand the phenomenon
as a result of a complex relationship between genetic influences and environmental determinants of the disease. And therefore propose trans-disciplinary interventions whose
centerpiece is mental health.
Like other countries in the matter of health and particularly with regard to the care of
substance, Mexico faces 3 major challenges, equity, quality and financial protection(6).
We believe that equity as there are municipalities with very low life expectancy, impaired
maternal death, newborn deaths, etc ... and other municipalities with life expectancy
similar to that of Japan. The quality and availability of services and in some places still is
stigma remains in the treatment of patients with substance use disorders and punished
instead of providing quality treatment. And finally, financial protection, since sometimes families take a patient to institutions or organizations where they have to spend all
their money savings in an attempt to quit using addictive substances.
Particularly on the issue of substance use disorders we identified the following challenges: an Integration of a treatment system, Availability of services, Quality of the services,
Social stigma, Gender perspective, treatment for people in prisons and Treatment for
other vulnerable groups.
The Centers for Youth Integration (CIJ) is a non-governmental organization where over
1,300 people work, all professionals, doctors, psychiatrists, psychologists, social workers,
nurses and administrative staff to attend along with more than 7,000 volunteers, more
than 6 million people in prevention and around 105,000 people on treatment. Treatment
in this organization is distributed throughout the national territory, is flexible regarding
hours, fees are very cheap and many people do not pay as they don´t have the sufficient
resources, the deal is friendly and meets the characteristics of ethnic groups and of course always gendered.
Patients, however, are not always treated the same way, everything depends on the diagnosis established, usually the DSM-V (7) is used and found to incorporate the DSMV to
identify the characteristics of the disorder. According to the criteria of American Society
of Addiction Medicine (ASAM) (8), the patient requiring the service is directed gene311
rally divided into:
• Outpatient treatment
• Treatment in intensive outpatient (day hospital)
• Brief Residential Treatment
• Residential treatment prolonged
One of the most important issues for CIJ, is the theme on dual disorders, we believe
that treating a single patient substance use is practically to invite the patient to relapse
quickly. Therefore an exploratory evaluation of the mental status is always fundamental.
Approximately one third of patients with psychiatric disorders will present some type of
substance use disorder, and more than half of people who abuse drugs, have presented
enough symptoms to meet the diagnostic criteria for any psychiatric disorder. This combination shows how dual diagnosis far from being rare, it is a common feature among
users of state services (9). We know that drug use can cause psychiatric symptoms and
mimic psychiatric syndromes, a psychiatric disorder can be triggered or worsened by
drug use, the drug may mask symptoms and psychiatric disorders and psychiatric disorders and related substances can exist independently.
Thus the lack of integrity in the evaluation weakens the ability to plan and implement
an intervention plan that accurately addresses the needs of the patient and reduces the
possibility of achieving good results in the recovery process. One difficulty to perform a
comprehensive patient assessment is the lack of training among those who call themselves counselors or who have been patient and kept in recovery and act contrary to their
program with arrogant attitude and lack of humility considering only their interventions
yield positive results and close the doors for psychiatric treatment, with often severe
consequences. On the other hand sometimes are the same psychiatrists who close the
doors to psychosocial interventions and self-help groups and then decrease the likelihood of successful interventions.
Today CIJ has 115 units including 12 units of hospitalization, Treatment and Rehabilitation Program aims primarily to eliminate or reduce the consumption of snuff, alcohol
and other drugs, as well as improve the living conditions of patients and their families.
The offer of treatment can be an outpatient, intensive outpatient treatment in day center,
a methadone program for heroin users or residential form.
To refer patients to either treatment a thorough clinical assessment is performed by a
team of doctors, psychologists and social workers interdisciplinary team, including the
application of rapid tests for detection of drugs in urine, blood HIV screening, detection
urine pregnancy, and spirometry and carbon monoxide detection.
Comprehensive treatment arises with the following specific objectives:
312
1. Monitor the patient’s clinical status.
2. Dealing with intoxication and withdrawal in parallel with the dual diagnosis.
3. Reduce the consequences of drug use.
4. Prevent relapses.
5. Educate individual and family in obtaining a healthy life.
The demand for treatment has increased. Since 2007 we attended 78.780 people (patients
and relatives), arriving in 2013 to a total of 103,000.
In the form of outpatient Basic are designed specific treatments per drug, such as dependency to snuff or clinics to stop smoking and for people with alcohol and heroin,
treating the patient and his family providing psychotherapeutic care: individual, family
and group with a gender perspective, as well as pharmacological treatments including
detoxification, abstinence control and dual pathology.
Day Centers are an intermediate care resource among the basic program and residential
outpatient, its goal is to encourage the patient in order to acquire and facilitate social
adaptation and social reintegration, under a frame of intensive treatment and close monitoring guidelines, which allows greater control over the maintenance of abstinence.
The professional residential care program, with elements of the Therapeutic Community
model, provides care to patients who require closer monitoring in the medical, psychological area, as also in the social area, through the creation of a therapeutic space whose
structure and logistics, promote the changes needed to achieve sustained abstinence,
once it is socially reintegrate their midst. Residential treatment involves two types of
stay: short 30 days, median 90 days; the patient recovers and develops skills through
a series of activities neuro-psychological, cognitive behavioral therapies under reeducation and rehabilitation approach. In this mode of 2007 to 2012 to 7,610 patients in
detoxification, control withdrawal symptoms, and were attended residential treatment.
Methadone and other opioid agonists maintenance programs for heroin users, under the
strategy of reducing physical and social consequences, provides heroine consumers with
the necessary and sufficient medication under close medical supervision with periodic
application of rapid testing drug in urine and blood screening for HIV, and psychosocial
support to reduce the probability of heroin consumption, always with the idea in mind
that this is the first contact looking for total and sustained abstinence.
On the other hand, Mexico has registered in the last years, a marked increase in the prison population. In 1996 there was a rate of 102 prisoners per 100,000 thousand, while
in 2006 the proportion increased to 245 per 100 thousand. In the same year there were
more than 200,000 inmates in different prisons, institutions with very different levels of
security for drug control (10). By 2007, this population numbered 217,000 inmates in
313
the national scope, of which 50,450 corresponded to the federal jurisdiction, 95% of the
population were male. According to the estimate of the prevalence of drug use, by 2007,
there were more than 100,000 inmates with an addiction problem. This means that in
Mexico almost 50% of the inmate population in prisons using drugs regularly. Although
in some states as in Mexico City, it is reported that seven out of ten inmates used drugs
regularly (11).
Resources intended for attention to drug use in prisons by federal, state and local governments are insufficient. Care programs that apply in these centers combine their
own technical staff, with non-governmental organizations, self-help groups, religious
associations and public institutions of health, education and job training, among others.
Admission criteria vary from program to program as well as the duration, which ranges
from three to 12 months, or until obtaining their liberty and can spend two to three years after the consumer has been released; however, not all people are successful and once
released many of them repeat their criminal behavior and consumption.
All intervention programs in these centers should consider three main aspects, both for
the social rehabilitation of inmates and for the achievement of the objectives of public
health and safety of society:
• The suspension or reduction of alcohol and illicit drugs.
• Improving the health of the individual and social functioning.
• Reduction of risks to health and public safety.
With effective treatment, many internal drug users change their attitudes, beliefs and
behaviors, they choose more functional behaviors and care to prevent relapse, which
contributes significantly to keep them away from anti-social activities.
Various sources show that comprehensive treatments decrease to 50 percent the rate of
drug abuse and 80 percent of the criminal activity; Also, the detection rate decreases by
up to 64 percent; beyond reducing practices involving infects risk of HIV / AIDS, hepatitis and other infectious diseases. The most effective models show an important link
between systems of criminal justice and drug treatment. Staff from both areas should
work together to develop plans and implement selection, placement, evaluation, monitoring and surveillance, as well as the systematic use of sanctions and rewards for drug
users who are under the jurisdiction of the criminal justice system. Additionally, these
models should include continuing care for addicts and supervision after release and during the period of probation.
Centers for Youth Integration, has been involved in various ways with substantive programs in prisons in 16 regions in Mexico:
Sharing guidance and counseling for family members of inmates.
314
Training Course to medical-technical staff and custodians.
Internal processing services - including rehabilitation to quit smoking and group-and
individual therapy, working with the staff responsible for the programs established by
the prison’s administration.
A Clinical Care Center for the follow up for people with substance disorders who were
in prison in Puerto Vallarta, Jalisco, since 1993.
We proposed in 2010 to the United Nations Office on Drugs and Crime (UNODC), a
training model with whom we have trained more than 60 workers that control the prisons in the capital of the country. Currently we are implementing treatment programs
that meet the basic principles and recommendations established by the different national
and international organizations. Also, we are working with the staff responsible for the
development of such training activities.
Finally it is worth mentioning that there have been established mechanisms to assess the
quality of treatment services granted, based on international guidelines.
Progress is being made in the development and consolidation of a system of ongoing
evaluation, with a practical design through the use of surveys rather than interviews.
Likewise reorganizing the information by these categories is proposed:
• Patient Identification
• Frequency of drug use and drug intravenous consumption
• Frequency of bio-psycho-social difficulties
• Activities during hospitalization
• Perception scale improvement on six areas: drug use, health, psychological, family and
occupation.
Regard to statistical analysis highlights that foundations for the development of three
indices were found: the first frequency of drug use, the second frequency problems in
different areas of life, and the third patient perception index improved. In all indexes excellent results were obtained, as required to produce the intermediate intervals perceived
improvement in order to achieve more subtle differences identified and provide a greater
specificity scale (12).
315
REFERENCES
1. Mexico. Censo Nacional de Población y Vivienda. Instituto Nacional de Estadística y Geografía; 2010.
2. Mexico. Programa Nacional de Salud 2013-2018. Secretaría de Salud; 2013.
3. Mexico. Encuesta Nacional de Adicciones 2011. Comisión Nacional contra las adicciones;
2012.
4. Mexico. Actualidades en Adicciones, Prevención y Tratamiento de las Adicciones en los
Servicios de Salud. Secretaría de Salud; 2012.
5. Kasten R.N., Ph.D., B.P. Self-medication with alcohol and drugs by persons with severe
mental illness. Journal of the American Psychiatric Nurses Association.1999; 5:80-87.
6. Mexico. Plan Nacional de Desarrollo: Programa Sectorial de Salud 2013-2018, Secretaría de
Salud; 2013.
7. Diagnostic and Statistical Manual of Mental Disorders, 5th Ed., DSM-5, American Psychiatric Association, Substance Related and addictive Disorders; 2013.
8. Mee-Lee D, Shulman GD & Gartner L. Patient Placement Criteria for the Treatment of
Substance Related Disorders. 2nd Ed. American Society of Addiction Medicine; 1996.
9. Francisco Arias, Nestor Szerman, Pablo Vega, Beatriz Mesias, Ignacio Basurte, Consuelo
Morant, Enriqueta Ochoa, et al., editors. Madrid study on the prevalence and characteristics of outpatients with dual pathology in community mental health and Substance misuse
services, ADICCIONES, 2013; VOL. 25, No. 2.
10. Mexico. Programa Integral para el Tratamiento del Consumo de Drogas para Personas
Privadas de su Libertad, Manual del Capacitador. Centros de Integración Juvenil; 2012.
11. Mexico. Programa de Intervención en Conducta Adictiva. Mexico City: Gobierno del Distrito Federal; 2009. Available from: HYPERLINK “http://sintesismetro.df.gob.mx/sintesis/
indexP.html?anio=2009&mes=1&valor=1” http://sintesismetro.df.gob.mx/sintesis/indexP.
html?anio=2009&mes=1&valor=1
12. Mexico. Sistema Institucional de Evaluación de Programas de Tratamiento: Evaluación de
Resultados del Tratamiento Hospitalario, Ciclo 2013.Centros de Integración Juvenil; 2013.
316
Kültegin Ögel*
Yeniden Association and Acıbadem University
ABSTRACT
Early intervention and treatments are very important issues in addiction field. Development of new, profitable, applicable and culturally
adapted intervention programs has gained importance. In the treatment of addiction, determining the internal and external conditions
of the person and constituting an individualized treatment program are determined as a necessity for obtaining change. For this purpose, the use of programs including computer-based scales is useful.
In this presentation, individualized intervention models in addiction will be discussed.
Keywords: Individualized Treatment, Addiction, Questionnaire, Computer-Based
* Prof. Dr. Kültegin Ögel was born in Ankara, 1964. He worked in the Alcohol and Drug Addiction Treatment and Education Center (AMATEM) and in Child and Adolescents Alcohol and Drug Addiction Treatment and Education Center (CEMATEM). He was the founder of an
NGO called YENIDEN and works in Acıbadem University Medical Faculty in Turkey.
He has 8 books on addiction and 2 books on depression. He won 6 prizes for his research.
317
INDIVIDUALIZED INTERVENTIONS IN ADDICTION RELATED PROBLEMS
Individualized Treatment in Addiction
Early intervention or brief intervention has begun to play an important role in addiction
treatment. Producing fast and convenient results, these methods especially prevent development of the addiction. They can also be named as secondary prevention.
Effectiveness of the early intervention and/or brief intervention is scientifically proven
and it is obvious that it’s time for the next step which is to reveal who will get which
intervention.
Can we administer the same interventions to individuals with severe addiction and less
severe addiction levels? This seems to be impossible. There are studies showcasing that
especially brief interventions are more effective in less severe addiction levels.
Another question here is how we can determine severity level of addiction or what the
addiction level is. Our typical knowledge defines addiction on number of the addiction
diagnosis criteria. Existing classification systems accept that as number of the addiction
diagnosis criteria increases, severity of addiction increases as well.
Is determining addiction severity by its number of diagnosis criteria enough information for us? For instance, an individual shows all addiction criteria but none of them are
severe enough to have adverse effects on his/her lifestyle. In this case, how can we determine individuals with more severe addictions than others? Thus, I believe that effects
of the substance used on an individual’s life is a key factor determining the severity of
addiction.
On the other hand, we know that the amount of substance used and use of mixed substances influence the addiction process. How can we tell the difference between a person
who consumes a little alcohol but gets drunk easily and therefore has many problems in
his/her life and a person who consumes a lot of substance but can keep up with his/her
life because s/he use them in a specific order? I think that number and quantity of substances used must be deemed as a factor determining severity level of addiction.
Let’s assume that a person has less addiction criteria but very high level of craving. High-level and severe craving must be evaluated as one of the factors increasing severity
of addiction.
In brief or early intervention, we must tell the difference between individuals who would
like to quit the substance and those who don’t. For example, it would be beneficial to
administer motivational interviewing with people who don’t want to quit. If they still
don’t want to quit, in such case, harm reduction methods may be administered. Various
methods may be used with a person who wants to quit. So, without making this differen318
ce, how beneficial is to administer the same treatment to people who want to quit and
those who don’t?
Can we achieve using the same methods to someone who consumes alcoholic beverages
as anxiolytic and someone who drinks only for enjoying themselves? Must treatment
planning be different in people with family support and people who don’t have family
support? Relapse prevention methods may be effective with people who have frequent
relapses while it would be more beneficial to provide shelter for a poor young person.
Addiction is a disease with many components. It is suggested that factors influencing
the addiction treatment must be considered in choosing the treatment. According to the
literature, factors influencing the addiction treatment are listed below (1):
Severity of addiction (type and frequency of substances used, effects of the addiction on
lifestyle, number of addiction diagnosis criteria, willingness to use the substance)
•
Mental health (Depression, anxiety etc.)
•
Personal characteristics (Impulsivity, sensation seeking, anger management, assertiveness etc.)
•
Family characteristics (relationship with the family, substance abuse history in the
family, family support, attitude of the family etc.)
•
Social factors (Place of residence, relationships with friends, education level etc.)
•
Economic factors (economic income level, employment status etc.)
Therefore, people with alcohol-substance abuse or addiction must be considered as a
whole.
All of these show the importance of individualization of treatment in addiction. Individualized treatments have different nomenclature (tailored treatment, individualized treatment, adaptive interventions etc.). Individualized treatment is to choose custom-made
treatment program.
We see that number of researches regarding individualized treatment in addiction have
been increasing around the globe in recent years (2). It is determined that external and
internal circumstances of a person and creating a custom-made treatment program in
addiction treatment are necessary to ensure behavioral change (3).
In order to create an individualized treatment plan, an assessment and evaluation tool is
necessary. Preparing such scales in electronic medium as software is required to fill out
the forms, to minimize data entrance errors and to ensure easy calculation and visual
reporting.
Advantages of web- or computer-based measurement tools are listed below (4):
•
Involvement of health-care personnel is minimal, therefore it is more “cost effective”.
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INDIVIDUALIZED INTERVENTIONS IN ADDICTION RELATED PROBLEMS
•
Minimizing problems resulting from clinical relationship.
•
Keeping information in a database makes sure that a late analysis is possible.
Unfortunately, there are a few tools to achieve individualization. A web-based tool called
BAPISOFT that we developed in cooperation with TUBITAK provides us this distinction. It is developed to use in tablets for convenience purposes.
Individualized treatments are now required to be compared ton on-individualized treatments. However, before doing so, it is important to create individualized modular treatment methods. I believe that modular individualized treatment methods will provide
convenience to users and enhance substance abusers’ compliance to the treatment.
We must think one step further in addiction treatment.
REFERENCES
1. Reilly PM, Shopshire MS, Durazzo TC et al., Anger Management for Substance Abuse and
Mental Health Clients: Participant Workbook, DHHS Publication No. (SMA) 02-3662, Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health
Services Administration; 2002. p.124.
2. Lei H, Nahum-Shani I, Lynch K, Oslin D, Muprhy SA. A “SMART” design for building
individualized treatment sequences. Annual Review of Clinical Psychology. 2012; 8, 14.1 14.28.
3. Carlo C. DiClemente, Debra Schlundt, Leigh Gemmell. Readiness and Stages of Change in
Addiction Treatment. American Journal on Addictions. 2004; 13, 2, 103-119.
4. Turner CF, Ku L, Rogers SM et al. Adolescent sexual behavior, drug use, and violence: Increased reporting with computer survey technology. Science. 1998; 280:867–873.
320
Dr. Lars Moller*
Julie Brummer
ABSTRACT
A large proportion of the prisoners who enter criminal justice systems and prison have a history of drug use and injecting. The prison
environment may have a positive impact on some drug users, but for others, prison will be an environment where they switch to more
harmful patterns of drug use.
The harms include:
• High rates of HIV and viral hepatitis
• Higher rates of TB
• Increased rates of overdose after release
• Increased risks of re-offending after release.
WHO recommends that all drug services available in the community should be available in prisons, in the same quality, size and accessibility as those outside. Throughout the world, the introduction of prevention, treatment and harm reduction measures in prisons is
still inadequate compared to developments achieved in the communities.
The best evidence from the literature seems to be:
• Providing a comprehensive, countrywide framework for drug treatment and determining which service or agency must take responsibility.
• Opioid substitution therapy.
• Continuity of care and treatment stability both when entering prisons and when leaving the prison.
• Building partnerships and networks between the criminal justice system and external service in the community.
• Education for all stakeholders including prisoners, staff and external service providers (such as community care workers and non-governmental organizations).
• Recognizing and addressing the specific needs of particular sub-groups.
• Monitoring, risk assessment and evaluation of interventions.
* Lars Moller is a medical doctor with a medical specialization in public health medicine and a doctoral degree in disease prevention.
Since 2011 he has been working for the WHO Regional Office for Europe and is the Programme Manager for the Alcohol and Illicit Drugs
Programme at the Division of Noncommunicable Diseases and Life Course.
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TREATMENT IN THE CRIMINAL JUSTICE SYSTEM
Drug Treatment and Overdose Prevention in
the Criminal Justice System
The lifetime prevalence of illicit drug use is overrepresented among prisoners. While this
rate differs extensively by country, between 2000 and 2011 many of the studies about
imprisoned populations in the European Union and Norway documented a lifetime
prevalence of over 50% (1). In some of the countries examined, 50–60% of prisoners
recalled ever having used heroin, amphetamines or cocaine, and over a third recalled
ever having injected drugs. In Asia, Europe and North America, opioid-dependency is
disproportionately high among prisoners, representing as much as 80% of prisoners in
central Asia, while the drug of choice in Latin America is cocaine (2). Also, considering
the high turnover rate in prisons (3, 4), large numbers of prisoners with a history of drug
use are incarcerated and then released into the community annually.
The prison environment may have a positive impact on some drug users, helping them
to stop or reduce their drug use or to use less frequently, but for others prison will be an
environment where they switch to more harmful patterns of drug use. Unfortunately,
some prisoners also have their drug debut in the prison setting (5). Prisons are risky
environments because they are often overcrowded, stressful, hostile and often violent
places in which individuals from poor communities and from ethnic and social minorities are overrepresented, including people who use drugs (4).
The presence of illicit drugs and the associated harm from their problematic use has
changed considerably the reality of prisons throughout Europe and the rest of the world.
In the past two decades or so, the linked resurgence of communicable diseases such as
tuberculosis and sexually transmitted diseases and the arrival of the new life-threatening
epidemic of HIV/AIDS as well as the increasing attention being paid to the prevalence
of hepatitis C has led all countries to seek the best ways of reducing their harmful health,
economic and social effects.
In many prisons, the most commonly used drug is cannabis. Some studies have shown
that more than 50% of prisoners use cannabis while in prison: prevalence on entry varies between 38% in France (6) to 50–55% in the United Kingdom (England and Wales)
(7, 8), 65% in Switzerland (9), 74% in Greece (10) and 81% in the United Kingdom
(Scotland) (11). A much smaller percentage of prisoners report that they inject drugs
in prison (12). The extent and pattern of injecting and needle-sharing vary significantly
from prison to prison. Prisoners who use drugs on the outside usually reduce their use
in prison, and only a minority of prisoners uses drugs daily.
According to various studies undertaken in Europe, between 16% and 60% of people
322
who injected on the outside continue to inject in prison (13). Although they inject less
frequently than outside prison, prisoners are much more likely to share injecting equipment than are drug injectors in the community, and with a greater number of people
(14). Many were accustomed to easy and anonymous access to sterile injecting equipment outside prison and start sharing injecting equipment in prison because they lack
access to safe equipment there. Although injecting drug use in prison seems to be less
frequent than in the community, each episode of injection is far more dangerous than
outside due to the lack of sterile injecting equipment, the high prevalence of sharing and
already widespread infectious diseases.
Drug injection is a particularly harmful way to use drugs, being associated with the spread of communicable diseases, especially when drug injectors share needles and/or other
paraphernalia. Injecting use is also associated with a higher risk of overdose, resulting in
significant mortality. Rates of ever-injecting drugs are substantially higher among prisoners than among the general population (on average, current injectors among the general population are estimated to be 0.3% of all adults). Based on available data, countries
report that between 5% and 38% of prisoners admit that they have ever injected drugs
prior to imprisonment (15).
Overwhelming scientific evidence shows that a comprehensive package of interventions
can prevent and reverse an HIV/AIDS and hepatitis C epidemic among injecting drug
users.
Treatment of illicit drug users
The close linkage of prison health and public health systems is essential for improving
the health of prisoners, to perform effective treatment of drug users (16) and reducing
overdose deaths in the post-release period. The following conclusions should be jointly
considered by both the health ministry, the ministry responsible for prison health services and the ministry responsible for prison services.
Service delivery and programmes
System-wide service delivery of drug treatment protocols and programmes for prison
populations should adhere to the following principles.
Equity of care
Drug treatment services provided in prison should be equivalent to that provided in the
community. This includes staff training, therapeutic quality, coverage rates and treatment alternatives. Ensuring homogeneity of drug treatment across prison jurisdictions
and between prison and community settings is necessary to ensure therapeutic consistency and optimal outcomes.
323
Evidence-based practice
Opioid substitution therapy has been demonstrated to be an effective treatment option for opioid dependent persons. Opioid-dependent prisoners should be given the opportunity to commence or continue opioid substitution therapy if this is available in
the community. Psychotherapeutic or psychosocial interventions and drug education
should be available in prisons as essential components of drug treatment programmes.
Continuity of care and treatment stability
Due to the long persistence of substance use disorders and the severity associated with
lack of treatment for this illness or therapeutic disruption, continuity of care and treatment stability are paramount. Comprehensive provision of health care services for
drug-dependent prisoners is necessary throughout both the periods in the care of the
criminal justice system and subsequent community reintegration. Individuals should be
linked to appropriate drug or support services on first contact with the criminal justice
system or when targeted as being at-risk of becoming a drug offender. The provision of
services for drug-dependent people must be available while they are in police custody,
pre-trial detention and prison. Furthermore, pre-release drug services are to be coordinated with and linked to appropriate after-care, to ensure uninterrupted service delivery.
In so doing, substance dependent prisoners are offered sustained continuity of care.
Building partnerships and networks
Interagency partnerships between corrections-based and external service providers are
essential to the establishment of effective and continuous services for prisoners. When
correctly managed, the processes of government and nongovernmental agencies and
community support can be integrated and coordinated, with appropriate referral systems. Formal and informal community interactions, especially social support structures,
are of significant importance to prisoners and will also provide a post-release psychological buffer. Effective programmes depend on government officials, policy-makers,
nongovernmental organizations, programme managers, researchers, prison staff and external stakeholders, as well as on the prisoners themselves and their supporters. To be effective, all interventions must address the specific needs of and risks to drug dependent
prisoners. Programmes need to focus on building capacity by utilizing integrated care
models that incorporate psychosocial, pharmacotherapeutic and educational aspects of
the best practices.
324
At the prison level
At the prison level, the service must include building healthy therapeutic relationships.
This requires a range of needs-based, client-centred treatment modalities. Also, multifaceted team case-management partnerships are a good practice. Treatment plans and service options need to be designed in consultation with service users to facilitate a culture
of mutual respect, active participation, increased motivation and empowerment. Also
at this level, education is needed for all stakeholders. Prison staff, prisoners, the people
that support them and external service providers (such as community care workers and
nongovernmental organizations) are to be made aware of the risk of overdose deaths.
Prisoners and the people that support them are to receive pre-release public health education in the following areas:
•
drug use prevention: various methods exist to educate people about drugs, including the dissemination of information, peer support, and group or individual
drug counselling;
•
risk behaviour: the acute risks associated with decreased tolerance and the concurrent use of multiple drugs should be explained in detail to prisoners and the
people that support them, especially their families; and
•
overdose prevention.
Drug-dependent prisoners and their family and community supporters are to be taught
to recognize and respond to the symptoms of an overdose. The emerging evidence points
towards considering teaching first aid – including the emergency use of naloxone – to
those with an addiction, their social network and their family and community support.
Further research in this area is urgently needed. Moreover, at this level, post-release vulnerability needs to be decreased. To help reduce such vulnerability, holistic programmes
are needed that meet the physical and/or practical and psychosocial needs of released
prisoners. The period after prison release may represent a period of uncertainty and instability for ex-prisoners, which can increase the likelihood of drug relapse and subsequent overdose mortality. It is necessary to ensure effective support to address the unmet:
•
physical and practical needs, such as securing an accommodation and employment, managing domestic and financial affairs, and acquiring education and training in practical skills;
•
psychological needs, such as deinstitutionalization, issues of traumatization and
marginalization, psychiatric co-morbidity, resilience and self-esteem; and
•
social needs, such as familial or community reintegration and social and parenting skills.
325
At the national level
At the national level, the provision of key structures and services must include:
•
providing a comprehensive, countrywide framework of drug treatment
•
determining which service or agency must take responsibility
•
recognizing and addressing the specific needs of particular subgroups
•
monitoring, risk assessment and evaluation of interventions.
Providing a comprehensive, countrywide framework of drug treatment
A comprehensive, countrywide framework of drug treatment needs to be incorporated
into all levels of the criminal justice system. This strategy should be integrated into or
consolidated with the efforts of community drug treatment within the national public
health system. The main principle is that, whenever possible, it is preferable for individuals with a substance use disorder to be diverted to an appropriate community treatment
facility rather than be sent to prison. In cases where prison is deemed necessary, drug
treatment should be provided, based on formalized end-to-end strategies of through
care and after-care.
Determining which service or agency must take responsibility
Determining which service or agency must take responsibility for and address the needs
of vulnerable subgroups at risk of overdose deaths after release from prison requires
conceptual reframing of prison health mandates to incorporate post-release well-being.
This may necessitate:
•
evaluating data collection, to continually monitor post-release outcomes in prison health data and so adequately identify service gaps;
•
analyzing the legal frameworks and extent of duty of care and accountability for
the health of people after their release from prison; and
•
including, under the jurisdiction of this national structure, individuals serving
community sentences, on home leave and those on parole.
These processes should begin prior to release and should be integrated into drug treatment programmes to ensure holistic need-based programmes.
326
Recognizing and addressing the specific needs of particular subgroups
Programme design should target the assessed needs of vulnerable subgroups at increased risk, including women, sex workers, migrants and foreign nationals. Also, standardized risk assessment and screening are useful in identifying prisoners who are at
an increased risk of drug-related post-release mortality and who would benefit from
specialized programmes and support.
Monitoring, risk assessment and evaluation of interventions
Monitoring, risk assessment and evaluation of interventions includes the implementation of a standardized monitoring protocol to:
•
determine baseline mortality rates
•
assess prisoner needs, inside prison and upon release
•
document implementation of interventions and the success of these measures
•
identify gaps in service provision.
Also, research is important to evaluate interventions to reduce post-release mortality,
and specific indicators should be developed.
327
REFERENCES
1. Statistical bulletin 2013. Lisbon: European Monitoring Centre for Drugs and Drug Addiction; 2013 (http://www.emcdda.europa.eu/stats13, accessed 29 July 2014).
2. Kastelic A, Pont J, Stöver H. Opioid substitution treatment in custodial settings: a practical
guide. Oldenburg: BIS-Verlag der Carl von Ossietzky Universität Oldenburg; 2008 (https://
www.unodc.org/documents/hiv-aids/OST_in_Custodial_Settings.pdf, accessed 28 July
2014).
3. Stöver H. Assistance to drug users in European Union prisons: an overview study. London:
European Network for Drug and HIV/AIDS Services in Prison and European Monitoring
Centre for Drugs and Drug Addiction; 2001.
4. Prisons and Health. Copenhagen: WHO Regional Office for Europe; 2014 (http://www.
euro.who.int/__data/assets/pdf_file/0005/249188/Prisons-and-Health.pdf?ua=1), accessed
9 September 2014).
5. Boys A et al. Drug use and initiation in prison: results from a national prison study in England and Wales. Addiction. 2002; 97:1551–1560.
6. Sahajian F, Lamothe P, Fabry J. Psychoactive substance use among newly incarcerated prison inmates. Sante Publique. 2006; 18(2):223–234.
7. Heidari E et al. Oral health of remand prisoners in HMP Brixton, London. British Dental
Journal. 2007; 202(2):E5.
8. Stewart D. Drug use and perceived treatment need among newly sentenced prisoners in
England and Wales. Addiction. 2009; 104(2):243–247.
9. Niveau G, Ritter C. Route of administration of illicit drugs among remand prison entrants.
European Addiction Research. 2008; 14(2):92–98.
10. Fotiadou M et al. Self-reported substance misuse in Greek male prisoners. European Addiction Research. 2004; 10(2):56–60.
11. Prisoner survey 2008. 11th survey bulletin. Edinburgh, Scottish Prison Service, 2008
(http://www.sps.gov.uk/Publications/Publication75.aspx, accessed 30 November 2013).
12. Shewan D, Stover H, Dolan K. Injecting in prisons. In: Pates R, McBride A, Arnold K, ed.
Injecting illicit drugs. Oxford, Blackwell. 2005; 69–81.
13. Stover H et al. Final report on prevention, treatment, and harm reduction services in prison, on reintegration services on release from prison and methods to monitor/analyze drug
use among prisoners. Brussels, European Commission, Directorate-General for Health and
Consumers, 2008 (SANCO/2006/C4/02) (http://ec.europa.eu/health/ph_determinants/
life_style/drug/documents/drug_frep1.pdf, accessed 30 November 2013).
14. Jurgens R, Ball A, Verster A. Interventions to reduce HIV transmission related to injecting
drug use in prison. Lancet Infectious Diseases. 2009; 9(1):57–66.
15. European Monitoring Centre for Drugs and Drug Addiction. Prisons and drugs in Europe:
the problem and responses. Luxembourg, Publications Office of the European Union, 2012
(http://www.emcdda.europa.eu/publications/selected-issues/prison), accessed 8 September
2014).
16. Good governance for prison health in the 21st century. A policy brief on the organization
328
of prison health. Copenhagen: WHO Regional Office for Europe; 2013 (http://www.euro.
who.int/__data/assets/pdf_file/0017/231506/Good-governance-for-prison-health-in-the21st-century.pdf, accessed 29 July 2014).
17. Fox A, Khan L, Briggs D, Rees-Jones N, Thompson Z, Owens J. Throughcare and aftercare:
approaches and promising practice in service delivery for clients released from prison or
leaving residential rehabilitation. London: Home Office; 2005 (Online Report 01/05; http://
www.portal.state.pa.us/portal/server.pt/gateway/PTARGS_0_2_1037828_0_0_18/doc79_
Fox_2005.pdf, accessed 29 July 2014).
329
330
Marie Nougier*
International Drug Policy Consortium
ABSTRACT
Harm reduction refers to public health interventions that seek to reduce the negative consequences of drug use and drug policies.
Harm reduction has been rigorously evaluated and shown to be effective at reducing the transmission of blood-borne infections as well
as morbidity and mortality related to drug use.
This paper offers key definitions, principles and examples of best practice related to harm reduction services. The document also provides advice on how to address the legal, ideological and economic barriers that may impact on access to harm reduction interventions.
The paper ends with a series of recommendations for policy makers to consider when developing harm reduction policies and services.
*Marie Nougier is a Senior Research and Communications Officer.
She is responsible for the communications and publications work stream of IDPC, and supports the IDPC Executive Director in networking and policy engagement activities. She has been involved with IDPC since December 2008, and has provided valuable input in the
drafting of the IDPC Drug Policy Guide and other key publications. Her language skills in English, French, Spanish and Portuguese have
constituted a valuable asset for the development of a multilingual centre of expertise at IDPC.
Marie has a Masters’ Degree in international law, human rights and the law of armed conflicts. Before working at IDPC, she worked on
issues related to compulsory drug detention in South East Asia, as well as police brutality in Western Europe.
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BEST PRACTICE IN HARM REDUCTION POLICIES AND INTERVENTIONS
Best Practice in Harm Reduction Policies
and Interventions
Acronyms
AIDS
Acquired Immunodeficiency Syndrome CAHR
Community Action on Harm Reduction
EMCDDA
European Monitoring Centre on Drugs and Drug Addiction
HIV
Human Immunodeficiency Virus
HRI
Harm Reduction International
IDPC
International Drug Policy Consortium
INCB
International Narcotics Control Board
LAS
Legal Affairs Section
LGBTTIQ eer
Lesbian, Gay, Bisexual, Transsexual, Transgender and Intersex and Qu-
NSP
Needle and Syringe Programme
OST
Opioid Substitution Treatment
UK
United Kingdom
UN
United Nations
UNAIDS
Joint United Nations Programme on HIV and AIDS
UNODC
United Nations Office on Drugs and Crime
USA
United States of America
WHO
World Health Organisation
Why is harm reduction important?
For 100 years, most drug control policies have been grounded in ideological perspectives which seek to create a drug-free world, by implementing harsh penalties on people
who use drugs. Experience from around the world demonstrates that this objective is
unlikely to be ever realised – in 2012, the United Nations on Drugs and Crime (UNO332
DC) estimated that there would be around 65 million more people using drugs in 2050,
compared to 2009-2010 (1).
Drug use, particularly in the context of the current drug control regime, may lead to a
number of preventable health consequences, including soft tissue infections and transmission of blood-borne infections such as hepatitis B and C and HIV, through use of
non-sterile injection equipment, death from overdose, and exacerbation of existing psychiatric or physical illnesses. Therefore, a harm reduction approach has been developed
across the world to address these issues practically and compassionately. Harm reduction is also concerned with the harms caused by public policies and attitudes directed at
people who use drugs. In many countries, most harms result directly or indirectly from
the criminalisation and mass incarceration of people who use drugs, but also include
discrimination in medical settings and subsequent problems with access to health care,
barriers to employment, housing or social benefits, or denial of child custody. As such,
harm reduction is often conceived as both a public health and a human rights concept.
Which harms are we seeking to address?
There are around 16 million people who inject drugs worldwide, (2) and it is estimated
that 10% of all HIV infections occur through injection drug use, with 30% of new infections occurring outside sub-Saharan Africa (3). In many countries in Eastern Europe,
the Middle East, North Africa, Central, South and Southeast Asia, and Latin America,
the largest share of HIV infections occurs among people who inject drugs (3). Injection-related transmission has more recently become an important part of HIV epidemics
in sub-Saharan Africa as well, where the prevalence of injection drug use now approaches the global average (4).
The European Monitoring Centre on Drugs and Drug Addiction (EMCDDA) identified
drug overdose as a major cause of mortality in EU countries (5). An international study
supported by the EMCDDA found that in seven European urban areas, between 10%
and 23% of all deaths among those aged 15 to 49 years could be attributed to opioid use
(6). In the USA, overdose is the leading cause of injury-related mortality among people
aged 35–54 years (7). Studies have found that 89% of heroin users had witnessed at least
one overdose in their lifetime in San Francisco (USA), (8) personal experience of overdose has ranged from 51% of heroin users in Australia, (9) to 66% in Yunnan province,
China, (10) and 83.1% in North Vietnam (11). In Russia, overdose caused 21% of all
deaths among people living with HIV in 2007, (12) and the country reported a total of
9,354 overdose deaths the previous year, which is almost certainly an undercount (13).
Non-opioid and non-injecting drug use can also be related to negative health outcomes.
Many parts of the world have seen an increase in use of cocaine and amphetamine-type
stimulants such as methamphetamine, and in the non-medical use of pharmaceutical
medications (14, 15). Non-injection drug use has been found to be associated with an
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increased risk of sexual transmission of HIV in some contexts (16). It has been speculated that sharing crack-smoking paraphernalia may increase the risks of hepatitis C
transmission (17). Stimulant drugs may cause hyperthermia, acute psychiatric disorders, and other harms, and inhaled drugs may cause lung infections and possibly leukoencephalopathy (18). Box 1 provides examples of effective harm reduction services for
people who use non-injectable drugs.
Box 1. Harm reduction services for people who use non-injectable
drugs
Although sometimes less visible because of the emphasis on HIV within
public financing around drugs and health, services supporting people who use
non-injectable drugs are a crucial part of harm reduction. In response to the
harms associated with non-injection drug use, organisations such as DanceSafe in North America have promoted education, pill testing, and other services
to ensure that ‘party drug’ users are well informed about safer use and know
what they are consuming.
Harm reduction groups in Canada and elsewhere have promoted kits for safer
crack use that include education and smoking paraphernalia made out of
materials that do not emit toxic chemicals when heated, and that have resulted
in adoption of less risky drug-using behaviour among participants (19). Similarly, in Latin America and the Caribbean, where powder cocaine and crack
use predominate, harm reduction services for people who use non-injectable
drugs, such as counselling, housing services, linkages to drug dependence treatment, etc, have existed alongside NSPs since the early 1990s. ‘Safer-inhalation facilities’, where people may smoke or sniff drugs in a medically supervised
environment have also been established alongside safer injecting facilities in
several countries (19).
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While sharing non-sterile injecting equipment has been a major source of HIV infections in North America and Western Europe, implementation of harm reduction services
has increasingly controlled the epidemic. For example, in 2009 New York City, which
had been supporting harm reduction services for nearly 20 years, reported that only 5%
of new HIV cases were transmitted through injecting drug use (20). Similarly, Australia,
the first country to have incorporated harm reduction into its national HIV strategy, has
maintained an extremely small HIV epidemic among people who inject drugs, and as
a result had net healthcare cost savings of more than US$820 million in the years 2000–
2009 alone (21). The UK, the Netherlands, France, Spain and other European countries
have seen similar success in reducing HIV incidence among people who inject drugs through widespread availability of NSPs, OST and related services. On the contrary,
countries like Russia and Thailand, which have refused to develop harm reduction interventions, have a high prevalence of HIV infections among people who inject drugs (22).
Harm reduction programmes have always had a commitment to evidence-based practice. Core harm reduction services have been exhaustively evaluated and found to be
effective at reducing the transmission of HIV and other blood-borne diseases, broadly
improving health, and have been found not to be associated with increased drug use
(23, 24). As a result, harm reduction has become the leading public health approach to
drug use, and has been endorsed by numerous international health agencies, professional associations, including the UN system, the International Federation of Red Cross
and Red Crescent Societies, the International AIDS Society, and the American Medical
Association. At least 97 countries support harm reduction in policy and/or practice (25).
Definition and principles of harm reduction
This chapter uses the definition of harm reduction principles espoused by Harm Reduction International (HRI) (26) and describes how these principles are applied in practice.
According to HRI, harm reduction refers to ‘policies, programmes and practices that
aim primarily to reduce the adverse health, social and economic consequences of the use
of legal and illegal psychoactive drugs without necessarily reducing drug consumption.
Harm reduction benefits drug users, their families and the community’ (26).
At its roots, harm reduction recognises that despite the negative consequences associated with drug use, many people are unwilling or unable to stop using drugs; that most
harms associated with drug use are preventable; and that drug use has positive aspects
for many people, which must be considered in the frame of reducing drug-related harm.
Harm reduction strives to respond to each individual’s unique experience of drug use,
and at the community level to integrate with primary care and specialist medicine, drug
treatment, housing services, the criminal justice system, and other relevant areas. At
local, provincial and national levels, harm reduction is concerned with orienting government policy toward health promotion and away from criminal justice approaches to
drug use.
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Harm reduction:
Is targeted at risks and harms – harm reduction begins from the standpoint of identifying what specific risks and harms are occurring with an individual’s or population’s
drug use, defining the causes of those risks and harms, and determining what can be
done to reduce them. In Thailand, this could involve encouraging methamphetamine
users to smoke methamphetamine rather than injecting it, in order to avoid the harms
associated with injection. In Ukraine, for example, this has led harm reduction practitioners to identify unequal access to reproductive health care for women who use drugs
and to develop innovative services in response (27). In the USA, harm reduction programmes have used geographic mapping to determine ‘hot spots’ where people who inject drugs most frequently run out of new, sterile syringes, in order to better target NSP
services (28).
Is evidence based and cost effective – harm reduction approaches are founded on public health science and practical knowledge, and employ methods that are most often
low cost and high impact. New evidence on the efficacy of syringe-cleaning methods,
for example, has led to renewed attention to how to support people who reuse syringes
(29). There is a growing body of literature on the cost effectiveness of harm reduction
intervention – particularly regarding needle exchange and OST (30).
Is incremental – as HRI explains, ‘Harm reduction practitioners acknowledge the significance of any positive change that individuals make in their lives. Harm reduction
interventions are facilitative rather than coercive, and … are designed to meet people’s
needs where they currently are in their lives’ (31). This principle plays out in countless
ways in the day-to-day work of harm reduction service providers, from working with
individuals to reduce immediate harms associated with chaotic crack cocaine use in Rio
de Janeiro, to helping people who use drugs to find housing in New York.
Is rooted in dignity and compassion – a harm reduction approach views people who
use drugs as valued members of the community, as well as friends, family members and
partners, and consequently rejects discrimination, stereotyping and stigmatisation. The
COUNTERfit harm reduction project in Toronto used this principle to develop widely
influential, drug-user-friendly workplace guidelines (32). Early harm reduction programmes in Iran propagated a caring, open environment and made a strong case for harm
reduction in Islamic terms, in order to reach out to an extremely marginalised population of people who inject drugs (33).
Acknowledges the universality and interdependence of human rights – the UN High
Commissioner for Human Rights, Navanathem Pillay, declared that ‘People who use
drugs do not forfeit their human rights, including the right to the highest attainable standard of health, to social services, to work, to benefit from scientific progress, to freedom
from arbitrary detention and freedom from cruel inhuman and degrading treatment’
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(see Section 1.2: Ensuring compliance with fundamental rights and freedoms) (34).
Challenges policies and practices that maximise harm – the political environment in
which drug use occurs plays an important part in creating the harms linked with drug
use. Harm reduction thus seeks to reduce harm associated with drug policy, just as it
seeks to reduce harms resulting from drug use. In much of Western and Central Europe,
this insight has led governments to decriminalise drug use, which in some countries,
such as Portugal, has resulted in substantial public health gains (35). In other countries,
the objective has been to remove policies that prevent people who inject drugs from accessing HIV treatment, (36) OST and other life-saving medical care
Values transparency, accountability and participation – harm reduction staff, donors,
public officials, and other relevant people are ultimately accountable to people who use
drugs. Harm reduction seeks to ensure such accountability by prioritising participation
and leadership by people who use drugs in the design and implementation of policies
and programmes that affect them. Examples of this principle include the central role of
people who use drugs in conceiving and building the US harm reduction movement,
requirements by harm reduction organisations that people who use drugs be represented on their boards of directors, the 2006 ‘Vancouver Declaration’ (37) and founding of
the International Network of People Who Use Drugs (INPUD).
Box 2. The Community Action on Harm Reduction project
The Community Action on Harm Reduction (CAHR) project is an example
of how harm reduction principles can be incorporated into a comprehensive programme. The CAHR project seeks to expand access to harm reduction services for people who inject drugs in Kenya, China, India, Indonesia
and Malaysia. The project is unique in its approach to develop and expand
services to people who inject drugs by supporting grassroots community
initiatives, building pragmatic partnerships with local authorities, public
health facilities, and academics, and addressing the policy and structural
barriers to programme sustainability.
The project places a deep emphasis on building the local capacity of community-based organisations and sharing knowledge and experiences in order to introduce essential harm reduction interventions in Kenya, improve
access to community-based support services in China, increase the quality
of behavioural change programming in India and Malaysia, and expand
quality harm reduction services to new communities within the injecting
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drug using population in Indonesia.
There is a strong policy agenda that is defined by the pragmatic objective of
developing effective HIV and drug use services based on available evidence.
Experiences of the project on the ground are captured to influence policy
debates both at the national and international level. Finally, CAHR objectives include the full and meaningful participation of people who use drugs in
policy and programme design and a strong commitment to protecting and
promoting human rights.
A wide range of interventions
Harm reduction entails a holistic approach to dealing with the health of people who use
drugs. UNODC, the Joint United Nations Programme on HIV and AIDS (UNAIDS)
and the World Health Organisation (WHO) recommend a comprehensive package of
harm reduction interventions (38) and recognise that such interventions mutually reinforce each other and maximise effectiveness in terms of health outcomes. Evidence also
shows that harm reduction services lead to an increase in access to general healthcare
interventions. The following, while not exhaustive, is an indication of evidence-based
and cost-effective harm reduction interventions.
Needle and syringe programmes (NSPs)
The most recognisable harm reduction intervention is the supply of sterile injecting equipment to reduce the spread of HIV and other blood-borne infections. Such programmes also prevent skin and soft tissue infections (such as abscesses and cellulitis) that may
result from using non-sterile injection equipment. NSPs also serve as a bridge by which
people may access a wide array of other health and social services, including primary
health care, drug treatment, etc.
The success of NSPs depends on a wide range of factors. These include the involvement
of people who use drugs in the design and implementation of the service; accessibility
and breadth of coverage; adaptability of the service to moving local drug use patterns;
(39) engagement with law-enforcement agencies not to interfere with the services; (40)
and consultation with the wider community (41).
While many early NSPs were developed primarily for heroin and cocaine injectors, today harm reduction addresses the complete spectrum of drug use. Similar in concept
to NSPs, Canada and the USA, for example, pioneered the development of safer crack-smoking materials to reduce the potential for burns, lung infections and possible
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transmission of hepatitis or other infections through blood–blood contact from sharing
pipes (42). Methamphetamine-oriented programmes like Crystal Clear in Vancouver,
Canada have used peer-based programming to adapt the approach to both injecting and
non-injecting use (see Box 4).
Treatment for drug dependence
Opioid substitution therapy (OST) using methadone or buprenorphine is currently the
most widely used evidence-based method of treatment for opioid dependence. Some
countries also prescribe pharmaceutical heroin (diacetylmorphine) as a substitute for
street heroin, which is usually adulterated. OST programmes have been shown to reduce
or eliminate injection drug use, reduce criminality, and improve a wide range of measures of health and social well-being (43). OST plays a crucial role in supporting adherence
to HIV, (44) hepatitis C and tuberculosis (45) treatment among opioid-dependent people, and is a potent tool for overdose prevention (46). Although substitution therapies
are not yet available for non-opioid drugs, alternative forms of treatment, such as cognitive-behavioural therapy and other psychosocial approaches, are supported by public
health evidence. For more information, see Section 3.3: Treatment for drug dependence.
Overdose prevention
Overdose is experienced by a substantial portion of opioid users over their lifetime, and
is a leading cause of death among people who inject drugs, and young people generally, in many countries. In the 1990s, programmes in the UK, the USA (see Box 3) and
elsewhere began educating heroin users and their friends and families about overdose
prevention and response, and distributing naloxone, a medication that quickly and safely blocks the effects of opioids, thereby reversing the respiratory depression that may
lead to death. Such programmes have recently become more widespread, from Vietnam
to Tajikistan and Puerto Rico to Slovakia, and there is growing evidence that they have
contributed to significant reductions in mortality (47, 48). Drug consumption rooms
(see below) and OST facilities are also important tools for overdose prevention (see above). Cocaine overdose, which is implicated in a large number of deaths in some countries
(49), poses a challenge in that there is no medication equivalent to naloxone that could
be administered by lay people. Other policies that support overdose prevention include
improving emergency medical services for overdose, ‘good Samaritan’ laws protecting
people who respond to overdoses from potential liability, and increasing overdose surveillance and research.
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Box 3. The first overdose prevention programmes in New York City
After years of increasing overdose mortality and the deaths of many harm
reduction participants, and inspired by colleagues in Chicago, San Francisco and New Mexico, three community-based harm reduction programmes
launched New York City’s first overdose-prevention programmes in 2004
that included naloxone distribution to people who use opioids. The three
groups covered a geographically diverse section of the city, included one
programme of harm reduction services for young people, and quickly moved from an initially small-scale, periodic service to one that expanded to
street-based training and saturated communities with information and tools
to prevent and reverse overdose. In mid-2006, following an evaluation of
the first projects, the New York City government picked up the programme,
contributing enough funding to support overdose programmes at all of the
city’s harm reduction organisations and to hire a full-time medical director
for the programme. In the two years that followed, overdose mortality dropped by 27% city-wide, (50) and unpublished data indicate that this trend
has continued. Hundreds of similar projects have since proliferated around
the world, based on the simple model pioneered in the USA and parts of
Western Europe.
Prevention, testing and treatment of HIV and other sexually transmitted
infections
As with anyone else at risk of sexual transmission of HIV or other STIs, condoms and
sexual health education and services should be made available to people who use drugs,
and their sexual partners. STI testing and treatment is often linked to harm reduction
services, in part because STIs – particularly those that cause genital lesions – may increase the risk of HIV transmission. Voluntary HIV counselling and testing is also a core
harm reduction activity, and should be tied to efforts to connect newly diagnosed individuals to care and treatment services. Research has found that people with a history of
injecting drug use have comparable success with HIV treatment to non-drug users (51).
Prevention, testing and treatment of viral hepatitis
Vaccines for hepatitis A and B are highly effective and should be made available to all
people at risk of hepatitis infection, especially people who inject drugs. Globally, some
90% of new hepatitis C cases are related to injecting drug use, and while there is no hepatitis C vaccine available, hepatitis A and B immunisation may improve clinical outcomes for people with hepatitis C. There have recently been major advances in treatment
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for hepatitis C and it should be made available to any eligible person, regardless of their
drug-use status (52).
Prevention and treatment of tuberculosis
People who have compromised immune systems, such as people living with HIV, are
at high risk of active tuberculosis infection, particularly in closed environments such
as prisons and in countries with endemic tuberculosis (53). Tuberculosis is the leading
killer of people living with HIV worldwide, including people living with HIV who use
drugs, and notably in Eastern Europe and Central Asia, where multi-drug-resistant strains have proliferated. Harm reduction programmes like the Anti-AIDS Foundation in
Tomsk, Russia, have responded by leading surveillance efforts, educating people who use
drugs about tuberculosis prevention, and supporting people in tuberculosis treatment.
Drug-consumption rooms
Some governments, such as Australia, Canada, Spain, Germany and Switzerland, have
established drug-consumption rooms (54). These are supervised facilities where people may bring their own drugs and inject (or in some places smoke) them without fear
of arrest, and where overdoses or other health problems can be addressed by medical
staff. They have been especially successful at reducing overdose mortality: deaths in the
neighbourhood around Vancouver’s Insite facility dropped by 35% in the year after it
opened (55).
Mental health, social welfare, and other services
While sometimes not considered to be core harm reduction strategies, a number of other services are often offered to people who use drugs. Psychiatric illness, for example, is
more prevalent among people dependent on drugs than among the general population
(56, 57). Major depression, post-traumatic stress disorder, and other illnesses may exacerbate drug-related risk behaviour, and drug use may complicate psychiatric care. Chronic stress related to social, economic and other circumstances may also impact drug
use and psychiatric comorbidity (for more information, see Section 3.1: Prevention of
drug use) (58). New York’s Lower East Side Harm Reduction Centre has, for example, established a team of mental health professionals to support clients living with psychiatric
illness, as well as housing services, legal support, and case management to co-ordinate
health and social services.
Supporting groups at higher risk of drug-related harm
Some groups, including women, young people and minorities, are at higher risk of
drug-related harm because of discrimination, power relationships, and other factors.
Harm reduction programmes consequently have a responsibility to identify people in
their communities who may face unique challenges in terms of drug use, and develop
appropriate services.
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Young people
Although many young people use drugs, (59) most harm reduction services are designed for adults. Most obviously, young people often have shorter drug-use histories than
adults, and may also have different risk behaviours and different social, economic and
legal circumstances, and may be at risk of exploitation by adults. For all these reasons,
youth-specific harm reduction programmes are needed (see Box 4), yet are absent in
many countries. Many barriers also exist that prevent young people from accessing harm
reduction services, including parental consent. These barriers should be removed. Successful youth-oriented harm reduction programmes, such as The Way Home in Odessa,
Ukraine, and the Homeless Youth Alliance in San Francisco, USA, have given young
people a leading voice in the design and administration of programmes, and grow out
of a rights-based approach to health. Other interventions have targeted young people in
nightlife settings, with interventions ranging from drug-information leaflets to drug-checking services, information sharing through websites, etc. (60).
Box 4. Harm reduction services for young people
Established in 2003, Vancouver, Canada’s Crystal Clear harm reduction
project began as a three-month, peer-based training course for street-involved young people concerned about their methamphetamine use. With
support from the national and city health agencies, Crystal Clear expanded
to become an ongoing programme that includes peer outreach, support and
leadership development, harm reduction education and health services, and
engagement with other civic and governmental organisations, to represent
young people who use methamphetamine. The project has also produced a
manual published by the Vancouver Coastal Health Authority, Crystal Clear:
a practical guide for working with peers and youth (61).
Similarly, Youth RISE, a membership-based international harm reduction
network of young people, was established in 2006 to advocate for high-quality harm reduction services and policies for young people. Rooted in peer-based leadership and human rights, including application of the Convention on the Rights of the Child to harm reduction, among other work, Youth
RISE piloted a series of workshops on harm reduction for young people in
Romania, India, Mexico and Canada, subsequently producing a training manual with Espolea, a Mexico City-based youth AIDS, gender and drug policy
organisation (62).
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Women
Although women represent a minority of people who inject drugs in most countries,
they often face specific social stigma and marginalisation due to their drug use, because of cultural perceptions. A range of factors increase women’s risk of drug-related
harm, including misogyny; unequal social and economic power relationships with men;
discrimination, extortion, or sexual violence perpetrated by law-enforcement officers
or others; discrimination by healthcare providers, especially towards pregnant drug-using women; and a preponderance of harm reduction and treatment programmes that
are primarily directed at men. Women who use drugs are often less likely than men to
buy drugs themselves, know how to inject properly, or access harm reduction services.
Pregnant and parenting women who inject drugs are particularly vulnerable (63). Some
harm reduction programmes have addressed these issues in numerous ways (see Box 5
and 6), including by creating women-only spaces and support groups, adapting outreach
models to better suit women, and developing a range of sexual and reproductive health
services specific to the needs of women who use drugs. Global networks have also been
formed to advocate for the rights of women who use drugs, including the International
Network of Women Who Use Drugs and the Women’s Harm Reduction International
Network.
Box 5. Building services for women who use drugs in Ukraine and Russia
In response to the particular issues facing women who use drugs, harm
reduction organisations in Ukraine and Russia have made important progress in establishing model services in recent years. After discovering that
some two-thirds of drug-using women in their city had no access to health
services, the Tomsk Anti-AIDS Foundation in Western Siberia established a
women-only space that has resulted in better linkages to medicine and uptake of harm reduction services by women, and a more than 100% increase in
the number of women tested for HIV. Similarly, St Petersburg’s Humanitarian
Action Foundation operates an outreach bus exclusively targeting female sex
workers, as well as one of Russia’s few crisis centres for women with young
children (64).
Simple efforts to focus more attention on outreach to women can have a
dramatic effect on access to services: by doing so, the organisation Virtus,
in Dnipropetrovsk, Ukraine, saw a 50% increase in the number of women
clients and an 80% increase in the number of women clients with children.
The MAMA+ program in Kyiv, meanwhile, offers a more intensive service
model for women living with HIV. MAMA+ has increased the proportion
of clients who use drugs, and provides HIV and STI testing and treatment,
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counselling, family planning, gynaecological care, child care, and nutritional
services, multidisciplinary support for pregnant women, home visits, and
legal assistance (65).
Box 6. Reaching out to women who inject drugs in Manipur, India
Although women only constitute a small proportion of people who inject
drugs in Manipur, India, they are highly vulnerable to blood-borne infections,
especially HIV. In partnership with the Social Awareness Service Organization, the International HIV/AIDS Alliance India developed a programme to
meet their immediate needs, enhance access to harm reduction services for
women who inject drugs and their partners (66).
A drop-in centre was established as part of the project where women receive
support such as NSP, free condoms, health check-ups (including basic healthcare, clinic-based detoxification, OST, counselling and referrals to other
institutions for reproductive health and HIV care and support. The drop-in
centre also offers recreational opportunities including watching TV, reading
newspapers and magazines, and a space for chatting with friends and staff.
Women can also bathe and use make-up kits provided by the centre. Finally,
the centre acts as a venue for meetings for self-help and support groups as well
as for educational classes. As women who use drugs constitute a particularly
marginalised group of society, the main objective of the centre is to reach out
them and encourage them to access harm reduction and general healthcare
services (67).
Minority groups
Some minority groups, including lesbian, gay, bisexual, transsexual, transgender and
intersex and queer (LGBTTIQ) people, racial or ethnic minorities, immigrants, or refugees, may be at increased risk of drug-related harm due to discrimination, legal or
economic pressures, and barriers to accessing services. Local harm reduction services
should be explicitly designed so as to be accessible by minority groups, and should be
undertaken as collaborative projects between policy makers and affected communities.
They should also be accessible to minorities in their own language and be culturally sensitive (68). Numerous positive examples exist (see Box 7), such as NSP services targeting
Uzbek minority communities in Osh, Kyrgyzstan or Roma in Bucharest, Romania, and
peer-based amphetamine-type stimulant harm reduction counselling at the San Francisco AIDS Foundation.
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Box 7. Protecting the health of minority groups in Australia and Romania
From London to Chiang Mai to Zanzibar, racial and ethnic minorities often
have relatively poor access to harm reduction services, and services that are
less culturally appropriate when they do gain access.
In Australia, rates of drug use, HIV, viral hepatitis, and related health issues
are significantly higher among Aboriginal (indigenous) communities than
Australians of European descent (69). While some drug services for Aboriginal Australians are longstanding, efforts to expand them are more recent, and
have included engagement by the governmental National Council on Drugs
and partnerships between key organisations such as the National Aboriginal
Community Controlled Health Organisation and the Australian Injecting and
Illicit Drug Users League.
In Romania, Roma are a significant minority group that is overrepresented
in terms of poverty, poor health and drug use. From the time the first harm
reduction programmes were founded in Bucharest in the late 1990s, such services have targeted Roma communities, employed Roma staff, and developed
materials in the local Romani dialect. Roma communities deeply stigmatise
drug use, which has created barriers to services. In response, in 2009 the first
Roma-led harm reduction initiative was launched in Bucharest’s Ferentari district by Sastipen, a Roma health services organisation. Among other
tactics, Sastipen’s basic preventive health services were made available to the
entire community, as a means of increasing acceptance of the harm reduction
programme.
Addressing barriers hindering access to harm reduction
Policy and legislative barriers
It has been argued by some, including by the International Narcotics Control Board
(INCB), that harm reduction practices fall outside the terms of the three UN drug control conventions to which most countries are signed up. The debate prompted the INCB
to request the Legal Affairs Section (LAS) of the UN Drug Control Programme, now
part of the UNODC, to examine the legality of harm reduction interventions.
In 2002, the LAS provided a nuanced response to the INCB (70). It drew attention to the
fact that the treaties do not define either the ‘scientific and medical’ purposes to which
drugs are to be restricted, or the nature of the ‘treatment’ and ‘social reintegration’ that
states parties are allowed (and encouraged) to provide. This means that there is an inherent flexibility within the drug control treaties, of which member states can make use. Of
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the four specific harm reduction interventions discussed by the LAS statement, it found
that OST, drug consumption rooms, and NSPs fall comfortably within the measures allowed by the treaties and subsequent UN resolutions. LAS also found that drug quality
control interventions (such as the testing of dance drugs and tablets at clubs or festivals)
run ‘contrary to the spirit of the Convention’ – though even here it noted a lack of any
intention to induce or facilitate the use or possession of drugs (the intent that would be
necessary for informal drug-testing to constitute a legal offence).
In general, the LAS found harm reduction practices to be well within the ‘wiggle-room’
built into the drug control conventions. It should be added that, across much of the
world, harm reduction concepts and practices are now an established element of policies
aiming to manage drug use, and are widely supported by many countries, and UN agencies, including WHO, UNODC and UNAIDS (71).
However, in some countries, it has proved difficult to roll out interventions even though
they fall within the provisions of the international drug control treaties. For instance, the
overregulation of substances, such as methadone and buprenorphine, does not allow the
development and scale up of OST programmes in certain countries. A notable example
is that of Russia, where OST is explicitly outlawed by the State. The Russian government
usually defends its position on the grounds that substitution treatment ‘merely replaces
one addictive drug with another’, and therefore does not qualify as a medical treatment.
This is, however, a very reductive argument that fails to acknowledge the enormous impact that the provision of a safe, quality-controlled and legal alternative to heroin has
on the stabilisation and quality of life of people dependent on opioids. It also wilfully
ignores the considerable evidence-base supporting the use of medications such as methadone and buprenorphine, which can produce clear and demonstrable improvements
in health and social function.
In other countries, coverage of harm reduction services remains low, hindering their
ability to respond efficiently to drug-related harms. This is often due to lack of national
political and financial commitment to support the programmes, and/or lack of international funding. Indeed, in countries where harm reduction is not officially recognised
and endorsed at the political level, it is not included in national programmes and is therefore not allocated any funds within national state budgets.
Finally, in many countries, the criminalisation of people who use drugs presents a direct barrier to the effective provision of harm reduction services. If the police arrest,
or are widely perceived as targeting, people who access harm reduction and treatment
facilities, this will deter many individuals from seeking support and life-saving services.
Similar barriers exist where drug services are perceived as being too closely linked to
law enforcement agencies – for example, where people who use drugs must be added to
police registries before accessing support.
346
Institutional and socio-cultural issues
Often, cultural and ideological assumptions can represent the greatest obstacles to the
design and implementation of harm reduction programmes. The notion that providing
NSPs, for example, ‘is likely to encourage drug use’ is entirely unsupported by scientific
evidence, but is a familiar argument.
At their most basic, social and cultural barriers include prejudicial, stereotypical images
of people who use drugs, and harm reduction programmes must address these attitudes
and misconceptions among the general population and policy makers. An education-oriented advocacy intervention that addresses these beliefs and prejudices is, in consequence, an essential element of harm reduction.
Economic and technical resource issues
Globally, there is a huge funding gap for harm reduction – with the available resources
from governments and international donors falling far short of the estimated need. This
is often a result of a lack of political will in both developed and developing countries,
rather than an actual shortage of resources (72). In 2007, it was estimated that approximately US$ 160 million was invested in HIV-related harm reduction in low and middle
income countries: just three US cents a day for each person who injects drugs. To put
this into perspective, the estimated need in 2009 was more than US$ 2 billion (73). The
lack of funding for harm reduction interventions is in many cases a harm caused by the
hostile political environments and reluctance from governments to provide support to
people who use drugs.
However, these interventions are generally highly cost-effective. In fact, a powerful economic case can be made in favour of harm reduction, since a relatively modest outlay
can often prevent very significant costs accumulating in the longer term. For example,
costs incurred in the on-going treatment of conditions such as HIV and hepatitis C, or
the very large sums spent on criminal justice measures such as imprisonment, can be
avoided by the timely scale up of harm reduction interventions that prevent infection
and help people to avoid the criminal lifestyles often associated with the funding of drug
dependence (74).
Recommendations
1. Based on public health, economic, and other evidence, a package of harm reduction services and policies should be adopted in all locations where injecting drug
use is prevalent, in order to promote access to healthcare services and commodities and reduce unintended negative consequences of criminal, health and social
policies.
2. Harm reduction should not be conceptualised as a standalone service but as an
integrated approach that complements, and is complemented by, all levels of he347
alth, social and other services that people who use drugs come into contact with.
Harm reduction should therefore be integrated whenever possible with drug treatment, primary and relevant specialist health care, social services and justice
systems.
3. Harm reduction aims to empower people who use drugs to improve their health
and manage, reduce, or eliminate the negative consequences of drug use. Programmes should therefore be evaluated in terms of harm reduction’s core objective
– to lead to any positive change. While abstinence is a potential outcome of harm
reduction approaches, reducing ‘success’ to abstinence-only goals runs counter to
scientific evidence about drug dependency and ignores the great value to individuals and society of countless incremental positive steps.
4. Harm reduction services should be as comprehensive as is feasible in a given
setting, at minimum seeking to address the following either directly or through
referral networks: prevention of HIV, hepatitis, STI and tuberculosis, and links to
care and treatment; promotion of safer drug-use practices; overdose prevention
and response; and basic mental health and social welfare needs.
5. Harm reduction programmes that target women, young people, and minorities
who use drugs should be established, improved or scaled-up to ensure that such
groups have equal access to appropriate services.
6. Harm reduction programmes and drug policies gain legitimacy when people
who use drugs are meaningfully involved in their development, implementation and evaluation. Harm reduction and allied organisations, and government
bodies should encourage the development of community-based organisations of
people who use drugs, and should ensure that people who use drugs are represented at all levels of decision making and policy implementation and in ways
that actively support participation.
7. It is critical that all these harm reduction interventions be extended to prison
settings (for more information, see Section 2.4: Effective drug interventions in
prisons).
348
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354
Minerva - Melpomeni Malliori*
Athens University Medical School
ABSTRACT:
This presentation describes the impact of the current economic crisis on overall access to care and more specifically on access to drug
demand reduction services. It presents responses and policies that were developed in Greece to address increased demand for services
and decreased funding and their impressive outcomes on managing the outbreak of HIV amongst People Who Inject Drugs (PWIDs).
Since the end of 2010, PWIDs have played a major role in the explosion of HIV incidences in Greece (+1250% in 2011 versus 2010), mainly in
Athens Metropolitan Area. Meanwhile and due to the economic crisis, demand for treatment services was growing. At the same time, it
became increasingly hard to sustain funding for harm reduction services, including Opioid Substitution Treatment (OST), where Greece
consistently displayed one of the lowest coverage rates in Europe, at around 20% of treatment demand, with more than 5,500 people
waiting to access treatment for more than 7 years.
Greek authorities responded to the challenge by opening up an additional 33 OST treatment units in general hospitals, thus increasing
coverage to over 40%, eradicating also the waiting list. Additionally governmental organizations in collaboration with nongovernmental organizations expanded street work and increased the meagre 7 syringes per patient per year (2011) to over 145 syringes per patient
per year (2013). At the same time within 24 months, per patient treatment cost was reduced by approximately 50% compared to 2009
and by end 2012, the HIV epidemic amongst PWIDs was taken under control.
* Associate Professor of Psychiatry, Athens University Medical School
Education
Degree in Dentistry, Athens University
Degree in Medicine, Athens University
PHD Athens University, Medical School
Professional Experience
· Consultant in the Mental Health Department of the World Health Organization
· President of the Greek Organization against Drugs 1997-1999 and 2010-2013
· Member of the European Parliament 1999-2004
· Representative of the European Parliament for the European Centre for Disease Prevention and Control 2004-now
· Vice President of the Greek Centre for Disease Prevention and Control 2009-2010
· Member of the Management Board of the European Monitoring Centre for Drugs and Drug Addiction 1997-1999 and 2010-2013
Publications
· 35 Publications in international medical Journals and books
· 70 Publications in national medical journals and books
355
DESIGNING AND IMPLEMENTING RESPONSIVE DRUG POLICIES UNDER FISCAL CONSTRAINTS: THE CASE OF GREECE
Designing and Implementing Responsive
Drug Policies under Fiscal Constraints:
The Case of Greece
Introduction
International literature indicates that economic down turns increase injecting drug use
and HIV incidence among people who inject drugs (PWIDs). There are reasons to suspect that the current economic turmoil has had and will continue to have adverse effects
on Drug Use and HIV incidence in some European countries. It is expected to have an
impact on public health budgets including services targeted at vulnerable populations
such as PWIDs. In its 2011 annual report the EMCDDA noted that the current economic crisis may increase the risk of localized HIV epidemics among drug injectors.
In the same line evidence indicates a temporal association between reduction, or initially
low, level of provision of prevention services and an increase in HIV incidence as well as
changes in patterns of risk behaviors among PWIDs in Greece. The extent to which these
service reductions or changing patterns of risk among PWIDs have been related to the
current economic crisis cannot be easily measured, and causal links are impossible to establish so far. Based on available data, the prevalence of injecting drug use may increase
during an economic crisis and public health budgets may be reduced. Another key factor
in relation to the above seems to be that economic crisis, gives limited opportunities to
make money from e.g. occasional employment, hand-outs, pocket money from parents
etc., while leading to an increasing number of (mostly) problematic users prostituting
themselves to make money to support their habit. However, molecular epidemiology
data suggest that HIV transmission through needle sharing is currently the most important route of transmission.
All the above-mentioned factors are indicative for two main hypotheses. First, behavioral risk factors, such as an increase in needle-sharing and unsafe sex practices have
deteriorated recently, facilitating a change from sexual to needles/syringes sharing HIV
transmission patterns. Second, the economic crisis and the concomitant social and behavioral disruption facilitated and catalyzed HIV transmission.
For all these reasons there is a continuous need to keep public health and sufficient preventive services on the agenda, even in challenging economic times.
356
Drug situation in Greece
The number of heroin users in Greece in 2010 was estimated to be 22.515 (range 20.202–
25.171). Approximately 70 % of them lived in Athens Metropolitan Area. For the same
reference year, the estimated number of injecting drug users (IDUs) in the general population, 15–64 years old, was estimated to be 9.4 (range 8.1–11.0). The majority of IDUs
(52 %) belonged to the 25–34 age group, while 28.5 % were older (Greek Reitox focal
point). According to data of high reliability, the prevalence of hepatitis C virus in IDUs
was estimated to be 50.2 % (44.9–55.5), while the prevalence of anti-HBc was estimated
to be 20.5% (14.6–26.3) and HBsAg 2.5% (2.3–2.7).
In 2010, 74 therapeutic programs existed in Greece, providing all treatment modalities.
These include 25 opioid substitution units, 43 psychosocial interventions (drug-free)
programs and six treatment programs implemented in the prison settings. A little more
than 8.000 users were treated in these agencies in 2010 with approximately 70% of them
being IDUs (Greek Reitox focal point). Laboratory testing for HIV/AIDS is a prerequisite for admission to all drug treatment services in Greece.
Brief background of HIV in Greece, description of the outbreak
The Hellenic Center of Disease Control and Prevention (HCDCP) is responsible for general HIV/AIDS surveillance in Greece. Case reporting is mandatory, anonymous and
confidential. During 2011, the number of reported cases of HIV/AIDS among IDUs has
sharply increased and the same observed during the year 2012. From 2001 to 2010, the
number of reported cases ranged from 3 to 19 per year (Figure 1). The increase in the
reported cases in 2011-12 is consistent to a more than ten-fold increase in the incidence
of diagnosed cases of HIV infection among IDUs.
Reported infections among IDUs increased from less than 20 cases annually to over 190
in the first ten months of 2011. Genetic analysis shows close similarity among a subset of
the viruses sampled from IDUs. This suggests a recent outbreak. The possible causes for
the increase may have different origin in connection with the following:
(a) Social, economic, institutional, legal or other factors which may have prevented or
limited the implementation of interventions designed to provide needles and syringes or
opioid substitution programs and to screen, inform and treat IDUs;
(b) Factors which may have changed the patterns of use including increase of needle
sharing;
(c) Factors which may have changed the patterns of illicit drug trafficking;
(d) Factors which may have shifted the IDUs’ sexual practices towards riskier ones including increased sex work;
357
(e) The role of the country’s economic crisis in this development.
According to experts, various reports suggest the increase in HIV/AIDS cases started
already in the last quarter of 2010 and continued with more intensity in 2011-2012. The
overwhelming majority of cases have been detected only in Athens. Critical examination
of prevention activities and indicators of risk prior to the HIV outbreak in Greece identifies several potential weaknesses of the prevention programs which may have contributed to the outbreak. Among these, the major factors of vulnerability were the following:
1) long waiting times for access to opioid substitution treatment (on average 89 months
in Athens, prior to the epidemic);
2) low (insufficient) volume of injection equipment exchange or provision.
These factors have created favorable conditions for the rapid transmission of HIV in the
population of users, especially in the Athens area.
National Policy to face the HIV epidemic
In 2011, Greece faced an outburst of HIV epidemic among drug users. This was considered as a consequence of both the socio-economic crisis and the long waiting lists
for substitution treatment that had ended up in the limited access of drug addicts to
treatment and harm reduction for more than a decade. Overconcentration of active
drug users in open drug scenes was also observed in certain areas in downtown Athens.
Contrary to a repression approach, current policies promoted the cooperation of all the
co-competent, specialized agencies towards the adoption of measures that would create
a shield of protection for public health and safety.
Since the detection of the increase in cases at the beginning of 2011, a number of new
interventions have been introduced. Foremost among these is the rapid expansion of
opioid substitution treatment services, with the objective of attracting IDUs to care and
reducing related risks of infectious disease transmission. This effort has significantly reduced mean waiting times for entering treatment in the Athens–Piraeus area and eliminated waiting lists in Thessaloniki. During September 2011, OKANA has launched 33
new substitution units, in collaboration with hospitals in Athens, Thessaloniki and other
main cities of Greece.
During the same period 2011-2013 different Organizations with the collaboration of
NGOs provided mobile prevention services offering information, voluntary testing, referrals and clean needles and syringes in Athens. However, the level of activity is still
insufficient to meet the demand within the injecting drug using population. Systematic
HIV screening of IDUs in treatment programs has been implemented and an awareness
campaign directed to IDUs was implemented in the center of Athens.
More specifically, it was developed a comprehensive plan aiming at the:
358
•
Increase of treatment availability with the establishment of the new substitution
units within state hospitals, in order to eliminate the waiting list and to reduce
the risk among the intravenous drug users,
•
Intensification of already existing health promotion interventions of low threshold services (NSP/Needle Syringe distribution Programs in collaboration with
NGOs, raising awareness etc.),
1. Increase of treatment availability, new Substitution Treatment (OST)
provision:
Expansion of the OST program in order to eliminate the waiting list in Athens and to
reduce the risk within the PWID population
1.1 Opiate Substitution Treatment-OST
2010
2011
2012
2013
Total N of OST Units in Greece at the end of
the year of reference
25
42
53
53
N of OST Units in Athens at the end of the
year of reference
7
18
23
23
Total N of new OST applications per year
1859
2773
2325
1474
N of new OST applications in Athens per year
675
1321
866
533
Total N of OST applications on waiting list at
the end of the year of reference
5394
4275
2873
2563
N of OST applications on waiting list in
Athens at the end of the year of reference
3689
3838
2541
2301
Waiting time for entering OST in Athens at
the end of the year of reference (in months)
74
90
42
44
Waiting time for entering OST in
Thessalonica at the end of the year of
reference (in months)
48
1
0,5
1
Total N of patients in OST at the end of the
year of reference
5101
6625
8031
8202
2098
2404
3078
3157
N of patients in OST in Athens at the end of
359
After the major expansion of the OST programs in the years 2011-2012, there has been
no further scale up as a consequence of budget cuts.
More specifically, by the end of 2013:
•
Overall 53 OST units were in operation, 23 of them in Athens metropolitan area.
•
There was a decrease of 36.6% in the total number of OST applications as compared to the previous year. The decrease was higher in Athens (38.5%).
•
Regarding waiting list, there was a minor decrease in the number of applicants
waiting for admission in Athens (5.3%). At the end of the year 2,301 heroin users
were still waiting for entering OST. The waiting time for entering treatment was
decreased in Athens from 79 months in 2011 to 43 months in 2013. In Thessalonica, the waiting time decreased also from 48 months in 2010 to 1 month in 2013.
•
As regards OST provision, the total number of patients in treatment at the end of
Dec-13 was 8,187, with 3,185 of them in Athens OST units.
•
Finally, a number of 307 HIV (+) patients were receiving OST at the end of 2013
in Athens. The total number of HIV(+) patients receiving OST all over Greece at
the end of 2013 were 353.
1.2. Drug Free Treatment Programs
As regards to the drug free programmes, no problem of availability in treatment slots has
ever occurred all over Greece.
2. Intensification of health promotion and harm reduction programs: intensification of standard health promotion activities of low threshold services (needles-syringes and condom distribution, awareness raising activities etc.) & implementation of
extra interventions (i.e. implementation of ARISTOTLE project, supervised drug use
centers in Athens, ‘boule de neige’ campaign in Athens & Thessalonica, street-work service in Thessalonica)
2.1. Low threshold services in Athens
In the following table, data on the range of services available for drug addicts and comparative data on their respective annual visits, for the years 2010-2013, are presented.
360
Direct Aid and Support Unit (MAVY)
2010
2011
2012
2013
N of drug users who received services in
the last month of the year of reference by:
Pathology Clinic
228
375
226
216
Dental Clinic
41
62
55
78
Cardiology Clinic
-
-
-
23
Laboratory
212
382
165
179
Nursing Service
115
105
62
46
Social Service
66
57
38
26
Mobile Medical Unit
161
160
133
72
Drug Addicts Care Facility (SFEA)
2010
2011
2012
2013
N of visits in premises in the lastmonth of
704
714
324
717
N of PWID approached in Street-work in
the last month of the year of reference
136
108
1079
706
2.2. Needles-syringes and condom distribution in Athens Metropolitan area
In 2013, delays in the provision of injecting equipment due to limited budget reduced
the NSP coverage in Athens.
Overall 212,319 syringes and 54,158 condoms have been distributed by the harm reduction services of OKANA and the OKANA network of NGOs (distribution in premises or
in street work). As compared to 2012, there was a decrease of 18.1% in the N of syringes
and a 16.9% decrease in the N of condoms distributed. In order to respond to the observed increase in HIV/AIDS cases, the ΟΚΑΝΑ Direct Aid and Support Unit (ΜΑΒΥ)
increased, as of May 2011, the number of syringes allowed for exchange (from 25 to 40
per patient weekly) and the number of condoms distributed to active users (from 7 weekly to 25 or even 40 for injecting sex workers).
Number of syringes and condoms distributed by the Needle exchange program of OKANA
in the years 2010–13
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Cardiology Clinic
Laboratory
2010
2011
2012
2013
43,405
92,829
259,127
212,319
2,925
11,324
65,189
54,158
3. Complementary activities
Additionally to the above described measures, targeted harm reduction interventions
and actions for specific drug populations were established. These interventions, financed by the European Cohesion Policy Fund, are:
3.1. Supervised drug-use facility in Athens
The launching of drug consumption rooms was primarily based on the need to “control” problematic drug use, which was associated with overdoses and the transmission of
blood borne viruses. At the same time the consumption rooms offered an alternative to
drug use that was made in public. Insofar there is evidence that they constitute an efficient measure to reduce health and social harms for users and to shield public safety against minor delinquency related to drug use and drug scenes. However, there are barriers
in regard to their social acceptance: harm reduction measures continue to be a controversial issue in Greece between treatment agencies as well as between political parties.
The first supervised drug-use facility in Athens “ODYSSEAS” started its operation in
October 2013 as a pilot project that aims to address issues of personal and public health
and improve neighboring conditions in downtown Athens. It is a fully equipped medical unit including medical doctors with various specialties, nursing staff, social workers,
psychologists, socio-therapists and outreach workers who encourage people who inject
drugs to use this facility. It aims to provide access to harm reduction, advice on safer use/
injection, access to drug dependence treatment for intravenous drug users and to reduce
the risk of overdose deaths and of HIV and HCV infections.
However, having a closer look at the graph, one can assume that although the number
of visits in the station was on the increase until February, reaching 280 visits in total, of
which 235 were for safer use, in March the respective numbers declined. Evidence shows
that the decline can to a large extend be attributed to the intense police patrols around
“Odysseas”.
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3.2 Police-staff Training in Drug Related Issues
The scope of this project is that police could and should play a crucial role in reducing
the harms of drug related crime by adopting policing practices that can reduce the harms associated with drug markets, thus contributing to the protection and promotion of
public health and ensuring public safety. The program is developed through the production of innovative interactive educational material. Emphasis is put on the human rights
dimension regarding drug users but also on safety issues (i.e. personal safety) regarding
police officers. Violence issues and good practices during policing are also included.
Overall 575 police officers will receive training.
1.1. Measures alternative to imprisonment
The implementation of measures alternative to imprisonment is an effective way to
reduce crime and other substance-related problems including HIV risk. The new
drug law (4139/2013) provides the possibility of introducing drug treatment for addicts instead of incarceration.
Within the framework of this project, 2 new services have been launched in Athens
and Thessalonica. Information and awareness raising activities as well as outreach activities for the programming of special counseling provision have been implemented.
1.2. Opiate Substitution Treatment in prison
Special reference should be made to the Opiate Substitution Treatment program in
prison.
As long ago stated by the World Health Organization, opioid substitution therapy
(OST) is the most effective treatment for preventing HIV and hepatitis C among
opiate users. (WHO 2007). There is evidence that the benefits of the OST in prison
are similar to the benefits in the community settings as it presents an opportunity to
recruit problematic opioid users into treatment, to reduce illicit opioid use and risk
behaviors in prison and thus to reduce HIV and other blood-borne viruses transmission etc.
As mentioned in the 2012 Annual EMCDDA Report, Greece was among the four
countries in the EU, where OST was still not an option for opioid-dependent prisoners (EMCDDA 2012). The new drug law (Law 4139/2013) provides for the possibility of introducing drug treatment during incarceration making an explicit reference
to the operation of the OST program in prisons. The operation of the two substitution units is expected soon.
363
3.5 An integrated and combined prevention initiative for control of the HIV1 outbreak among Injecting Drug Users (IDUs) and their high risk contacts in
Athens (ARISTOTLE Program)
This project was successfully completed in Dec 13. During a 16-month period, 7,110
questionnaires and blood samples were collected from 3,320 unique participants who
have been also offered HIV prevention and health promotion services.
3.6 Education and promotion of health of the active drug users, ‘Boule de
Neige Campaign’ in Athens & Thessalonica: Provision of information and assistance services to active drug users in order to prevent and reduce damage from drug use
Drug addicts were approached and offered prevention messages about HIV risks, sterile
injecting equipment, information and counselling on the risks associated with other infectious diseases, on safer drug use and harm reduction, provision of injecting material
as well as information on the existing drug treatment and welfare services.
3.7 Programs in the Community and in the Street: Executive training in new
interventions in the field of harm reduction & supply reduction (drug use prevention,
early intervention)
Mental health professionals have participated in this training in order to implement new
interventions for drug users and special population groups (students, immigrants, repatriated, Roma, prisoners, released prisoners, juvenile offenders, sex workers, HIV/AIDS
patients etc.) in the Regions of Attica and Central Macedonia.
3.8 Public Awareness Campaign against Drugs
Campaign targeted among others to highlight the necessity of the harm reduction programs and the fact that their implementation is of equal importance as compared to other
interventions within the treatment system.
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PROPOSALS OF INTERNATIONAL ORGANIZATIONS
International experience suggests that in the case of Greece, without a major and successful preventive effort, a 10% or higher anti-HIV prevalence can be reached within 2–4
years (5–10). In the case of a 10% increase, this would imply that some 1.200–1.300 new
HIV infected IDUs plus 1.200–1.300 new HIV-infected people from other risk groups
could present to services, which would not be manageable by the National Health System, especially under the current circumstances of economic crisis. To face this threat,
the following measures were proposed:
(a) evaluation of the proposals of international organizations and the Greek ability to
implement such proposals;
(b) concrete prevention measures to be taken immediately.
Nine interventions outlined in the WHO, the UNODC, UNAIDS technical guide for
the prevention and treatment of HIV among drug injectors
•
Needle and syringe exchange programs;
•
Drug dependence treatment and in particular opioid substitution therapy for people who use opioids;
•
Antiretroviral therapy for HIV-positive people (and their sexual partners);
•
HIV testing and counselling;
•
Prevention and treatment of sexually transmitted infections;
•
Condom programs for people who inject drugs and their sexual partners
•
Targeted information, education and communication for people who inject drugs
and their sexual partners;
•
Vaccination, diagnosis and treatment of viral hepatitis;
•
Prevention, diagnosis and treatment of tuberculosis.
(Source: WHO, UNODC, UNAIDS (2009) Τechnical guide for countries to set targets for
universal access to HIV prevention, treatment and care for injecting drug users, WHO,
Geneva).
Ιndependent Reference Group to the United Nations
•
Improve engagement with people who inject drugs in shaping responses to HIV/
AIDS.
•
Support a public health, rights-based approach to HIV programming that recognizes that access to life-saving, proven interventions for the prevention and treat365
ment of HIV is a human right for all people, including people who inject drugs.
•
Urgently implement and/or scale up the comprehensive package of nine interventions outlined in the WHO, the UNODC and UNAIDS technical guide for the
prevention and treatment of HIV among people who inject drugs.
•
Remove legislation and policies that prevent the introduction or inhibit the delivery of these nine interventions.
•
Commit to ending punitive law-enforcement approaches to injecting drug use.
•
Improve integration of HIV services with treatment for drug dependence.
•
Commit to treating health conditions that co-occur alongside HIV among people
who inject drugs.
•
Gather data to enhance the response to HIV among people who inject drugs.
(Source: Ιndependent Reference Group to the United Nations calls for Member States to
scale up evidence-based interventions to address HIV among people who inject drugs ahead of the High Level Meeting on AIDS).
Joint ECDC and EMCDDA Guidance
•
Injection equipment: Provision of, and legal access to, clean drug injection equipment, including sufficient supply of sterile needles and syringes free of charge, as
part of a combined multi-component approach, implemented through harm-reduction, counselling and treatment programs.
•
Vaccination: Hepatitis A and B, tetanus, influenza vaccines, and, in particular for
HIV-positive individuals, pneumococcal vaccine.
•
Drug dependence treatment: Opioid substitution treatment and other effective
forms of drug dependence treatment.
•
Testing: Voluntary and confidential testing with informed consent for HIV, HCV
(HBV for unvaccinated) and other infections including TB should be routinely
offered and linked to referral to treatment.
•
Infectious disease treatment: Antiviral treatment based on clinical indications for
those who are HIV, HBV or HCV infected. Anti-tuberculosis treatment for active
TB cases. TB prophylactic therapy should be considered for latent TB cases. Treatment for other infectious diseases should be offered as clinically indicated.
•
Health promotion: Health promotion focused on safer injecting behavior; sexual
health, including condom use; and disease prevention, testing and treatment.
•
Targeted delivery of services: Services should be combined and organized and delivered according to user needs and local conditions; this includes the provision of
366
services through outreach and fixed site settings, offering drug treatment, harm
reduction, counselling and testing, and referrals to general primary health and
specialist medical services.
(Source: ECDC and EMCDDA guidance (2011), ‘Prevention and control of infectious diseases among people who inject drugs’, EMCDDA/ECDC, Stockholm, October 2011)
With regard to the above mentioned interventions outlined in the WHO, UNODC and
UNAIDS technical guide, the proposal of the Independent Reference Group to the United Nations, and the ECDC–EMCDDA Joint Guidance, it is true that although all of
them have been developed in Greece, several of them are not adequate. More specifically, in Greece:
•
HIV/AIDS anonymous screening and counselling, as well as antiretroviral therapy for HIV-positive people and their sexual partners are provided for by law and
are widely available. This also holds true for prevention interventions targeting
AIDS or other infectious diseases, i.e. hepatitis B and C and tuberculosis.
•
All treatment modalities are available to drug-dependent individuals. Psychosocial interventions (drug-free programs) can admit users who seek treatment immediately, i.e. they have no waiting list. On the other hand, the Substitution Programs and, in particular, the units based in Athens, where the focus of the problem
of increasing HIV/AIDS cases is located, have a long waiting list. By the end of
2013, all over Greece, 8.187 drug users were actively enrolled in opioid substitution programs (approximately 40% of the estimated number of heroin users).
As a consequence, Greece manages to have during the period 2011-2013 a good
coverage of opioid substitution treatment in comparison with other EU countries.
•
All HIV positive IDUs, including illegal immigrants, were offered prioritized opioid substitution and antiretroviral therapy (active before detection of the outbreak).
•
Syringe and injecting equipment exchange or distribution programs are available.
During the last 2 years 2011-13 the coverage of needle and syringe provision in
Greece is 145 syringes per year per addict and the WHO recommendation is 200
syringes per year per addict. A switch from high to low dead-space syringes is
implemented.
•
Low-threshold programs for active users also include condom distribution, though with limitations in terms of number and coverage.
•
A molecular epidemiology surveillance program was initiated to describe the
transmission networks, the origin of HIV strains and to identify index cases.
•
Awareness-raising and information interventions addressed to problem users and
their injecting and sex partners concerning the risks and high-risk practices are
367
insufficient, and the specific needs or characteristics of such groups have not been
taken into the sufficient consideration while designing or implementing the interventions.
Broader discussion of implications for harm reduction, drug treatment policies
The increase in HIV/AIDS cases among IDUs is a serious and recent problem. The most
probable causes may be, among others, lack of information, increased needle-sharing,
and recent influx of immigrants, resulting in higher pressure on the already limited services. Interestingly, a neighboring country, Bulgaria, experienced a steady increase in
HIV reporting rates, from zero per million population in 2003 to almost 10 per million
in 2009. Among IDUs and problematic drug users, there is a lack of information concerning the routes of HIV transmission and the precautions, as well as poor access to
infectious disease control and management services.
The measures to be taken immediately in order to respond to this situation include an
information/awareness campaign to raise public and IDUs’ awareness, increased precautions, improved access to specialized substitution therapy programs and infectious
disease control services of IDUs, expansion of low-threshold services, and specialized
training for health professionals. The major and most urgent change is the restructuring
of opioid substitution programs which is anticipated to eliminate the waiting lists and
reduce substantially the residual risks within the IDUs community in Greece.
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BIBLIOGRAPHY
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Strathdee SA. HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage Lancet. 2010; 375, pp. 1014–1028.
Friedman SR, Rossi D, Braine N. Theorizing “Big Events’’ as a potential risk environment for
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Strathdee, S.A., Hallett, T.B., Bobrova, N., Rhodes, T., Booth, R., Abdool, R., Hankins, C.A. HIV
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HIV prevention, treatment and care for injecting drug users. WHO, Geneva, 2009.
Independent Reference Group to the United Nations Calls for Member State to Scale up Evidence-Based Interventions to Address HIV among People who Inject Drugs ahead of the High-Level Meeting on AIDS 2010: http://www.unodc.org/documents/hivaids/HLM_statement1.pdf
ECDC and EMCDDA guidance (2011), ‘Prevention and control of infectious diseases among
people who inject drugs’, EMCDDA/ECDC, Stockholm, October 2011. http://www.emcdda.
europa.eu/publications/ecdc-emcdda-guidance
EMCDDA (2010), Annual report on the state of the drugs problem in Europe, European Monitoring Centre for Drugs and Drug Addiction, Lisbon, November 2010. Available from http://
www.emcdda.europa.eu/attachements.cfm/att_120104_EN_EMCDDA_AR 2010_EN.pdf
EMCDDA (2011), Statistical bulletin, European Monitoring Centre for Drugs and Drug Addiction, Lisbon, July 2011. Available from: http://www.emcdda.europa.eu/stats11
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370
Nurmuhammat Amat*
Xinjiang Medical University
Halmurat Upur
Traditional Uighur Medicine Institute of Xinjiang Medical
University, Urumqi, China.
Muhtar Ayup
Affiliated Traditional Chinese Medicine Hospital of Xinjiang
Medical University, Urumqi, China.
ABSTRACT
In reference of Uighur medicine, Traditional Chinese medicine clinical research reports, we conclude the method combination therapy of
Uighur medicine with Chinese medicine on rehabilitation. Uighur medicine mainly according to the abnormal sawda theory and applied
humoral maturation on abnormal black sawda, also use some medicine for tonic control organ function. Traditional Chinese medicine
generally uses the traditional Chinese medicine with acupuncture treatment at the same time. Uighur medicine and traditional Chinese
medicine on rehabilitation attaches great importance to the overall treatment, has good effects on eliminating protracted withdrawal
syndrome, rehabilitation period of comprehensive control. Traditional medicine researches seek new ways of drug detoxification.
* Nurmuhammat Amat, Professor, works in Traditional Uighur Medicine, Institute of Medical University, Xinjiang Uighur Autonomous
Region Urumqi, 09/1990–07/1996: MD in Clinical Medicine. Clinical Medicine Institute of Xinjiang Medical University;3/1990-12/2000: MD in
Pharmacology. Xinjiang Medical University, (Prof. Dr.Halmurat Upur); 9/2004–07/2007 Ph.D. in Pharmacology. Pharmaceutical Institute
of Xinjiang Medical University (Prof. Dr.Halmurat Upur); 8/2007-9/2008. Postdoctoral Fellow at the Institute of Pharmaceutical Sciences–
Department of Pharmacognosy of Karl-Franzens Universitaet Graz, Austria (Prof. Dr.Rudolf Bauer); Now he is the Dean of Traditional
Uighur Medicine Institute of Xinjiang Medical University. During the work spirit and co-authored over nearly more than 80 papers
published in core journals at home and abroad. And more than 10 academic books thesis being published.
371
TRADITIONAL CHINESE AND UIGHUR MEDICINE IN DRUG TREATMENT
Integrative Therapy of Uighur Medicine and
Chinese Medicine in Rehabilitation Process
of Drug Addiction
Drug addiction continues to be an important public health problem in the world. Effective medications are available for the treatment of nicotine, alcohol, and opioid addictions. Unfortunately, no medications have been proven to be effective for cocaine as well
as no medications have been approved for the treatment of methamphetamine or cannabis addiction, although fewer clinical trials have been conducted for those addictions.
To date, peer education and methadone maintenance therapy have been the most widely
used harm reduction strategies in China (1). But methadone maintenance cannot solve
the protracted abstinent symptoms.
Traditional herbal medicines that formed the basis of healthcare since the earliest of days
are still widely used. Complementary and Alternative Medicine (CAM) is becoming
more and more important in improving human health (2). Traditional herbal medicines
are often used for the treatment of different diseases in developing countries, especially
in the rural areas where there is a lack of an efficient primary healthcare system. Chinese
Medicine (CM) has a long history covering thousands of years with extensive literature
and clinical applications that play a critical role in Chinese healthcare (3, 4).
Traditional medicine has been used to treat drug addiction in clinics and valuable experiences have been accumulated with regard to patients’ detoxification and rehabilitation. According to the treatment characteristics and the clinical needs, it is recommended that the protracted abstinent symptoms can be used as target indications of new
traditional medicine development. Conclusion herbal medicine treatment intervention
can reduce the anxiety of drug addicts during rehabilitation of detoxification treatment
and enhance the effect of medical maintenance treatment. Therefore, there is a place for
new or alternative approaches to the control of drug addiction such as those found in
complementary and alternative medicine (CAM), and especially in traditional medical
systems(5, 6).
CAM approaches include those such as traditional Uighur medicine (TUM), which is
used in Xinjiang Uighur Autonomous Region of China. Equilibrium quantity and quality of these humours are important for maintaining the optimum human health. The
balance of Hilit is relative and automatic. The four Hilits naturally control the balance
in the body, which ensures good health. These Hilits, (Sapra, Kan, Balgham and Savda)
mutually compensate, balance, control and support each other. Maintaining a balance
of Hilit prevents diseases. This means that disequilibrium of humours quantitatively or
372
qualitatively causes diseases (7, 8). On the contrary, imbalance in quality and quantity
causes different diseases. The imbalanced fluids are called abnormal fluids. Thus, the
syndromes generally described in TUM can be divided into four main categories: abnormal Savda, abnormal Sapra, abnormal Belghem and abnormal Kan syndromes. According to TUM, the origin of drug addiction and symptom is due to an imbalance in
abnormal savda. In Uighur Medicine certain complex prescription such as Munziq and
Mushil are highly esteemed as special tonics and purgatives to expel abnormal Hilit bile
when it becomes excessive or aggravated, and thus restore health. First use the Munziq
to adjust the Hilit concocted system and ripe abnormal Hilit, before any definite positive
changes can be seen it may be purged or expelled by Mushil when it becomes excessive
or aggravated, and thus restore health. Because the pathological manifestations of different Hilit imbalances are so varied, an equal diversity of therapeutic modalities, strategies and approaches are needed to correct them.
According to the Traditional Uighur Medicine (TUM), the abnormal Savda syndrome
can be caused by exogenous (environmental, psychological, and emotional) as well as
endogenous stimuli or stressors (7). We thus hypothesized, in terms of modern medicine, the etiology and pathogenesis of abnormal Savda syndrome as the state under stress
conditions whose symptoms, manifested in the clinical conditions of chronic diseases,
include mental stress, tantrum, hypomnesis, dry skin, polydipsia, polyphagia, and memory dysfunction (8).
Rationally therefore, the treatment or prevention of drug addiction is aimed at regulating and adjusting abnormal savda by complex prescription---Abnormal savda Munziq.
Different Hilit takes different time to ripen according the character of abnormal Hilit.
Among of them (Sawda) black bile, of all the four humors, takes the longest time to
ripen, or be concocted so that superfluities of it may be purged or expelled, being in this
attribute contrary to blood humor. In the drug addiction treatment we will use the Abnormal Savda Munsiq for 60- 90 days. After that we will use some prescription for improving liver , heart and brain function such Awrixim syrup, Dawyi mixki, Ustikuddus
syrup, this has good effect in the treatment, can improve the protracted abstinent symptoms.
Research also found that oral administration of Abnormal Savda Munsiq (ASMq), a herbal preparation used in Traditional Uighur Medicine, was found to exert a memory-enhancing effect in the chronic stressed mice, induced by electric foot-shock. The memory
improvement of the stressed mice was shown by an increase of the latency time in the
step-through test and the decrease of the latency time in the Y-maze test. Treatment
with ASMq was found to significantly decrease the serum levels of adrenocorticotropic
hormone (ACTH), corticosterone (CORT) and β-endorphin (β-EP) as well as the brain
and serum level of norepinephrine (NE). Furthermore, ASMq was able to significantly
reverse the chronic stress by decreasing the brain and serum levels of the monoamine
373
neurotransmitters dopamine (DA), 5-hydroxytryptamine (5-HT) and 3,4-dihydroxyphenylalanine (DOPAC). The results obtained from this study suggested that the memory-enhancing effect of ASMq was mediated through regulations of neurochemical
and neuroendocrine systems (9).
Traditional Chinese medicine (TCM) includes Chinese medicine and acupuncture.
TCM has been practiced in China for more than 2000 years, and for the past 200 years
has been used in treatment of drug addiction. Clinical practice is based on the idea that
pathology follows etiology and therapeutics follows pathology. If we can differentiate
etiology in substance abuse then we imply that there must be resulting differences in
pathology (10, 11). In the clinical practice the abusing population should benefit from
differentiation in therapeutics. Current clinical practice in the acupuncture detoxification field is heavily based on the use of the same or nearly same protocol for most or all
patients presenting to a clinic for treatment of substance abuse related symptomatology.
During in acute withdrawal the addict experiencing symptoms of Liver Qi Stagnation. Chronic addiction, with its long-term Liver and Heart heat, results in kidney yin
deficiency. Sweating secondary to acute opiate withdrawal and Heart qi deficiency damages the yin. Diarrhea due to Spleen qi deficiency (as a consequence of Liver-Spleen
disharmony) also damages the yin. Yin deficiency may be further exacerbated by fluid
and blood loss and malnutrition. Lastly many addicts are involved in excess sexual activity that damages the kidney yin. For the lung pathology has lung qi deficiency, lung
Yin deficiency. Chronic drug abuse may damage the Kidney yang as well as the Kidney
yin. Drug abuse resulting in chronic Kidney yang deficiency leads to shortness of breath, with difficulty in inhalation. The general therapeutic principle of Chinese medicine
developed was based on its unique theory of “reinforcing healthy Qi and resolving and
removing effects of toxicity”. Currently, the SFDA has issued approval of 10 Chinese medicines for use in clinical practice for the treatment of addiction, including the Fukang
tablet, Lingyi capsule, Yian Liquid, Jitai tablet, Fuzhengkang granule, Anjunning mini
pill, Kangfuxin, Xuanxia detoxification capsule, Shifusheng capsule and Zhengtongning
granule for opiate acute detoxification (12, 13, 14). Clinical trials of 6 Chinese medicines are currently underway and pending approval by the SFDA. These include the
Taikangning capsule, Jiedukang capsule,Yanshen liquid, Fuyuan granule, Jingan Jiedu
pill,Jinjiawang granule and Junfukang capsule. Several additional Chinese medicines are
undergoing preclinical trials.
Acupuncture, another essential part of TCM, which was developed based on the principle that “functions of the human body are controlled by the ‘Jing-Luo’ and ‘Qi-Xue’
system”, has been used not only in China, but also in Europe, the USA and other countries, for controlling opiate addiction (15). In acupuncture usually select some main
treatment acupoint such as Zusanli, Neiguan,Yinjiao, Baihui, Shenshu, Hang jian, San
Yinjiao,Pishu (16). We select main acupoint and adjunct acupuncture points in accordance with patients’ illness. There are 3 major advantages of employing acupuncture for
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the treatment of drug addiction. First, acupuncture therapy for addicts is inexpensive,
simple and has no side effects (17).
There are some advantages in using traditional medicine for drug addiction, including
less harmful side effects, high safety and ideal effects in the inhibition of protracted withdrawal symptoms and relapse. Co-administration of herbal medicine with modern
medicine shows some synergistic effects in detoxification. Many traditional medicines
for drug addiction also have efficacy in the rehabilitation of abnormal body functions
induced by chronic drug use, including improving immune function, increasing working memory and preventing neurological disorder. Given that alternative medicine is
effective in the prevention of relapse and causes fewer side effects, it may be used widely
in the treatment of opiate addiction.
375
REFERENCES:
1. Lu, L., & Wang, X. (2008). Drug addiction in China. Annals of the New York Academy of
Sciences, 1141, 304–317.
2. Hsieh CL, Lao L, Lin YW, Litscher G. Complementary and alternative medicine for the
treatment of central nervous system disorders. Evid Based Complement Alternat Med.
2014;2014:175152. doi: 10.1155/2014/175152.
3. Zhang C, Jiang M, Zhang G, Bian ZX, Lu AP .Progress and perspectives of biomarker discovery in Chinese medicine research. Chin J Integr Med. 2014 Sep 2. [Epub ahead of print]
4. Chang R. Making theoretical principles for new Chinese medicine. Health History.
2014;16(1):66-86.
5. Lu L1, Liu Y, Zhu W, Shi J, Liu Y, Ling W, Kosten TR .Traditional medicine in the treatment
of drug addiction. Am J Drug Alcohol Abuse. 2009;35(1):1-11.
6. Cai-Lian Cui, Liu-Zhen Wu, Yi-jing Li Chapter Twelve - Acupuncture for the Treatment of
Drug Addiction International Review of Neurobiology, 2013( 111), s235-256.
7. H. Upur and A. Yusup, The Theory of Mizaj and Hilit of Traditional Uighur Medicine Modern Study on Mizaj and Its Modern Study, Xinjiang Science and Technology Publishing
House, Xinjiang, China, 2003.
8. H. Upur, A. Yusup, A. Umar, and N. Moore. Uighur traditional medicine syndrome of abnormal savda in men is associated with oxidative stress, which can be improved by Munziq
and Mushil of abnormal savda. Therapie. 2004; 59(l4) . 483–484.
9. Amat N, Hoxur P, Ming D, Matsidik A, Kijjoa A, Upur H. Behavioral, neurochemical and
neuroendocrine effects of abnormal savda munziq in the chronic stress mice. Evid Based
Complement Alternat Med. 2012; 2012:426757. doi: 10.1155/2012/426757.
10. Wang X, Zhang A, Sun H, Wang P. Systems biology technologies enable personalized traditional Chinese medicine: a systematic review. Am J Chin Med. 2012; 40(6):1109-22
11. Shi J, Liu YL, Fang YX, Xu GZ, Zhai HF, Lu L. Traditional Chinese medicine in treatment
of opiate addiction. Acta Pharmacol Sin. 2006 Oct; 27(10):1303-8.
12. Li LJ, Xing XF, Shao HX. Preparation of traditional Chinese herbs on addiction detoxification: recent progress. Chin Med 2003; 34: 20-2.
13. Li SC, Li B, Cheng DG, Li F. Studies on treatment of traditional Chinese herbs on opiate
addiction. J Beijing Univ Tradit Chin Med 2005; 28: 84-8.
14. Liang Y, Cao HB, Mu JP, Wang JH. Recent progress of traditional Chinese herbs in opiate
addiction detoxification on clinical and experimental studies. Chin Mag Drug Abuse Prev
Treat 2003; 9: 40-5.
15. Cui CL, Wu LZ, Li YJ. Acupuncture for the treatment of drug addiction. Int Rev Neurobiol.
2013; 111:235-56.
16. Lu L, Liu Y, Zhu W, Shi J, Liu Y, Ling W, Kosten TR.. Traditional medicine in the treatment
of drug addiction. Am J Drug Alcohol Abuse. 2009; 35(1):1-11.
17. Yang CH, Lee BH, A possible mechanism underlying the effectiveness of acupuncture
in the treatment of drug addiction. Evid Based Complement Alternat Med. 2008 Sep;
5(3):257-66. doi: 10.1093ecam/nem081.
376
Nesrin Dilbaz*
Üsküdar University
ABSTRACT
This presentation provides an overview of neurobiology and treatment principles of drug addiction for individuals. An important part of
the reward system and the major structures are: the ventral tegmental area (VTA), the nucleus accumbens (nuc. acc.) and the prefrontal
cortex. Because of the way our brains are designed, and because these drugs activate this particular brain pathway for reward, they
have the ability to be abused.
Science has consistently documented that drug addiction is a chronic disease of the brain that affects behaviors. Addiction happens
in a social context and therefore environment plays a key role in the development, prevention, and treatment of this disease. As is the
case with many chronic diseases, relapse can occur. However, relapse does not mean that drug addiction cannot be treated or that
treatment has failed-rather it calls for a reinstatement of treatment and a long-term view to managing the disease.
Addiction treatment goals include promoting abstinence from drugs and increasing functionality in family, work, and community settings and reducing criminal behavior.
The impact of addiction on the brain and associated behaviors are long-lasting and complex. Recovery from drug addiction has two
key components: treatment and continuing care. Behavioral therapies will modify the attitudes and behaviors related to drug abuse,
and increase the addict’s life skills. Medications are now available to treat opioid, alcohol, and tobacco addictions. It is critical that
treatment services match the needs of the individual if treatment is to be successful.
* She completed her degree in medicine from the Faculty of Medicine at Hacettepe University in 1984 and was appointed as a psychiatrist to Nümune Training and Research Hospital in Ankara. In 1994 Dr. Dilbaz became an Associate Professor and appointed as Chief at
the Second Psychiatry Clinic in 1999 and together with the work she conducted on the extent and treatment of alcohol and substance
abuse she became the founding President of AMATEM in Ankara in 2004.
She retired from Ankara Nümune Hospital in and took a past in Uskudar University as psychiatry Professor at 1 February 2012 where
she is still working.
Dr. Dilbaz won the ECNP poster award for her work together with Dr. Cem Şengul on the Effects of Memantine on Alcohol Deprivation in
2005. She won the “One of the Best” award On Social Responsibility in 2007 for her work on protecting the youth in our country from
substance abuse and currently works on the Treatment Platform for Substance Dependence with the United Nations, the European
Union and the Council of Europe, Pompidou Group. After undertaking work at the national coordinatorship together with the Ministry of
Health and the United Nations on “The Profile of Substance Abuse Among 16-Year Old Lycee Students in Turkey,” Dr. Dilbaz was appointed ESPAD Coordinator in Turkey. She is a member of the National Coordination Council’s the National HIVAIDS Project and the National
Tobacco Council and the Substance Abuse Science Committee of the Ministry of Health since 2005.
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ADDICTION HEALTH PROBLEM? TREATMENT PRINCIPLES
Addiction Treatment
Addiction is a complex brain disease characterized by compulsive, at times uncontrollable, drug craving, seeking, and use that persist despite potentially devastating consequences. Addiction is also a developmental disease; that is, it usually starts in adolescence
or even childhood and can last a lifetime if untreated. Addiction has multiple components such as being a chronic disease of the brain that affects behavior. Addiction is a
brain disease that affects multiple brain circuits, including those involved in reward and
motivation, learning and memory, and inhibitory control over behavior. Environment
plays a key role in the development, prevention, and treatment of addiction. The chronic
nature of the disease means that relapsing to drug abuse is not only possible but likely,
with relapse rates similar to those for other well-characterized chronic medical illnesses
such as diabetes, hypertension, and asthma. The presence of co-occurring psychiatric disorders is the expectation rather than the
exception. Social issues such as friends, employment; social skills impact one’s ability to
abstain from substances. Recovery is based on hope, cultivation of a healthy self-esteem, and sense of control over one’s life. After a relapse, strive to use a person-centered,
strength-based approach that supports the patient’s commitment to change and self-determination.
Relapse is common during recovery from alcohol or substance abuse. It’s estimated that
>90% of patients will experience a relapse with 1 year of initiating abstinence.
After a relapse, patients often feel shame and guilt. They may be hesitant to talk about it
and may skip appointments. When a patient relapses, it is important to educate the patient and family about substance use disorders and the availability of treatment options.
It is also to important help the patient for establishing links to support systems needed
to foster recovery.
Anticipation It is important to assess precipitating events that led to the relapse and anticipate warning signs. Anticipating triggers such as stress, loss, relationship problems will
allow patients to be proactive in maintaining recovery.
Drug abuse treatment’s goal is promoting abstinence from drugs and increasing functionality in family, work, and community settings and reducing criminal behavior. According to studies, treatment reduces drug abuse and criminal activity by 40 to 60 percent
and increases employment by 40 percent. Addiction treatment must help the individual stop using drugs, maintain a drug-free lifestyle, and achieve productive functioning
in the family, at work, and in society. Drug abuse treatment is less expensive than not
treating addicts. Every $1 invested in addiction treatment programs yields up to $7 in
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savings.
Treatment and continuing care are very important factors for recovery from drug addiction. Because addiction is typically a chronic disease, people cannot simply stop using
drugs for a few days and be cured. Most patients require long-term or repeated episodes
of care to achieve the ultimate goal of sustained abstinence and recovery of their lives.
Motivational enhancement therapies and Behavioral therapies can engage people in treatment, modify their attitudes and behaviors related to drug abuse, increase their life
skills and increase the adherence of patient.
Principles of effective treatment:
•
Addiction is a complex but treatable disease that affects brain function and behavior.
•
No single treatment is appropriate for everyone.
•
Treatment needs to be readily available.
•
Effective treatment attends to multiple needs of the individual, not just his or her
drug abuse.
•
Remaining in treatment for an adequate period of time is critical.
•
Counseling—individual and/or group—and other behavioral therapies are the
most commonly used forms of drug abuse treatment.
•
Medications are an important element of treatment for many patients, especially
when combined with counseling and other behavioral therapies.
•
An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs.
•
Many drug–addicted individuals also have other mental disorders.
•
Medically assisted detoxification is only the first stage of addiction treatment and
by itself does little to change long–term drug abuse.
•
Treatment does not need to be voluntary to be effective.
•
Drug use during treatment must be monitored continuously, as lapses during treatment do occur.
•
Treatment programs should assess patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted
risk–reduction counseling to help patients modify or change behaviors that place
them at risk of contracting or spreading infectious diseases.
Recovery from Substance Use Disorders” is a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full
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ADDICTION HEALTH PROBLEM? TREATMENT PRINCIPLES
potential. Furthermore, SAMHSA has delineated four major dimensions that support
a life in recovery:
•
Health: overcoming or managing one’s disease(s) as well as living in a physically
and emotionally healthy way;
•
Home: a stable and safe place to live;
•
Purpose: meaningful daily activities, such as a job, school, volunteerism, family
caretaking, or creative endeavors, and the independence, income and resources to
participate in society; and
•
Community: relationships and social networks that provide support, friendship,
love, and hope.
380
REFERENCES:
1. Carroll KM, Onken LS. Behavioral therapies for drug abuse. The American Journal of Psychiatry. 168(8):1452–1460, 2005.
2. Christensen RC, Byrd JC. How to approach your patients relapse. Current Psychiatry. 2010;
52.
3. Goldstein RZ, Volkow ND. Drug Addiction and Its Underlying Neurobiological Basis:
Neuroimaging Evidence for the Involvement of the Frontal Cortex. Am J Psychiatry. 2002;
159:1642-165.
4. Hales RE, Yudofsky SC. Essentials of clinical psychiatry. 2nd ed. Arlington, VA: American
Psychiatric Publishing Inc.; 2004:149.
5. Miller WR, Yahne CE and Tonigan JS. Motivational interviewing in drug abuse services:
A randomized trial. Journal of Consulting and Clinical Psychology. 2003; 71(4):754–763.
Drugs, Brains, and Behavior: The Science of Addiction (Reprinted 2010). NIH Publication
#10–5605.
6. Seeking Drug Abuse Treatment: Know What To Ask (2011) NIH Publication #12-7764.
7. Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-Based
Guide (Revised 2012NIH Publication No.: 11-5316.
8. NIDA Drug Facts: Treatment Approaches for Drug Addiction (Revised 2008).
9. NIDA Drug Facts. September 2009.
381
INTERVENTION, RECOVERY AND REHABILITATION
382
Nijole Gostautaite Midttun*
Lithuanian University of Health Sciences, Faculty of Public Health,
Department of Health Psychology, Kaunas, Lithuania
Mental Health Initiative, Vilnius, Lithuania
Lithuanian Coalition for Tobacco and Alcohol Control
Aurelija Cepulyte
State Mental Health Center
Vaida Liutkute
Lithuanian Coalition for Tobacco and Alcohol Control
Lithuanian University of Health Sciences, Faculty of Public Health,
Health Research Institute, Kaunas, Lithuani
ABSTRACT
Lithuania has a well-developed network of services for persons with addictions, including children. Levels of experimentation with
illegal substances among underage population are similar to other European countries, while level of alcohol consumption is relatively
high - Lithuania is the third heaviest drinking country in the world (15.4 litres per capita). At the same time amount of services provided
to children consuming both legal and illegal psychoactive substances is very small. The aims of this study were to assess accessibility of
addiction services to the children consuming both legal and illegal psychoactive substances. Review of the epidemiological and service
provision data was combined with client (child), carer (parent or institutional representative) and service provider surveys. 46 children
(under 18) who have received addiction services, 46 carers and 80 specialists involved in the addiction service delivery for the children
completed structured surveys. In 79 % of cases service was provided due to alcohol (alone or in combination with another substance)
and in 21 % due to illegal psychoactive substance. Waiting time after initiation of the contact with the service was approximately 1 week.
The overall satisfaction with services and service accessibility was high, however nearly none of the cases has reached the service via
school or health system referrals. The study concluded that accessibility of the services for those who seek them is very high, but small
number of delivered services indicates that significant improvements in information and referral systems regarding those services
need to be implemented. Keywords: accessibility, addiction services, children, psychoactive substances
*Medical doctor, psychiatrist and health psychologist, psychotherapist and advocate for public mental health in Lithuania. The main
interests are mental health care system and service development, patient rights, health education and advocacy, alcohol and tobacco
control. Board member of the Lithuanian Psychiatric Association 1998-2013, Lithuanian Neurosciences Association since 2009, Lithuanian Coalition for Tobacco and Alcohol Control since 2011, editor of the Lithuanian Psychiatric Association Journal 2000-2011.
Over 20 years’ experience in collaborating with NGOs in mental health, building organizations and networks. Involved in alcohol advertising control advocacy in Lithuania.
Experienced trainer and lecturer, academic and in-service teaching positions, extensive involvement in training health specialists.
Research projects focused on quality of life and mental illnesses and service development.
383
ACCESSIBILITY CHALLENGES IN DELIVERING ADDICTION SERVICES TO CHILDREN IN LITHUANIA
Accessibility Challenges in Delivering
Addiction Services to Children in Lithuania
Background Epidemiology of substance use and abuse among children in Lithuania is similar to the
European average. Levels of experimentation with illegal substances among children
under 18 in Lithuania are comparable to their peers in other European countries. ESPAD 2011 report has shown that lifetime cannabis use among 15-16 year old students in
Lithuania is 20 %, while European average is 17 %, alcohol use in the past 30 days was 63
% (European average is 57 %) (1).
According to the survey performed by the governmental Drug, Tobacco and Alcohol
Control Department in 2012, consumption of tobacco and alcohol decreased among
adolescents, but self-reported consumption of illicit drugs during past 30 days has remained stable: illegal drugs (other than cannabis) were used by 2.1 % of 15-17 year
old student population. The most popular illicit drug among adolescents was cannabis.
Cannabis intake during past 30 days among 15-17 years old boys slightly increased from
2008 to 2012 (2).
In Lithuania data about mental and conduct disorders associated with substance abuse is
collected, analysed and evaluated based on statistical data collection by health care institutions (3). There is a well-developed network of health care institutions which provide
addiction services to clients, including children, yet the statistically recorded number of
services provided to children continues to be very small. According to the State Mental
Health Center, the number of children receiving services due to use of psychoactive
substances increased from 17 cases in 2009 to 29 cases in 2012 in absolute numbers. In
2012 more children received treatment from drugs and use of psychoactive substances:
48.1 % of mental and conduct disorders caused by the use of psychoactive substances
among children were caused by the use of alcohol, while 51.9 % by the use of illegal psychoactive substances. Assessing services provided to children with mental and conduct
disorders related to use of alcohol increased, while services received due to illegal drugs
and psychotropic substances decreased in 2008 - 2012 period (5).
In 2012 number of new cases of mental health and conduct disorders in children due
to use of psychoactive substances has increased compared to the period of 2009-2011.
In the past five years the highest number of new cases (n=18) was diagnosed in 2008.
Overall, more new cases of mental and conduct disorders due to use of drugs and psychoactive substances were diagnosed. The highest incidence of mental and conduct
disorders due to use of alcohol were in 2008 (n=8), while in the period of 2009 – 2010,
384
no cases were reported (5, 6).
Most cases of the mental and conduct disorder were reported from opioid use (F11). In
2012 there were 9 cases diagnosed, compared to 4 cases in 2008 (5, 6).
The official records confirm that there were many more children who received inpatient than outpatient services. In 2010 – 2011 seventy (n=70) children were hospitalized
due to disorders related to psychoactive substance use. In 2012 hospitalizations due to
psychoactive substance use among children rose by 18.6 %. Depending on type of psychoactive substance, 56.1 % (n=32) received treatment due to the mental and conduct
disorders related to use of alcohol (F10); 17.5 % (n=10) were hospitalized due to cannabinoid use (F12); 15.7 % (n=9) – due to use of several drugs and other psychoactive
substance use (F19). In 2011-2012 number of hospitalized children due to opioid use,
multi-drug use and other psychoactive substance use (F19) has decreased. The number
of children hospitalized due to use of cannabinoids increased from 1 case in 2008 to 10
children in 2012 (5, 6).
Comparison of the epidemiological data to the governmental statistical information on
addiction services provided to children under 18 due to use of psychoactive substances
reveals that the use of psychoactive substances is widespread, with the most common
psychoactive drugs being alcohol and tobacco. At the same time amount of services
provided to children remains unrealistically low.
Aim
The aim of this study was to assess accessibility of addiction services to the children
consuming both legal and illegal psychoactive substances and identify potential barriers
for service accessibility.
Method
Structured analogous questionnaires were provided to 3 groups of respondents: underage (under 18) clients of addiction services, who were receiving services due to use of
alcohol or illegal psychoactive substances (n=46), their legal carers (parents or institutional representatives, n=46), and a group of addiction service specialists providing services (n=80). Respondent groups were constructed based on the results of the screening
of the health care institutions, identifying those which had clients under age of 18, with
the diagnostic ICD-codes F10-19 entered into state statistical data collection system.
Specialists who had directly provided services were interviewed and their clients, whose
custodians consented and who received services 2011-2012 were surveyed. Specialists
from the institutions, identified as providing mental health services to children due to
psychoactive substance use, were also surveyed (n=80). Original questionnaires were
constructed focusing on the organizational accessibility, satisfaction with services and
385
effectiveness of the services. First questionnaire including 26 questions was delivered to
children and their carers receiving services, and the second questionnaire, including 15
questions was delivered to the service providing mental health specialists. Data collection and analysis were separated; investigators had access only to fully anonymous data.
Available epidemiological data from large population based studies was compared to the
official statistical service provision information.
Findings
Accessibility as reflected by the referral characteristics. Most parents and carers contact addiction services deliberately, consciously understanding that the child uses psychoactive substances (80.4 %) (Table 1). Only 8.7 % of parents and carers approached the services due to a
suspicion of mental disorder.
Meanwhile, responding specialists have noted that one of the most common reasons for referral are behavioural, social problems and problems at school (17.5 %). Specialists have also
emphasized that the majority of the children contact addiction services based on the decision
of the parent or carer: estimated 72.5 % of children are brought to the services by the carer.
386
Type of problem/complaint
Parents/guardians
Specialists
N
%
N
%
Use of psychoactive substances
(alcohol, tobacco, drugs,
sedatives, medication, etc.)
37
80.4
4
5
Symptoms of mental disorders
(delusions, anxiety, depression)
4
8.7
4
5
School, social problems,
behavioural problems
5
10.9
14
17.5
Children are brought in by their
parents/guardians, they do not
contact services themselves
-
-
Total
46
100
80
100
Table 1. Results: reasons for contacting addiction services
Survey of legal carers (parents or institutional representatives) has shown that main reasons for contact with the services were the use of alcohol alone or in combination with
other substances, followed by the tobacco use and cannabinoid use.
Table 2 presents responses of carers (parents and institutional representatives) regarding the reasons for contacting the services by substance. Survey showed that carers and
children opinions regarding identification of the problem substance were very similar:
the main reasons for contacting addiction services were alcohol, tobacco and cannabis
use, and in much fewer cases - illicit drugs and prescription drugs.
Reasons for Children:
contacting consumed
service –
substance
carers
Psychoactive
substance
N
Reason for
contacting
service –
children
Averages
analysis
N
X
46
Averages
analysis
N
Averages
analysis
X
0.76
Sx
0.064
Sx
46 0.61 0.073
Alcohol
37
0.76
Sx
0.072
X
Tobacco
36
0.44
0.084
46
0.54
0.074
46 0.43 0.074
Cannabis
37
0.35
0.065
46
0.17
0.057
46 0.32 0.057
Anxiolytics
37
0.05
0.038
46
0.04
0.030
46 0.02 0.022
Sedatives
37
0.03
0.027
46
0.02
0.022
46 0.02 0.022
Amphetamines
37
0.05
0.038
46
0.04
0.030
46 0.02 0.022
Opioids
37
0.03
0.027
46
-
-
46 -
Glue/inhalants
-
-
-
-
0.02
0.022
-
-
0.02 0.022
Table 2. Results: reasons for contacting the services (by substance)
387
Although there are no cases reported in the official statistics of the prevalence of the
disorders among children due to use of prescription drugs (sedatives, anxiolytics), this
survey has revealed that some children and carers have identified abuse of prescription
drugs as the reason for contacting services. Use of glue/inhalants was not mentioned by
any carer, but entered as a response of one child receiving services.
The longer is the period of psychoactive substance use, the greater the risk of the harmful
use and addiction. Therefore, a very important aspect of the accessibility to the services
is early detection of abuse problems and short waiting time before entering treatment.
Duration of the period between identifying the abuse problem and contacting the services and duration of the period between contacting the addiction services and actual
entrance into services was identified by carers (parents and institutional representatives)
and specialists. Average duration of the deliberation and waiting time reported was quite
similar: carers identified average of 18 weeks duration for the deliberation period and
specialists - 21 weeks, while the waiting time between contact and receiving the service –
carers identified on average as less than one week, and specialists as 2 weeks on average.
It is important to note that even when the problem of substance use is identified, there is
delay in contacting services, so the deliberation period is quite long, but once the contact
has been made, the services are provided very quickly and in this respect services are
very accessible.
Q
Carers
assessment average (n=46)
Specialist assessment
average (n=80)
Sx
X
X
Sx
After how many weeks, after it was clear
to you that the child has problems due to
use of psychoactive substances did you
contact the mental health care specialist*
17.91
4239
207
2275
After how many weeks after the initial
contact with mental health services the
child was provided services needed.
0922
00438
156
0184
Table 3. Results: access to service
Table 4 provides results for the responses regarding referrals and contacting the services:
in the majority of cases (64.1 %) carers (parents and institutional representatives) contacted the services on behalf of the child client (% of responses “very often” and “almost
always”). Very low number of referrals was initiated by GP (family doctor) or school and
social services specialists. Specialists providing services more often than carers indicated
that children are referred by a family doctor, social services, children right protection
agencies or school specialists.
388
Carers
(n=46)
Specialist
assessment
average (n=80)
“very often” and
“almost always”
“never” and
“rarely”
N
%
%
%
Contacted ourselves, we saw it
as a possible solution
29
63
64.1
13.8
Suggested and referred by the
family doctor/GP
1
2.2
19.7
65.8
school specialists
6
13.0
26.8
52.3
social services and or child
protection agencies
8
17.4
28
49.3
Referred by the legal system
2
4.4
-
-
Contacted because we were
urged by acquaintances or
family members
0
0
-
-
Total
46
100
-
-
Table 4. Results: referrals and contacting the services
In this assessment of addiction services accessibility for children extent and intensity of
abuse at the time of contact was also assessed. This helps to better understand perceptions of those in need for services: do they contact the services when the abuse problems
become very serious or do they contact services also in more trivial cases (regarding early signs of abuse, need of advice and in case of experimentation). The survey results have
shown that carers who contacted the services on average perceived that use of psychoactive substance by the child was of high intensity and troublesome, meanwhile service
providing specialists assessed more clients contacting the services as experiencing low
intensity of psychoactive substance use.
The results of analysis show that carers who contact mental health care services believe
that problems of psychoactive substance use of their children are very intense: 71.7 %
defined intensity of use by 8-10 points (scale between 0-10). The average assessment
of use intensity by carers (parent or institutional representative) was 8.2 points, while
assessment of amount of troubles caused by the use was 8.76 (scale between 0-10). Differently from carers 75.8 % of responding specialists noted that they consult and advise
more children whose intensity of psychoactive substance use is up to 5 points. Average
rating was 4.16 points and more children counselled by them use psychoactive substances episodically. 35.6 % of specialists identified hazardous use (at least once a week and
389
daily) as a most usual reason for provision of services.
Satisfaction with services by carers and children
The assessment of satisfaction with services among carers and children who received
services is provided in the Table 5. Overall satisfaction assessment is very high. Largest
differences between assessments by the children receiving services and their carers (parents or institutional representatives) are in regard to the following aspects of services:
how fast was the service provided (carers were more satisfied), positive outcome of the
service (children were more satisfied), effectiveness of the service (children were more
satisfied). The lowest satisfaction was with the support of the referring institution. 100
% of custodians and 95.6 % of children receiving services have reported full satisfaction
with service accessibility.
Service characteristics
Fully satisfied Fully agree
and satisfied and agree
Responsible
adults
Children
Specialists
N
%
N
%
N
%
How fast
46
100
40
87
69
85.5
How long
41
89.1
43
93.5
69
69.6
Specialist communication
44
95.7
46
100
69
72.5
Amount of information
43
93.5
45
97.8
69
89.8
Clarity of information
42
91.3
42
91.3
68
88.2
Positive outcome of the service
32
69.5
36
78.3
68
48.5
How easy to use the service
44
95.7
44
95.6
68
66.2
How effective is the service
33
71.7
37
80.4
68
50
Table 5. Satisfaction with service characteristics
Assessment of the service effectiveness
Carers and children had separately assessed difference in intensity and frequency psychoactive substance use before and after services, as well as difficulties and problems
related to the substance use and abuse. The results of these assessments are provided in
the Table 6. Significant changes were observed: 32.6 % of carers report after receiving
the service that the child does not use psychoactive substance, and 41.3 % of respondent
children report ending use of psychoactive substance. 47.8 % of children and carers reported reduced use of psychoactive substance, while no change is reported by smaller
number of children.
390
Carers
Children
N
%
32.6
19
41.3
22
47.8
22
47.8
No change, consumption as before
9
19.6
5
10.9
Total
46
100.0
46
100.0
N
%
Stopped using, problem solved
15
Uses less than before
Table 6. Results: effectiveness of the services
Important to note that after receiving services there was a significant reduction of perceived problems and difficulties related to substance abuse, as well as, as intensity of
consumption as assessed by carers had been reduced from average 8.2 before the service
delivery, to 2.59 after the child received the service.
Summary of the Results and Recommendations
•
Consumption of psychoactive substances in Lithuania is widespread, yet number
of actual services provided is very small;
•
Clients assessment of overall accessibility and different aspects of it have been rated very high: the results show high satisfaction with accessibility of the service of
those who received the services, and very brief time from contacting the services
to actual service provision (less than 1 week);
•
Specialists providing addiction service also assess the accessibility of the services
as good: 76.4 % agree that services are accessible, and 72.6 % agree that services
are accessible to majority in need as well as a low waiting time (little more than a
week);
•
Too few referrals are done through the systems directly responsible for the health
and welfare of the children.
Recommendations
1. There is a need for an efficient system of referrals for children – GPs (family doctors)
and schools in particular should be more attentive to needs of the children for addiction
services.
2. More efforts should be devoted to reducing stigma of the referral and entering of the
service, with the goal of reducing the period between identification of the use and contacting the services.
3. The main target group for increasing service provision is parents and carers; they
should have access to easy advice regarding availability of services.
391
REFERENCES:
1. Hibell, B., Guttormsson, U., Ahlström, S., Balakireva, O., Bjarnason, T., Kokkevi, A. and
Kraus, L. The 2011 ESPAD report. Substance use among students in 36 European countries. The Swedish Council for Information on Alcohol and Other Drugs. Stockholm,
Sweden: 2012.
2. Psichoaktyviųjų medžiagų vartojimo paplitimas Lietuvoje 2004, 2008 ir 2012 m. Narkotikų,
tabako ir alkoholio kontrolės departamentas. Vilnius: Europos narkotikų ir narkomanijos
stebėsenos centras. 2013. [accessed 2014 Sep 29] Available from: http://www.ntakd.lt/files/
Apklausos_ir_tyrimai/2012_Psichoaktyv_medz_paplitimas_WEB.pdf
3. Goštautaitė Midttun, N., Goštautas, A., Čepulytė, A. Sveikatos priežiūros paslaugų prieinamumas psichotropines medžiagas vartojantiems vaikams Lietuvos psichikos sveikatos
priežiūros įstaigose. Vilnius: 2013. [accessed 2014 Oct 1] Available from: http://ntakd.lt/
files/statistika/tyrimai/2014/2014_vaikams.pdf.
4. ESPAD-2011 Country report (Lithuania). [accessed 2014 Oct 1] Available from: [http://
www.ntakd.lt/files/Apklausos_ir_tyrimai/ESPAD_2011_ataskaita_SMM.pdf]
5. Statistical database of the State Mental Health Center. [accessed 2014 Sep 5] Available from:
www.vpsc.lt.
6. Statistical database of the State Information Center. [accessed 2014 Sep 5] Available from:
www.hi.lt.
392
Peter Sarosi*
Hungarian Civil Liberties Union (HCLU)
Eurasian Harm Reduction Network (EHRN)
ABSTRACT
NGOs play a key role in providing harm reduction services in Europe. In recent years these NGOs face significant barriers in many countries: the financial crisis hit public health and social services the most. There is a growing need among harm reduction NGOs for more
effective advocacy efforts to bridge the funding gap and protect the human rights of their clients. Several international and national
initiatives can be presented to provide good examples.
The Eurasian Harm Reduction Network (EHRN) initiated a large, targeted advocacy campaign that seeks to promote and facilitate the
adequate funding for harm reduction on both the national and regional levels in Eastern-Europe and Central-Asia. The “Harm Reduction
Works-Fund It!” regional program, funded by the Global Fund, was launched in April and supports national level advocacy programs
targeting governments in Belarus, Georgia, Moldova, Kazakhstan and Tajikistan.
The Drugreporter program has been created by the Hungarian Civil Liberties Union (HCLU) to provide innovative methods and technical
assistance to other NGOs to advocate for the human rights of drug users and a greater access to services. Video advocacy is such an
effective tool; our video advocacy program has produced hundreds of short videos that can reach out a significant number of people
through video sharing websites. The Drugreporter organizes trainings for professionals and activists to produce videos and make the
best use of the mainstream media.
* Peter Sarosi is the Drug Policy Program Director of the Hungarian Civil Liberties Union (HCLU), a human rights NGO based in Budapest.
He is the editor of the Drugreporter website (drugreporter.net) and the director of hundreds of short online documentaries on various
issues of drug policy.
He is the Co-Chair of the Eurasian Harm Reduction Network (EHRN) and the Core Group Member of the Civil Society Forum on Drugs, an
expert group of the European Commission.
393
ADVOCACY FOR HARM REDUCTION: BRIDGING THE GAPS
Advocacy for Harm Reduction:
Bridging the Gaps
The Harm Reduction Funding Gap
Although HIV infections and deaths from AIDS are decreasing, the world cannot achieve the UNAIDS target to end AIDS by 2030 if harm reduction programs are not scaled
up among one of the most vulnerable populations, injecting drug users (IDUs). While
HIV is decreasing in the general population, it is still increasing (1) among IDUs. The
sharing of injecting equipment among the estimated 16 million injecting drug users account for an estimated 10 percent of HIV infections in the world (2).
As early as in 1997, a global survey (3) found a significant decrease in HIV prevalence
among IDUs in cities with needle exchange program and a significant increase in cities
without needle exchange. In Eastern-Europe and Central Asia, where the prevalence
of injecting drug use is high but access to harm reduction programs is low, is the only
region in the world where HIV continues to increase, largely driven by the sharing of
injecting equipment. Investment in harm reduction is proven to reduce HIV transmissions among IDUs.
It is estimated (4) that globally 10 million IDUs live with the hepatitis C virus, often
dubbed as the silent epidemic because of the lack of awareness on its dangers. Among
marginalized populations it can reach 80-90 percent even in Central Europe. There are
significant barriers (5) of access to HCV treatment of IDUs. Punitive drug policies have
negative impact (6) on the hepatitis C epidemic among IDUs.
Harm reduction programs have been significantly scaled up in the first decade of the
21st century. In 2003, a total of 213 NSPs reportedly (7) existed across 25 Eastern-Europe and Central Asia countries, and just seven years later there were more than eight
times that number in Ukraine alone. The vast majority of harm reduction programs in
Eastern-Europe and Central-Asia have been funded by international donors, such as the
Global Fund to Fight AIDS, Malaria and Tuberculosis. From 2002 to 2009, the Global
Fund approved $263 million (8) for harm reduction in Eastern-Europe and Central-Asia
alone —more than all other international sources combined.
There is a significant gap between funding required and funding needed. It is estimated
(9) that only two sterile needles are distributed per injecting drug users per month, only
8 percent of IDUs access opiate substitution treatment and only 4 percent of IDUs have
access to antiretroviral drugs. The UNAIDS estimates that 2.3 billion USD is required to
fund HIV prevention programs among injecting drug users but only 160 million USD is
actually invested, approximately 7 percent of what is required. This situation is likely to
394
get worse. International donors are now retreating from the region because they reallocate resource from middle-income countries to low-income countries. The Global Fund
has recently changed its funding policies and introduced a New Funding Model, which
allocates resources to countries based on their income level. This means that middle income countries with a great number of injecting drug users will no longer be a priority
for the Global Fund. In most middle income countries national governments do not
provide any funding for harm reduction. Repressive drug law enforcement contributes
(10) to the risk of HIV infections among IDUs. In Odessa for example, a research (11)
estimated that 19 percent of new HIV infections could be avoided if arrests of drug users
by the police was halted.
Harm reduction services, especially needle and syringe programs, are primarily designed and provided by NGOs that are largely dependent on international donors. With
the retreat of international donors, advocacy plays a key role in diversifying funding resources and gaining political support. The following chapters will discuss some examples
of advocacy campaigns for harm reduction targeting international, national and local
decision makers.
“Harm Reduction Works – Fund It!” campaign
The Eurasian Harm Reduction Network (EHRN) was founded in 1997 (12), soon after
the dramatic increase in injecting drug use and the emergence of the HIV epidemic
across the region. EHRN now unites over 500 institutional and individual members,
tapping into a wealth of regional best practices, as well as expertise and resources in
harm reduction, drug policy reform, HIV/AIDS, TB, HCV, and overdose prevention.
All EHRN members contribute to advocacy efforts, technical assistance and information-sharing aimed at achieving EHRN’s three main objectives:
Reforming governmental and legal policies related to drug use and harm reduction
Building capacity for quality harm reduction services that meet the needs of people who
use drugs
Increasing funding for harm reduction, especially from domestic sources
The Regional Program “Harm Reduction Works – Fund It!” was prepared (13) in response to an invitation from the Global Fund to Fight AIDS, Tuberculosis and Malaria (the
Global Fund) to the EHRN to participate as an early applicant under the New Funding
Model. The goal and objectives target reducing the HIV epidemic in Eastern Europe and
Central Asia through improved advocacy for harm reduction. Strengthening of community systems for people who use drugs, including those living with HIV, is a critical area
of focus within this program.
The campaign has two objectives. The first objective is to build an enabling environment
395
for sufficient, strategic and sustainable public and donors’ investments in harm reduction (HR). The second objective is to develop the capacity of the community of people
who use drugs to advocate for availability and sustainability of harm reduction services
that meet their needs. The campaign has a 6 million USD budget for three years (201417). The national level elements of the project are implemented in Belarus, Georgia,
Kazakhstan, Moldova and Tajikistan, in strong cooperation with the 5 national harm
reduction networks (as sub-recipients of grants).
The campaign provides minigrants to groups of communities of people who use drugs to
strengthen their advocacy efforts in the national and local level. One of the key partners
of the EHRN to implement the campaign is the Eurasian Network of People Who Use
Drugs (ENPUD), an umbrella organization of drug user and OST patient groups and
activists from 13 countries of the region.
EHRN organized a high level Regional Forum (14) on healthcare and human rights of
people who use drugs. The forum took place in Chisinau (Moldova) on 19 - 20 May,
2014. The Forum was attended by over 150 participants. During the two days of sessions, social integration, human rights and access to healthcare for people who use drugs
were discussed, with a focus on the issue of transitioning from international to national
funding for health and social services. This was a unique opportunity for harm reduction service providers, national and international experts in public health, health finance
and human rights, people who use drugs, and high level officials and decision makers to
meet face-to-face and jointly discuss the most important issues in the region and ways
forward. This report provides overview of the Forum and its outcomes.
Police abuse against women who use drugs has been identified as one of the biggest
challenges in the region. A special campaign, Women Against Violence was launched
to address this issue. The campaign aims to empower women to break the silence as the
first step to end violence. An online map (15) was developed to feature the personal stories of women who fell victim to police abuse.
European Drug Policy Initiative
The Hungarian Civil Liberties Union (HCLU) is a human rights watchdog NGO promoting harm reduction. It launched the European Drug Policy Initiative (EDPI) to
strengthen harm reduction advocacy in Central- and Southern-Europe by conducting
research, working with the media, organizing joint campaigns and producing films for
change (16). Our website, Drugreporter is a regional news hub for drug policy related
news. We built an online video database (17) with hundreds of films distributed through
video sharing websites, such as YouTube and Vimeo. Most of our videos are subtitled in
several European languages. In cooperation with local NGOs we produce films to document human rights abuses, to educate the public about innovations in harm reduction,
396
to make international events more transparent and to mobilize people for a cause. The
EDPI project has identified two worrying trends in the region: the changing patterns of
drug use and risk behavior and the reduction in funding for harm reduction.
One of the key partners of the EDPI project is the Bulgarian NGO the Initiative for Health Foundation, the first NGO to have introduced harm reduction services in Bulgaria.
The Drugreporter video advocacy team traveled to Sofia in 2012 to produce two movies
(18): one on government plans to make drug laws more restrictive, the other on the pioneering work of the Initiative with street drug users. Bulgaria has one of the harshest
drug policies in the European Union: Possession of any quantity of illegal drugs is a
crime, punishable by one to five years’ imprisonment. According to current legislation,
the judge has discretion to punish minor offenders with a fine. In a country of 8 million
inhabitants, 800 people are imprisoned every year because of drug-related charges. Prisons are not a way of keeping people away of drugs. According to estimates by the prison
authorities, more than 20 percent of the prison population are dependent on drugs – and
many of them develop problematic use patterns only after being put in prison. Treatment opportunities are very limited in the country due to scarce financial resources;
many services that are now commonplace in Western-Europe are still not available here.
The government has drafted an amendment to the Criminal Code that would result in
increasing sanctions against people who use drugs. A domestic and international petition campaign was initiated to oppose the draft bill, which has been recently withdrawn
by the government.
In the year 2000, Poland amended its criminal legislation on drug possession. As a result,
any person possessing even the smallest amount of an illegal substance was liable to be
prosecuted (19). There were two assumptions behind this amendment: first, it is more
difficult to catch the dealers if they can carry small amounts of drugs on them; second, if
you cannot catch the small retail users and dealers, it is impossible to arrest the big bosses of drug trafficking gangs. Since the amendment in 2000, the number of drug-related
offences has been increasing steadily. In 2006 there were more than 70,000 drug-related
criminal offences reported, and most of them were instances of personal possession.
There has also been an upward trend in the amount of illicit drugs seized by the police.
The enforcement of Art. 62 of the drug law (the article criminalizing drug users) costs
tax payers an estimated 80 million PLN (20 million EUR) every year as well as an estimated 1.5 million working hours for law enforcement officials each year. However, the
stringent punitive measures of Art. 62 have not yielded the positive results that were
expected. The size of the illicit drug market has not been reduced over the past ten years,
and drugs are more available now than they ever were in Poland. There is also a severe
unintended consequence: tens of thousands of young people have been sentenced to
prison, and many of them have actually been incarcerated – resulting in broken careers,
families and lives.
397
The Polish Drug Policy Foundation, in cooperation with the Drugreporter, launched a
campaign to support an amendment of the drug law aiming to depenalize drug use in
April 2011. As part of this campaign, the Drugreporter produced a documentary movie
(20) to raise awareness on this issue and several small campaign clips to mobilize Polish
citizens to support the campaign. The movie was viewed by more than 50.000 people in
a few weeks and more than 60.000 people joined the initiative on social media (21).
In April 2011, the Polish Parliament (Sejm) amended the drug law in order to give discretion to prosecutors in deciding whether to prosecute small scale drug offenders. This
was a very small step forward, and we could hardly call it decriminalization, but the bill
is facing fierce opposition from Conservative MPs who claimed this law will “legalize
drugs” and send the wrong message to young people. The Polish Drug Policy Network
sent the DVD-version of this movie as part of a comprehensive package to all members
of the Senate. The amendment was successfully adopted by the Senate and signed by the
president.
According to a study (22) conducted by the Hungarian Civil Liberties Union (HCLU)
in 6 European countries in 2013, new psychoactive substances (NPS) use is a significant
challenge to public health and social care systems. Policy responses of government are
primarily focusing on legislation and law enforcement. Professionals interviewed reported the lack of prevention, treatment and harm reduction measures addressing NPS
users. The growing injecting use of NPS in Romania and Hungary contributed significantly to more frequent and risky injection practices among IDUs. While heroin use
has been declining in Europe for several years, many IDUs switched from heroin to new
stimulants, such as amphetamines and cathinones. These drugs are injected more frequently (ten-fifteen times a day) than heroin (three-four times a day). Unlike heroin, new
stimulants do not need preparations such as cooking, so they can be injected faster, in
less safe and hygienic environments.
HIV prevalence in Central- and Southern-Europe has always been relatively low among
injecting drug users compared to Eastern-Europe and Central Asia. This situation is now
changing, even within the European Union. The EMCDDA and ECDC reported (23)
that new outbreaks of HIV were occurring in Greece and Romania despite an overall
long-term declining trend in newly diagnosed HIV cases among IDUs in Europe. HIV
among IDUs has been steadily increasing in Bulgaria (24) in the past 5 years. NGOs
reported an increasing trend in HIV cases among IDUs in Hungary as well, where the
outbreak of the HIV epidemic has not yet been confirmed by official sources by September 2014 (25).
Beside the changing drug market and injecting practices, the outbreak of HIV has been
associated with reduced access to harm reduction services. During the last decade efforts
to reduce HIV prevalence among drug users in Romania, including needle exchange,
were funded almost entirely by international organizations such as the European Union,
398
United Nations and Global Fund to Fight AIDS, Tuberculosis and Malaria, despite it
being the responsibility of the Romanian government to provide public health services
for its citizens. Since 2010 financial support from international organizations was drastically reduced, forcing 4 out of 6 organizations providing needle exchange and opioid
substitution treatment in Romania to shut down. This resulted in a severe reduction in
the number of vulnerable people who have access to essential services and a sharp increase in HIV infections.
Although causal relationship is difficult to prove, the outbreak of HIV was preceded by
a drop in the provision of sterile injecting equipment both in Greece and in Romania.
In Romania (26), the number of sterile needles and syringes reduced the number of
respondents who report having used a syringe exchange programme decreased from
76% in 2009 to 49% in 2010. Furthermore, a reduction in numbers of distributed sterile syringes was reported from 1.7 million in 2009 to 965 000 in 2010. The correlation
between the shortage in sterile injecting equipment and the outbreak of HIV is even
more convincing if we examine the data from the Romanian penitentiary system. According to the data of the National Administration of Penitentiaries (27) the number
of sterile needles and syringes distributed in Romanian prisons dropped from 18,383
to 3,000 between 2010 and 2012. In the same period, the annual number of new HIV
infections increased from 76 to 194.
The HCLU’s Drugreporter, in cooperation with the Romanian Harm Reduction Network,
organized a campaign to raise awareness on the need to prevent HIV infections among
drug users and to mobilize people to ask the government to provide adequate funding
for harm reduction programs. A documentary movie (28) was filmed in March 2013
in Bucharest, key informants from the government, service providers, law enforcement
agencies and affected communities were interviewed. The movie featured the lives of
homeless street drug users who live in the canalization system of the capital, escaping
from the cold seasons. The movie asked people to sign the AVAZ petition urging the
prime minister and the health minister of Romania to support harm reduction initiatives. The film was screened and discussed (29) at a hearing of the European Parliament
in Brussels.
Another partner in the EDPI is the Serbian NGO ReGeneracija, providing street outreach services for young people on the streets of Belgrade. In September 2013 the Drugreporter video team visited the country and produced a movie (30) about the impact the
ending of Global Fund grants has on harm reduction services. Serbia is a country at the
crossroads of a number of heroin trafficking routes. It has a significant injecting drug
user population, many of them belonging to a marginalized ethnic minority, the Roma.
Thanks to grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria, several harm reduction services were introduced into Serbia during the first decade of this
century. There are approximately two thousand people enrolled in opiate substitution
399
programs, and four NSPs (needle and syringe programs) provide sterile equipment to
injecting drug users. The prevalence of HIV among drug users has so far remained low
– the best indicator of risk being the high prevalence of Hepatitis C infections. Hopes,
on the part of service providers, that programs can be scaled up, seem to be going up in
smoke: the country is not eligible for any more money from the Global Fund, and the
last grant ended in June.
Harm reduction programs face an uncertain future in several European countries. International donors are retreating or changing their funding policies. National governments
have made no commitment to continue funding and allocate their resources on often
ineffective law enforcement interventions instead. Public health and social services are
often the first victims of financial austerity measures. NGOs need to improve their advocacy efforts to diversify their financial resources and change negative public attitudes
and the priorities of national drug policies.
400
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and Non-injecting Drug Users: Current Trends and Implications for Interventions,” Current HIV/AIDS Reports May 2010; 7 (2): 99-106. HYPERLINK “http://www.ncbi.nlm.nih.
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globalreport/documents/20101123_GlobalReport_full_en.pdf ” http://www.unaids.org/
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in people who inject drugs: results of systematic reviews. Lancet. 2011; 378(9791): 571-583.
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Neuropsychopharmacologica Hungarica. 2010 Dec; 12(4):459-62.
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Health: The Hidden Hepatitis C Epidemic.
7. Carmen Aceijas et al. Access and coverage of needle and syringe programmes (NSP) in
Central and Eastern Europe and Central Asia. Addiction. 2007 Aug; 102(8):1244-50. Epub
2007 Jun 12.
8. Jamie Bridge at al. Global Fund investments in harm reduction from 2002 to 2009. International Journal of Drug Policy. 2012; doi: 10. 1016/j.drugpo. 2012.01.013.
9. Harm Reduction International, International Drug Policy Consortium, International HIV/
AIDS Alliance, The Funding Crisis for Harm Reduction, London: 2014.
10. HYPERLINK “http://www.ihra.net/files/2014/07/20/Funding_report_%C6%92_WEB_(2).
pdf ” http://www.ihra.net/files/2014/07/20/Funding_report_%C6%92_WEB_(2).pdf
11. Global Commission on Drug Policy, The War on Drugs and HIV/AIDS: How the Criminalization of Drug Use Fuels the Global Pandemic. 2012. HYPERLINK “http://globalcommissionondrugs.org/wp-content/themes/gcdp_v1/pdf/GCDP_HIV-AIDS_2012_REFERENCE.pdf ” http://globalcommissionondrugs.org/wp-content/themes/gcdp_v1/pdf/
GCDP_HIV-AIDS_2012_REFERENCE.pdf
12. Strathdee SA, Hallett TB, Bobrova N, et al. HIV and risk environment for injecting drug
users: the past, present, and future. Lancet, 2010; 376(9737): 268-284.
13. EHRN’s website: HYPERLINK “http://harm-reduction.org” http://harm-reduction.org
14. EHRN Concept Note of the Regional Program “Harm Reduction Works - Fund It!” Vilnius,
2013. HYPERLINK “http://www.harm-reduction.org/library/ehrn-concept-note-regional-program-harm-reduction-works-fund-it” http://www.harm-reduction.org/library/
ehrn-concept-note-regional-program-harm-reduction-works-fund-it
15. Report on the Regional Forum on healthcare and human rights of people who use drugs
(Chisinau, 19-20 May 2014) HYPERLINK “http://www.harm-reduction.org/Chisinau%20
Regional%20Forum%20Report%20EN” http://www.harm-reduction.org/Chisinau%20Regional%20Forum%20Report%20EN
16. Online map: HYPERLINK “https://waveeca.crowdmap.com/” https://waveeca.crowdmap.
com/
401
17. EDPI website: HYPERLINK “http://drogriporter.hu/en/edpi” http://drogriporter.hu/en/
edpi
18. István Gábor Takács, HCLU Film 2013 – Video Advocacy Activites of the HCLU. Budapest:
2014.
19. HYPERLINK “http://drogriporter.hu/en/hclu_tv” http://drogriporter.hu/en/hclu_tv
20. Bulgaria: On the Dark Side of Drug Policy. URL HYPERLINK “http://drogriporter.hu/en/
bulgaria_film1” http://drogriporter.hu/en/bulgaria_film1
21. Krysztof Krajewski. Polish Drug Policies: Between “Hard” and “Soft” Prohibition. Journal
of Drug Issues. 2004 July; vol. 34 no. 3 587-621.
22. It’s Time for Drug Policy Reform in Poland. URL: HYPERLINK “http://drogriporter.hu/
en/poland” http://drogriporter.hu/en/poland
23. Successful Drug Policy Reform Advocacy in Poland. URL: HYPERLINK “http://drogriporter.hu/en/node/2096” http://drogriporter.hu/en/node/2096
24. Peter Sarosi, The Not-So-Balanced Approach: Policy Responses to New Psychoactive
Substances. Budapest: HCLU, 2014. HYPERLINK “http://drogriporter.hu/en/nps_report”
http://drogriporter.hu/en/nps_report
25. HIV outbreak among injecting drug users in Romania. EMCDDA, Lisbon, November
2012; HIV outbreak among injecting drug users in Greece. EMCDDA, Lisbon, November
2012.
26. HIV in injecting drug users in the EU/EEA, following a reported increase of cases in Greece and Romania. EMCDDA/ECDC, Lisbon, January 2012.
27. Hungary is Facing an HIV Epidemic Among Drug Users. HYPERLINK “http://drogriporter.hu/en/node/2563” http://drogriporter.hu/en/node/2563
28. National Anti-drug Agency. National report: new developments, trends and in-depth information on selected Issues. National Anti-drug Agency, Bucharest, 2011.
29. Data obtained by the Romanian Harm Reduction Network from the National Administration of Penitentiaries via a request for information under the Public Information Act
544/2001. HYPERLINK “http://rhrnnews.blogspot.ro/2014/09/hiv-explosion-in-prisons-most-afected.html” http://rhrnnews.blogspot.ro/2014/09/hiv-explosion-in-prisons-most-afected.html
30. Stop the HIV Epidemic Among Drug Users in Romania. URL: HYPERLINK “http://
drogriporter.hu/en/romania” http://drogriporter.hu/en/romania
31. Videos from the hearing: HYPERLINK “http://drogriporter.hu/en/nps_report” http://
drogriporter.hu/en/nps_report
32. At the Crossroads: Will Serbia Fund Harm Reduction Programs? URL: HYPERLINK
“http://drogriporter.hu/en/serbia” http://drogriporter.hu/en/serbia
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Rowdy Yates*
University of Stirling, Scotland
ABSTRACT
An understanding of addiction as a complex disorder involving biological/physiological; psychological; socio-cultural; and socio-economic elements is well established as a foundation for good practice in treatment interventions. More recently, we have begun to
view recovery from this disorder as being reliant upon a realignment of all these elements within the context of a sustained structure
of encouragement and support rather than as an illness which will respond to a short, time-limited intervention such as treatment.
Drug treatment-seeking populations have been rigorously researched and we know much about their journey towards and through
treatment and even into post treatment. However non treatment-seeking populations are far less well known and we know almost
nothing about their experiences of long-term recovery. What is known is that ‘natural’ recovery, from even the most serious episodes
of addiction is widespread; perhaps even commonplace. In Europe, the majority of these natural recovery episodes appear to take
place outside formal treatment and even in defiance of the injunctions and advice of treatment providers. Understanding this process
of natural remission and the structures or elements which both make remission possible and sustain it over the long-term will help to
identify the most critical aspects of treatment interventions in general and after-care processes in particular. This chapter reviews the
history of recovery movements, the implications of the accepted theories of addiction and argues for the need to create communities
of recovery in order to limit the inter-generational transmission of addiction.
* An earlier version of this paper was published as a book chapter: Yates, R. (2012) In it for the long haul: recovery capital, addiction
theory and the inter-generational transmission of addictive behavior. In: A. Adan and C. Vilanou (eds.) Substance Abuse Treatment
generalities and specificities. Barcelona: Marge-Medica Books, 35-51.
Rowdy Yates is Senior Research Fellow and facilitator of the Scottish Addiction Studies group at University of Stirling. He has worked in
the substance misuse field for over forty years and, prior to this appointment, he was the director and co-founder of the Lifeline Project;
one of the longest established drug specialist services in the UK. He has published widely on addiction issues; including an edited book
(with Barbara Rawlings) on drug-free therapeutic communities; a handbook on the purchasing and management of drug and alcohol
services; and an edited collection (with Margaret Malloch) on recovery and ways out of addiction. In 1994 he was awarded the MBE for
services to the prevention of drug addiction. He is the current Executive Director of EWODOR (the European Working Group on Drugs
Oriented Research), President of the EFTC (European Federation of Therapeutic Communities), Chair of Recovery Academy UK and a
member of the Scottish Government’s Drug Strategy Delivery Commission.
Contact details: 01786 467737; e-mail [email protected].
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RECOVERY CAPITAL, ADDICTION THEORY AND THE DEVELOPMENT OF RECOVERY COMMUNITIES
Recovery Capital, Addiction Theory and the
Development of Recovery Communities
Introduction
In recent years, there appears to have been a growing interest both in a wider view of
addiction and its treatment in general and of the issue of recovery in particular (1-3). In
part this rebirth of interest in recovery appears to have been driven by a media-led dissatisfaction with the perceived failures of the substitute prescribing policy of the previous
two decades (4). In part also, though, it appears to owe much to a largely grassroots led
movement to redefine the nature and direction of the treatment process (5).
This chapter briefly charts the early history of the recovery movement and outlines its
beliefs. Most of these groups were self-help mutual-aid groups with little or no input
from the mainstream treatment providers who were largely content to leave the state
response to excessive alcohol use to the relevant criminal justice systems (6-9).
It was not until the middle of the Twentieth Century that the scientific and academic
community began to seriously explore the theoretical frameworks of addictive behaviour. Prior to that time, there was a general acceptance of the broad position within the
various temperance movements that the addictive element was firmly located within the
substance: the Devil was in the bottle (6, 7, 10). With the development of competing theoretical models of addiction came the associated treatment and, though more gradually,
changes in public perception and attitude (11, 12). The history of addiction theory and
its implications for treatment are outlined here and in the latter part of this chapter, the
relevance of these two associated histories for the modern recovery movement and for
the development of recovery communities is set out.
The Early Recovery Movement
Some of the earliest examples of self-help mutual-aid fellowships appeared amongst the
Native American population (13). Both Kenekuk, the so-called Kickapoo prophet and
Handsome Lake, a Seneca chief, founded popular movements in the Eighteenth Century
(13), built around the concept of recovery and sobriety but extending across much of the
cultural life of their tribe (14-16). Both Kenekuk and Handsome Lake were reformed
drinkers. Both saw sobriety as a first step in restoring cultural integrity and ‘upright
living’ to a people humiliated and disenfranchised by decades of white aggression and
deceit.
Handsome Lake did much to restore the broken Iroquois Nation and rebuild the confederation as a respected force in Native American politics. His Gaiwiio (Good Message)
404
runs to many pages and was (and still is) learnt by heart by many of his followers (17).
Both of these early movements, coming over 150 years before the establishment of Alcoholics Anonymous, recognised that simply stopping drinking was only a small part of
the solution. What was required was a significant change in belief and behaviour. Kenekuk railed against the high prevalence of domestic violence amongst the Kickapoo and
Handsome Lake argued that the work of a sober Indian was to organise and restore the
dignity and cultural self-belief of the red man (13, 16, 18).
Similarly, the Washingtonian movement which flourished across America in the mid-Nineteenth Century argued that a reformed drunkard had a crucial duty to become the
family’s main breadwinner. The Washingtonians (more formally entitled the Washington Temperance Society), a recovery movement founded in 1840 by a group of former
drinkers, eschewed religious doctrine and allowed only “reformed drunkards” to speak
at their meetings (6, 19). The Washingtonian meetings followed a format remarkably
similar to that adopted by the Alcoholics Anonymous fellowship almost a hundred years
later. T. S. Arthur (72), in a temperance tract published some eight years after their formation, paints a vivid picture of his attendance at Washingtonian meetings in Philadelphia and offers a series of somewhat romanticised vignettes of the lives and tribulations
of some of its members. Even within this short space of time, the Washingtonians were
holding regular meetings in most East-coast cities in America and had already established a number of lodging houses for the respite of their fallen members. On the anniversary of the 110th anniversary of the birth of George Washington, Abraham Lincoln
chose the meeting of the Springfield Washingtonians to deliver his memorial address
(20). At its peak, the Washingtonians numbered between 300,000 and 600,000 (reports
vary wildly) and could boast at least 150,000 members in long-term recovery (6, 13, 19).
Although the organisation allowed only those in recovery to speak at their meetings,
both membership and attendance was open to all. As a result, membership appears to
have been swelled by an influx of temperance campaigners and religious proselytisers.
This resulted in a series of damaging and, ultimately fatal, internal schisms with some
members insisting that the organisation be more active in the prohibition campaign,
more meaningfully connected to the established church and even, more active in the anti-slavery movement. For some twenty years, the Washingtonians flourished, founding
new branches across America but by the 1860s, the internal feuds caused the organisation to implode. Some of its sober houses continued, often under the management of
other temperance organisations, the sober house in Chicago became the Washington
Hospital and continued to offer alcohol treatment up until the 1980s. But mostly, the
organisation simply crumbled. Members left to join other related organisations and, by
the 1940s, the dissolution was so complete that the founders of Alcoholics Anonymous
claimed never to have heard of it (6).
In the early years of the Twentieth Century, the Emmanuel Movement, based in the Em405
manuel Baptist Church in Boston, began to achieve significant attention for their blend
of spirituality, medicine and a kind of basic psychotherapy. The movement attracted serious criticism from Freud, during his brief visit to the United States in 1909. Freud was,
perhaps understandably, particularly scathing about the limited medical qualifications
of the movement’s main protagonists (21). Despite Freud’s scepticism and that of many
other medical professionals the movement grew and in 1909, Ernest Jacoby began to
organize weekly meetings at Emmanuel Church. More meetings began to be established
as Jacoby Clubs, (“A Club for Men to Help Themselves by Helping Others”) and Jacoby
Clubs and their weekly meetings flourished (22). In Boston, the Jacoby Club provided
meeting space for one of the earliest AA groups but the two organisations remained
separate and the Jacoby Clubs gradually lost out to their newer, more vigorous fellow
traveller (13, 21).
What seems striking about these early recovery groups is the similarity of their insistence that stopping drinking alone was not enough to sustain recovery. What was required
was a much more radical alteration in the former addict’s thinking about themselves
and how they behaved towards others and the company they kept. In this, they foreshadowed the central tenets of the Black Power movement – similarly led by a reformed
criminal and multi-drug user, Malcolm X – in the 1960s (15). Malcolm X argued that
stopping using drugs and drinking and stopping offending was not enough. Members of
the movement were exhorted to be “black and proud” (23).
The Alcoholics Anonymous (AA) fellowship has been one of the most successful mutual-aid groups and has spawned a number of parallel organisations including Narcotics Anonymous, Gamblers Anonymous and Cocaine Anonymous. They too have, from
their earliest writings, discussed the concept of the “dry drunk”: the former drinker who
continues to behave in ways which are unacceptable and which were the hallmark of
their former drinking career (24).
Largely informed by the work of therapeutic community (TC) pioneer, Charles Dederich at the experimental commune, Synanon and bolstered by the ‘second generation of
therapeutic communities on the East coast of America (25, 26), the residential self-help
community, modelled on AA practices, rapidly gained a foothold in Europe in the early
1970s. In Europe, this development was melded with the existing therapeutic community practice in psychiatry pioneered by Jones, Laing, Clark and others and grafted onto
a century long tradition of caring for (and addressing the needs of) “maladjusted” children (25). Even with this rich history however, the notion that a community of addicts
could manage and control the elements of their own recovery, was initially greeted with
scepticism within mainstream addiction treatment (26, 27).
Perhaps one of the most telling clues to the origins of the TC movement lay in its insistence on the AA concept of the ‘dry drunk’. Early in the history of Synanon, Dederich
argued that Synanon was emphatically not a treatment service, rather, he said, it was a
406
school where people learned to “live right”. Subsequently, De Leon, one of the foremost
evaluators of the TC and undoubtedly its foremost chronicler, argued that the notion of
‘right living’ lay at the heart of the TC approach (28). The TC, he suggested was more
school than hospital and could better be viewed as a learning environment where individuals learned (or relearned) correct behaviour. Abstinence was not a goal, necessarily,
rather a serendipitous outcome of overall behaviour change.
Addiction Theory
Peele (6) has noted that the vigorous promotion of alcoholism as a chronic, relapsing
disease by the scientific medical community in the 1950s and 1960s (29-32) has effectively embedded the notion of addiction, in both the public consciousness and (to a lesser, though significant extent) within the academic discourse, as an incurable condition
which can, at best, be managed and contained. Room (33) has charted the opposition to
this position by sociological researchers and proponents of the behaviourist schools, but,
although these arguments gained significant ground during the 1970s and early 1980s,
the increasing focus, during the past two decades, upon infection control and crime
reduction has resulted in a general return to a medical model of addiction treatment
predicated upon the management of the problem and containment of its physiological
and criminological sequalae.
The notion of a disease, which robs those afflicted with it of their individual will, is embedded in a cultural context where individuality and liberty is a paramount aspiration
and where appropriate behaviour is an individual personal responsibility. This, of course, is precisely the cultural matrix which developed with the industrialization of previously rural communities, where controls had tended to be vested more explicitly within
the family or ‘tribe’ than in the individual.
These concepts have proved to be of an enduring nature. The current definition of addiction or dependence, as set out in the International Classification of Diseases (ICD10) (World Health Organisation, 1992), neatly sets out this diagnostic requirement as,
“Impaired capacity to control substance-taking behaviour in terms of onset, termination
or level of use”. ICD-10 lists a number of other manifestations of addiction, including a
preoccupation with the substance of choice, which disregards other important concerns
or alternatives. Room argues that this definition again, is culturally specific, relating to
a social structure in which time has become a commodity in itself, “a cultural frame in
which time is… used or spent rather than simply experienced.” (12, p. 226).
Thus, the discovery of addiction (and, consequently, of ‘recovery’) came during a period
of extraordinary social upheaval and change. In America, in particular, the period was
also associated with additional changes in established communities as existing residents
moved out to explore and settle new territories and were replaced by significant numbers
407
of immigrants from Europe. In the period between 1785 and 1835, the population of the
United States almost doubled (6). In the newly settled territories, drinking houses were
largely rudimentary, frequented by prostitutes and gamblers, and generally structured to
encourage drunkenness and heavy, drink-related spending; a far cry from the community-oriented taverns in the close-knit communities most settlers had left behind. In the
cities and established communities, the new immigrants brought with them European
drinking practices, which were often frowned upon and largely misunderstood.
The publication of Jellinek’s (29) work on phases of alcoholism and its subsequent incorporation into World Health Organisation guidelines (34), significantly influenced
discussions on the nature of addiction and recovery for most of the 1950s and 1960s.
This disease model of addiction was not without its critics. Trice and Wahl (34) tested
Jellinek’s hypothesis and concluded, “if the concept of a disease process in alcoholism is
valid, only the earliest or the most advanced stages are reliably indicated.” Similarly, the
presentation of alcoholism as an irreversible disease, has been subjected to much debate
and criticism.
Davies (1962) provided an early challenge to this notion with a paper in the Quarterly
Journal of Studies on Alcohol, which noted the capacity of many of his patients to return
to normal drinking patterns. Commentaries in subsequent issues -on both his findings
and his diagnostic methodology- were heated but largely scholarly. Not so the response
to the Rand Report, Alcoholism and Treatment (35). The controversy which surrounded
the publication of this report, with its finding that not only was a reversion to controlled
drinking possible but that it was the most likely successful outcome, sparked a public argument which refused to die down. Room (33) has noted that some studies of controlled
drinking had their funding withdrawn at this time and that the debate became at times,
extremely emotive. The authors were accused of providing struggling abstainers with a
“scientific excuse for drinking” (33) and numerous commentators predicted dire consequences as a result of its publication (11). However, as Roizen points out, subsequent
studies (36) indicated that this apprehension had been misplaced and the publication of
the report – and its interpretation in the media - had had little or no impact on drinking
behaviour.
By this time also, the notion of addiction as a disease was being increasingly challenged;
particularly by sociological and psychological theorists. As social concern switched from
being largely dominated by alcohol misuse and began to respond to increasing use of
illicit drugs, particularly heroin and cocaine, the emergence of theories based upon psychodynamic, socio-cultural and behaviourist traditions multiplied inexorably.
Khantzian (37, 38), Wurmser (39) and others suggested that the origins of addiction might lie in deep-rooted childhood trauma. Psychoanalytic and psychodynamic theorists
have been prominent in developing theories of drug dependence based on personality
factors. Early psychoanalytic theories suggested that alcohol abuse reflected an indivi408
dual who was experiencing severe conflict concerning dependence which was expressed
by oral fixation. Over the years, these theories have ranged from suggestions that drug
dependence reflects low self-esteem to sex-role conflicts, or feelings of powerlessness
which are masking a need for control (40). According to Wurmser, addiction is the result
of a “narcissistic crisis” which creates “neurotic conflict” (39, 41). In this model, a harsh
superego creates intense feelings of rage, fear, guilt, and anxiety. The use of drugs is a way
of escaping these feelings.
Others (42) proposed a behavioural origin to the addiction phenomenon based largely
upon the work of Skinner and Pavlov. Addiction was, they argued, a learned behaviour which could, in turn be unlearned or, perhaps more accurately, replaced with less
self-destructive behaviours. These theories, in their turn, spawned a raft of cognitively
based interventions still in use today, including motivational interviewing (43) and relapse prevention (44).
Perhaps the greatest leap forward in understanding addiction came with the work of
theorists such as Engel (45), Robbins (Robbins et al., 1970) and Zinberg (46) through the
development of models of addiction –most often described as biopsychosocial– which
are multi-dimensional.
Bio-psychosocial theories of addiction argue that the addiction experience is impacted
upon by three distinct factors. These factors –Zinberg’s ‘drug, set and setting’- are the
chemical interaction and any biological or genetic predisposition to intoxication; the
individual’s psychological and spiritual state; and the environment in which he or she
exists. This three-part model has been hugely influential in the drug treatment field in
the past thirty years. Some practitioners have argued that the model provides an essential framework for assessment and treatment planning (47) and most validated instruments, such as the Maudsley Addiction Profile, the Addiction Severity Index and the
Client Treatment Matching Protocol would appear to owe their genesis to this layered
and individualistic approach to the problem.
Subsequently, a number of practitioner authors argued that the model was not only a
tool for understanding addiction but could also be used to assess problems and plan
treatment interventions. Yates (47, 48) developed an assessment model which set out the
various questions which would need to be asked to ascertain the balance of difficulties
experienced by the individual in each of the three domains. Thus, if the level of drug-taking was relatively low and of short duration whilst self esteem and the availability of
non-using friends and relatives was correspondingly high, then a fairly low intensity
intervention would be required. Madden (49) similarly argued that the three domains
outlined by Zinberg could be used in an understanding of the ‘treatment strengths’ with
which the addict came to their first appointment.
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Addiction Theory and Long-Term Recovery
Addiction theory matters not simply because it underpins the approaches used in drug
treatment interventions but because it also has implications for recovery and for the
long-term sustainment of recovery.
If indeed, addiction is a result of a fluid interaction between the biological propensity,
the environmental setting and the self-esteem and self-belief of the individual, then clearly, an intervention must address all three elements if it is to be successful. Treatment
interventions, which are limited to a concentration on the addicts consumption of substances will at best, deliver a level of stability. At the worst, they will attempt abstinent
recovery for which the individual will – without radical changes to his/her environment
and their own self-esteem – be both ill-prepared and ill-equipped.
The tem, social capital, is generally used by sociologists to describe the connections within and between social networks. The term was probably first used by the American
schools inspector, Lyda Hanifan. Introducing the term in a 1916 report on rural schools
in Virginnia, Hanifan explained:
“I do not refer to real estate, or to personal property or to cold cash, but rather to that
in life which tends to make these tangible substances count for most in the daily lives of
people, namely, goodwill, fellowship, mutual sympathy and social intercourse among a
group of individuals and families who make up a social unit… ” (50, p. 130)
Sheldon & MacDonald (51) note that Hanifan’s notion of ‘social capital’ was rooted in
a belief in self-help and peer support. Hanifan himself was content to conclude that: “It
was not what they [professionals] did for the people that counts in what was achieved; it
was what they led the people to do for themselves that was really important” (50, p. 138).
Whatever its origins, it is clear that the term has become a shorthand for all that is good
about community spirit in the related fields of sociology, social policy and social work.
Significantly, Hanifan maintained that social capital, unlike other forms of capital was
not depleted with use. On the contrary, its use resulted in an increase, a phenomenon
which Hanifan described with the pithy slogan, “use it or lose it” (50, p. 139): a concept
not a million miles from the therapeutic community principle, “you can’t keep it unless
you give it away” (25, 28), a slogan designed to describe the personal benefit which those
in recovery receive by helping others with their own recovery.
More recently, writers on recovery, such as White & Cloud (52) and Best & Laudet (53),
have taken this idea and coined the term ‘recovery capital’ to describe changes they have
observed in the resilience and robustness of people’s social and emotional circumstances in long-term, abstinent recovery. There are, they argue, dramatic improvements in
self-esteem, civic and social engagement, physical and psychological health and overall
well-being. These changes, they argue are fundamental to the successful outcome of any
abstinence-based recovery journey (54).
410
“The best predictor of the likelihood of sustained recovery is the extent of ‘recovery
capital’ or the personal and psychological resources a person has, the social supports
that are available to them and the basic foundations of life quality, i.e. a safe place to live,
meaningful activities and a role in their community (however this is defined).” (54, p. 8)
Cloud & Granfield (55) have recently suggested that this concept can be further refined
as four individual, though overlapping, categories: social, physical, human and cultural. Best & Laudet (53) endorse this view but note that of these, the social, human and
cultural capital ‘reserves’ are probably of the most significance, particularly in group or
community settings:
“Although the focus here is primarily on individual factors, it is the meshing of three of
these components – social, human and cultural capital – that may be particularly important in assessing recovery capital at a group or social level.” (53, p. 4)
But significantly, these categories bear a striking resemblence to Zinberg’s ‘drug, set and
setting’ (and to Madden’s ‘the seed, the soil and the atmosphere’, op cit.; and Yates’ effect,
expectation and situation’, op cit.). In all of these analyses, it is argued that changes in
these three central areas are vital for both a comprehensive assessment and the development of a person-appropriate treatment plan. What was not examined in any systematic
way in these earlier writings was the use of this model to measure long-term improvements in individual resilience and social reintegration. What is argued here is that the
use of the bio-psychosocial model in all phases of the recovery journey would provide a coherence to the role of various interventions throughout the process and enable
drug treatment practitioners –even those who remain sceptical of the so-called ‘recovery
agenda’– to view their role in the process from within an accepted scientific framework.
411
Recovery Communities and the Way Forward
Drug and alcohol addiction is heavily stigmatised within most cultures (56) and this
stigma impacts upon former addicts in recovery; further problematizing their condition
and making their recovery more, rather than less difficult.
In some respects, the blame for this stigmatisation can be laid at the door of the major
treatment agencies. Many recovery-oriented services encourage drug users and their
partners to be continually on their guard against relapse and constantly vigilant for signs
of the imminent return of their disease. Similarly, many harm-reduction oriented treatment services argue for continuing maintenance prescribing; so-called opioid replacement therapy. In practice, both groups are in effect encouraging a wider societal view of
addiction as an incurable disease which can only be managed – either with continuing
attendance at recovery meetings or with continued prescriptions for substitute drugs.
Thus a public view of relapse as an inevitable event for most, if not all former addicts,
underpins many of the negative attitudes which are directed towards this group.
Clearly the long-term solution is the creation of visible, recovery-friendly communities
where the individuals’ recovery status is celebrated and seen as an asset for that community to use rather than a liability for it to prepare for. Such a change will inevitably
involve encouraging those in recovery to be more active within their communities as
recovery champions and advocates. It will also, though demand changes in practice and
outlook in treatment providers themselves.
Numerous authors (9, 15, 57, 58) have commented upon the apparent antipathy, even
occasionally outright hostility, of mainstream treatment practitioners to the ‘unscientific’ nature and ungrounded optimism of the self-help recovery movement (9, 57). In
order for this scepticism to be modified, the recovery movement in all its forms (spiritual healing communities, 12-step groups, therapeutic communities etc.) will need to
demonstrate an openness to research and innovation and a willingness to debate their
role and responsibility within the wider sphere.
Why this seems important is not only because of issues of individual well-being but
about the wider issue of intergenerational transmission of addiction and its associated
problems: low educational achievement, unemployment, offending behaviour, teenage
pregnancy, physical and mental ill-health. Numerous authors have noted this phenomenon (54, 59-61) and argued that improvement in this area is the ultimate prize for
treatment intervention. Whilst some have argued that this apparent inheritance of problematic behaviour may have its roots in genetics (62), the argument for a mixture of the
biological, social and psychological (echoing the bio-psychosocial model) seems particularly compelling. Since long-term, abstinence-oriented recovery appears to require
significant improvements in all three domains it seems appropriate to explore whether
such recovery journeys have an impact upon parenting and subsequent behaviour in
412
drug-affected families.
Andreas & O’Farrell (63) have noted improvements in behaviour and attitude amongst
the children of parents in long-term engagement with mutual-aid fellowships. Similarly,
in a large Australian study, Callan & Jackson (64) reported significantly better behaviour
and well-being of children in families where one or both parents had achieved long-term
recovery than amongst children where parental drug use was continuing.
Conversely, numerous studies have shown that whilst long-term substitute prescribing,
concentrating as it does, on the biological elements of the addiction experience, whilst
having a significant impact upon illicit drug use and its consequent criminality and joblessness, seems largely unable to completely eradicate these behaviours in the majority
of individuals (65-68). Illicit drug use and criminality appears to continue at a reduced
level in most thus prescribed (69-72).
Thus, whilst long-term substitute prescribing might seem to offer the greatest gains –in
terms of treatment expenditure– over the short-term, it would appear that long-term
abstinence-oriented recovery is likely to deliver the most significant gains when examined over a more significant period.
413
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418
Sacide Pehlivan*
Istanbul University
ABSTRACT
Addiction is a chronic, relapsing disorder with a huge impact on both society and individual. Understanding the genetic basis of addiction is crucial to characterize individuals’ risk and to develop efficient prevention and treatment strategies. As a result of current
developments on the area of molecular genetics, there is growing interest on the genetic aspect of addiction types (drug, alcohol, smoke, etc.) Data from classical genetic studies (mutation, gene expression, polymorphism, etc.) to new epigenetic and microRNA studies
could show us new dimensions of addiction. In this review, recent developments related to the genetics of addiction will be discussed.
Keywords: Addiction, Genetics, Drug/Alcohol/Smoke, Susceptibility
* Prof. Dr. Sacide Pehlivan has received PhD in Department of Medical Biology of Hacettepe University during the period of 1992-1997.
Currently, she is working as Prof. Dr. in Department of Medical Biology of Istanbul Medical Faculty of Istanbul University. She has
successfully completed his Administrative responsibilities as both teacher and researcher. She is serving as an editorial board and/
or member of several reputed journals like OMICS: Journal of Biochemistry & Physiology & Genetics, Acta Oncologica Turcia, Journal
of Paediatrics, Turkish Clinics. She has authored 113 research articles. She is a member of European Human Genetics, Turkish Medical
Genetics, Turkish Medical Biology and Genetics. She is honored with 17 prizes.
419
GENETICS OF ADDICTION
Genetics of Addiction
Addiction can be defined as an uncontrolled situation in which an individual finds
themselves without ignoring harmful consequences on themselves or the society. Or it
can be described as continuance of a substance or activity although it adversely affects a
person’s mental or physical health (1, 2). General characteristics of addiction are;
•
It’s a medical disease; it won’t heal but it will get better.
•
It is characterized by a control loss on its use.
•
It is not about using non-stop but it is about not being able to stop once a person
starts using addictive substances.
•
Family-related, social, legal, financial and mental problems accompany this situation.
•
It is a chronic and progressive disease.
•
It is likely to relapse.
•
It is more commonly encountered in men than women (3-5).
Types of addiction can be categorized in two main groups as substance-related and fact-related addictions (Table 1).
Substance-related addictions
Fact-related addictions
Alcohol
Human / relationships
Opiate
Gambling
Heroin
Eating
Cocaine
Sex
Ecstasy
Sports
Volatile substances
Internet / Virtual environment
Caffeine and nicotine
Medication addiction
Other addictions (Bonsai,…..)
Table 1 Types of Addiction.
420
The most important factors influencing addiction prevalence are religion, culture, laws, accessibility to the agent, health-care policies and individual’s biologic tolerance. In terms
of biologic tolerance, the biggest risk factor is that if either or both parents have addictions. For example, children of alcohol addicts are 4-5 times more likely to suffer from
alcohol addiction (6, 7). As far as all addictions are concerned, men present higher ratios
of addiction while addiction of using prescribed drugs, eating and workout are reported
higher in women (4, 8). One of the most important biological tolerances is the role of
Dopamine D2 receptors (DRD2). Lack of DRD2 is presented as a reason of reduction in
susceptibility to awarding that is reported to be important in substance addiction and it
is determined that it may have a key role in continuance of the addiction (8). Consequently, although genetics is not reported to have a role in starting/trying phase, it has a
role in recurrence of using the substance, i.e. continuance of the addiction.
Substance addiction is described as a psychic and somatic disease presenting itself with a
desire to take a substance continually or periodically in order to sense pleasure-inducing
effects of a substance having characteristics of a medication affecting the central nervous
system or to avoid the restless that may be caused by the lack thereof. Or it is described
as a neuroplasticity disorder of reward and cognition systems in brain which is caused by
abnormal activations in gene expression programs in cells due to long-term medication
use. Or it can be described as a complex and multifactorial disease developing based on
environmental and genetic factors (8-10). Genes have effects on biological characteristics of the organism creating the risk of substance addiction. These characteristics are
related to pharmacokinetics or pharmacodynamics. If the body can rapidly metabolize
the substance, the individual does not feel the effects of that substance. However, if it
is slowly metabolized, small amounts cause greater effects. In family studies, it can be
determined to what extent a proband (patient) having a substance addiction and next of
keen of the proband will suffer from addiction. Hser et al. Conducted a study on 1267
individuals with addiction and found out that next of keen of the probands are 5 to 8
times more likely to suffer from addiction (11).
Deoxyribonucleic Acid (DNA) is a biomolecule that is in charge of transmitting genetic
data in nucleus and mitochondria of eukaryotic cells from one generation to another
and synthesis of all proteins in the body. It shows resemblance among species. 2% of the
DNA in our cells are coded on protein while 75-80% of it is reported to be transcribed
(2, 16). 77-78% of the transcription consist of non-coding RNA (ncRNA) molecules that
are not coded on protein. Only the relationship between RNA and protein synthesis was
known before while it has been discovered that almost all control mechanisms in the
cell are conducted by ncRNA molecules. These RNAs are categorized in two groups as:
short ncRNA: with 18-200 nucleotide and long ncRNA: 200+ nucleotide. ncRNAs act
as regulating key molecules in every step of cell physiology. Its main duties include; imprinting DNA, regulating chromatin, assigning transcription factors, carrying out nuclear-cytoplasmic biomolecule transfer, RNA splicing, DNA/RNA editing, transcription,
421
GENETICS OF ADDICTION
degradation of mRNA, repression of protein synthesis (translational repression). It has
been demonstrated that over 800 types of ncRNA are expressed in brain cells (with the
transcription of 77% of DNAs) and miRNA of which are included in over 300 types. The
difference between number and types of miRNAs in brain in individuals with and without drug addiction has also been demonstrated (2, 12). Over 70 gene clusters on which
miRNAs are coded (except 3, 4, 16, 22 and Y chromosomes) are spread on chromosomes
(http://www.ncbi.nlm.nih.gov/omim).
Epigenetics; it is a hereditary change that can be passed on from a generation to the next
generation across gene expression or cellular phenotype nuclear division (mitosis and/or
meiosis) without basic DNA cluster. It occurs both in nuclear DNA and mitochondrial
DNA (5, 13, 14). Epigenetic modifications in cells under normal circumstances are different from genetic modifications owing to their characteristics of being reversible and not
causing modifications in DNA’s base cluster. However, it has been shown that they can
become permanent in all addictions including smoking and cocaine addiction (10, 15).
Epigenetic Modifications include; DNA methylation, histone methylation, histone acethylation, histone phosphoylation, editing that has direct effects on all chromatin structure by modifying nucleosome’s position such as re-editing chromatin (13). Determining
of the relationship between epigenetic modifications and addiction in detail would help
developing more successful treatment strategies and making the addiction one of the
treatable diseases otherwise causing material and non-material problems in the society.
In conclusion; with determination of biomarkers playing role in drug response gene
and risk promoting gene based on the addiction, new treatment strategies that are custom-made and more successful can be delivered. Especially, treatment strategies with
antisense olgonucleotides that are more effective in case of specific and short ncRNAs
can be started.
422
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1. Abay, E., Ateş, İ. (2001). Genetics of addiction. Bağımlılık Magazine, 2: 1-5.
2. Bali, P., and Kenny, P.J. (2013). MicroRNAs and drug addiction. Frontiers in Genetics
4:doi:10.3389/fgene.2013.00043.
3. Sengül, C., Herken, H. (2009). Alcohol addiction from genetics to epigenetics. Anadolu
Psikiatri Magazine, 10: 239-245.
4. Fattore, L., Melis, M., Fadda, P., Fratta, W. (2014). Sex differences in addictive disorders.
Frontiers in Neuroendocrinology. 35:272-284.
5. Tueste, L.M., Zhang, Y. (2014). Mechanisms of epigenetic memory and addiction. The
EMBO Journal, 33(10):1091-1103.
6. Kreek, M.J., Levran, O., Reed, B., et al. (2012) Opiate addiction and coccaine addiction:
underlying molecular neurobiology and genetics. The Journal of Clinical Investigation, 122:
3387-3393.
7. Edenberg, H.J., Foroud, T. (2014). Genetics of alcholism. Handbook of Clinical Neurology,
125: 561-571.
8. Blum, K., Chen, A.L.C., Giordano, J., et al. (2012) The addictive brain: All roads lead to
dopamine. Journal of Psychoactive Drugs, 44; 134-143.
9. Wetheril, L., Agrawal, A., Kapoor, M., et al. (2014). Association of substance dependence
phenotypes in the COGA sample. Addiction Biology, doi:10.1111/adb.12153.
10. Volkow, N.D., and Baler, R.D. (2014). Addiction science: Uncovering neurobiological
complexity. Neuropharmacology, 76: 235-249.
11. Hser, Y.I., Saxon, A.J., Huang, D., et al. (2014). Treatment retention among patients randomized to buprenorphine/naloxone compared to methadone in a multi-site trial. Addiction,
109: 79-87.
12. Madsen, H.B., Brown, R.M., and Lawrence, A.J. (2012). Neuroplasticity in addiction: cellular and transcriptiptional perspectives. Frontiers in Molecular Neuroscience, 5:1-11.
13. Nestler, E.J. (2014). Epigenetic mechanisms of drug addiction. Neuropharmacology,
76:259-268.
14. Sadakierska-Chudy, A., Frankowska, M., Filip, M. (2014). Mitoepigenetics and drug addiction. Pharmacolgy & Therapeutics, Doi.org/10.1016/j.Pharmtera.2014.06.002.
15. Kruman, I.I., Fowler, A.K. (2014). Impaired one carbon metabolism and DNA methylation
in alcohol toxicity. Journal of Neurochemistry, 129: 770-780.
16. Duncan, J.R. (2012). Current perspectives on the neurobiology of drug addiction: A focus
on genetics and factors regulating gene expression. International Scholarly Research
Network Neurology, Doi:10.5402/2012/972607.
423
424
Uğur Elaman*
Association of 180 Degrees Fighting Against Addiction
ABSTRACT
Addiction is the most important problem of our age which should be urgently faced by the modern human being with all its aspects. It
will not be possible to fight against this problem, its diversification potential and spreading speed without acting with cooperation and
collaboration with the network of producer, marketer, user, victim, affected, located around and those who have to produce solutions.
This presentation was prepared with the intention of considering a civil initiative experience which is made specifically in Ankara, and
the activities, methods and problems of other studies in this regard from this point forth.
We have been together with street children, children who are working on streets and drug addict groups since 1993, and we have been
operating at the point of producing solutions for, preventing the spread of, determining fighting policy for, and creating social conscience and awareness on the problems which are the subject of this meeting under the identity “180 degrees”.
In this notice, we will primarily address the place of civil initiative in fighting against this problem, differences from other solution
elements and the qualities of the relationship to be developed. Meanwhile, the treatment process of the addicts will be stepped at a
point where treatment and therapy are an inseparable whole and then the qualities of individual and corporate cooperation will be
addressed.
We believe that the solution of the problem can be provided in a strategy by completing physical, social, intellectual and psychological
processes together. The methods we use in the process that we follow in realization of this belief of ours are another important aspect
of this presentation.
Finally, the problems we encounter in the area and their discussion and solution offers are addressed within the scope of this text.
* Uğur Elaman was born in Ankara in 1969. He graduated from Hacettepe University Faculty of Literature Department of History and he
had his graduate degree at the same faculty. He is currently pursuing a PhD at Ankara University.
He has been dealing with children and young people who are living under marginal conditions and drug addict people within the context
of social responsibility since 1993. ILO-IPEC Project ASCCM Training Supervisor between 1995-1998. Founding member of Cocuk-Der
(Association of Child), founding member of the Association of 180 Degrees Fighting Against Addiction.
He has delivered hundreds of conferences and trainings on fighting against drug addiction in Turkey.
425
A POINT BETWEEN 180 DEGREES
A Faith-Oriented Civil Initiative Movement
in Combating Addiction
180 Degrees – The Case of Ankara Study
Introduction: A Point Among 180 Degrees
Humanity and its values have never faced such a destroying enemy as modernism at any
point in history. “Techno” threatens “Logos” in all areas of life and empties the inside of
the humans. Humanity is evermore in need of external resources to survive.
Unable to be different when producing, the individual becomes different while consuming and lives a life dependent on consumption. This triggers the two great problems
of “loneliness” and “alienation”. Without doubt, this is a very painful situation and like
any pain, it needs “sedatives”. There are two possibilities: “to forget and pretend it doesn’t
exist” or “to face it”… The first one leads to instant pleasures and increasing costs that
must be paid while the second leads to “combat” and a life worthy to be lived. If the first
one is preferred, the individual is alienated and becomes “addicted” to the dream and
the dreamer and “the intellect”, which is the greatest potentiality, becomes the enemy to
be escaped.
180 Degrees is a civil initiative movement which aims to stand by the modern individual
during this preference and to face the negative results of the decisions made by the individual, who is a mere point, on the 180 degree scale of values and to write it down in
the history. It is a civil initiative movement that combats all forms of addiction, which
was started in front of a discotheque in Farabi Street, Ankara in 1993 and has continued
until today.
This article has been prepared to show this experience of civil initiative movement specific to Ankara and to discuss the activities, methods and problems of other studies within
this respect, deriving from this.
In this article, primarily the place of civil initiative in combating this problem, its differences from other solution factors and the qualities of the relation to be developed will
be discussed. Afterwards, the qualities of the individual and corporate cooperation that
we realized during the pacing and follow-up of the treatment process of addicts will be
considered from the point of view that treatment and therapy is an indivisible whole.
We believe that the solution of the problem can be provided for the individual in a strategy to be realized by conducting together physical, social, intellectual and psychological
426
processes all together. The process we followed and the methods we used in realization
of our belief constitute another important aspect of this article.
In conclusion, the problems we faced in the field and the discussions and solutions related to these will be discussed within this text.
Parties
It is a reality that addiction is a serious problem and that discussing and speculating
about the scary dimensions of its consequences don’t contribute to the solution but rather inhibit it. First of all, the problem should be defined in all its dimensions and the
parties of the problem and the solution should be clearly determined.
Parties of this problem:
•
Victims and addressees: users- their families
•
Party causing the problem: producers/dealers
•
Those working towards a solution. The parties of the solution naturally include
all parties influenced by this problem. Under the main titles, they are as follows:
Parties of the solution:
•
Government Institutions, Relevant Ministries and their General Directorates
•
Media and Communication Channels
•
Universities
•
NGOs, Fund and Project Organizations
•
Foundation Organizations – Faith-Oriented Civil Movements where 180 Degrees
places itself.
Our Objective
180 Degrees aims,
•
To define addiction in all its dimensions, to determine and apply combating strategies,
•
To train volunteer departments to combat addiction,
•
To inform and catalyze the establishments, the real owners of this problem,
•
To convince the addressee that this problem can be solved,
•
To follow the determined parties of this process and to make itself long lasting.
427
Where Are We? - The Importance of Our Position
In the second article, we have indicated that we place ourselves under the title of “Foundation Organizations - Faith-Oriented Civil Initiative Movements” that we have stated
under the title of the parties of the solution. This situation makes us different from other
partners of the solution at some points;
•
We believe that man has been created with a reason and with an owner, even as
a “caliph” (divine representative), that life will acquire meaning with “awareness”
and that combating addiction is possible by raising the awareness of the addressee, we perform “studies raising awareness”.
•
We also count ourselves responsible for the problem of addiction and we see ourselves as a part of its popularization. We act in accordance with the principle of
“There is no right only duty”.
•
We should think performance-oriented rather than victory-oriented when there
is still an opportunity for each living person. Although we have general principles,
we have the approach and sensitivity that each individual we meet is a new story.
Everybody is someone. Everybody has at least the right to be listened.
•
With the understanding that combating addiction is a life-long process for the addict, we establish relations along the lines of sharing - making sense of life, rather
than treater – treated or serving – served.
•
We seek cooperation with all people and organizations which we believe to have
the capacity to produce solutions with the principle “truth has no nationality”.
•
The existence or absence of others is not the reason of our existence or absence
and we believe we should be a party so long as we exist. “We are both everyone
and no one”.
With whom are we working?
•
Ex-users (penitents)
•
Mothers
•
Professional Chambers
•
Psychiatrists, psychologists and social service specialists
•
Sport instructors
•
Art instructors
•
Volunteers
428
Our Principles
Union of treatment-therapy
A1. We first try to convince our addressee for treatment (detox, purification).
A2. During the treatment process, we accompany them as much as possible and try to
ensure that the process is handled appropriately.
A3. Depending on the situation of the addressee; we meet every day with the ones having the most need and at least two times a week with the ones having the least need.
A4. The communication language has been designed not to fall into the common errors
of normalizing the problem or excluding the addressee.
A5. We establish the control network with the ahi brotherhood model by benefiting
from ex-users and volunteers.
A6. There is no doubt that one of the most important elements of this process is the
family. Families develop overly reflexive reactions when adapting to the situation of the
child and this complicates the issues greatly.
Raising Awareness- Touching Life – PERSUASION
We criticize the situation of our addressee,
B1. The reason of this situation
B2. The situation of the addressee caused by this problem
B3. The possible results of this situation and we reinforce the persuasion process whenever possible.
Building the Process as a Whole
C1. Physically;
During the period of 3-6 weeks when deprivation is felt intensively, we provide information about issues to be careful such as
•
Nutrition
•
Sleep
•
Cleaning routine.
C2. Socially;
Environmental purification;
We limit the relations with the areas where the substance is used and from where it is
delivered. For this, we benefit from the penitents.
429
•
Promotion for production;
We promote productive professions, handcrafts and skills classes.
•
Professional rehabilitation;
We benefit from employers who know the situation to find work for the addressee.
•
Cure Visits
Historical places and ruins, hospitals – especially children oncology clinics, nursing homes, cemetery, forest, umrah…
•
Social Responsibility Projects
We ensure that they meet victims and needing people within the project “Guest”, another
study organized within 180 Degrees, we try to make them feel the honor of being the
giving hand.
So, we ensure that they recover from feeling a problem and from living closed to the
environment and that they compensate their deprivation.
C3. Mentally;
•
Reading Programs
In these programs organized periodically, we ensure that they read books, particularly
memories, biographic novels, etc. and we perform the observations together.
•
Double Wings Trainings
We try to ensure they engage in artistic and sportive activities.
•
Example – Model Studies
We attach a special importance to make them learn Quran and read prophetic biographies.
d- Spiritually;
D1. To Raise the Awareness of Time and to Fill the Internal Void;
In the addiction treatment, one of the biggest obstacles met during adaptation and required to be removed is the “active usage of time”. At this point, “prayer” constitutes a basis
to become aware of time, to comprehend “night” and “morning” which were possibly
not experienced for a considerable part of their lives and to realize that time is a wasting
source. While time is a reserve to be consumed for the addicted person, it becomes a
source to be used and made use with “prayers conscious”.
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D2. To Have Self-Consciousness;
An addicted person believes that life will become unbearable in deficiency of the substance and that life cannot be continued in its absence. He/she needs a triggering motivation to remove this acceptance. Fasting is one of the most ancient purification methods
and is prescribed by all religions.
Fasting is an exercise and natural detox that enables addicts to put a voluntary limit
between themselves and the substance and reinforces this limit through rituals such as
iftar and sahur.
D3. To Establish a Social Identity and to Actively Use the Brain;
One of the most important mental problems faced by the addicted people is that they
cannot control the direction and speed of their thoughts. They focus most on the supply
of the substance. Causing intense stress, this problem combines with the defects caused
by the substance usage, so that thinking and its natural result self-talk become a nightmare to immediately get rid of and even to silence. Mentioning (dhikr) is another practicing applied in this sense.
There is no need to prove that mentioning is an important source to apply for the addiction treatment and therapy as it provides the following factors;
•
It has a unique rhythm circle to be followed,
•
The meaning and the tone of the repeated expressions have positive effects on
human psychology,
•
Thoughts that are or can be concentrated in any desired way reduce and prevent
mental disorganization,
•
Sharing the understanding of being an individual of the human group sharing the
same words and meanings,
•
The images and the perceptions of words have direct effects on releasing chemicals regulating the happiness-unhappiness level in human brain,
•
Establishing a unity between body-tongue-mind-heart, contribution of this unity
to inner peace.
D4. For Inner Communication;
One of the methods we apply most for combating addiction is ensuring that “the individual touches his/her own existence”. Discussing different dimensions of the human body
and psychology together and practicing on the relations between sense organs such as
eye-sight, ear-hearing, hand-touching, etc. and their abilities.
The idea workshops such as “My life is like a novel”, “What would you do?” are other
methods we apply to earn intellectual variety and ability to empathize.
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D5. For the Sense of Belonging;
Each addicted person is aware of the negative effects of the circle he/she is in and seeks something that will rescue him/her from the pressure and the stress caused by this
awareness. The emotional motives appealed to most are sensations resulting from basic
communication such as “being hard done”, being left alone”, “not deserving this situation”, “not being understood by people”, etc. These sensations create an effect “legitimizing” their situation.
In this process, it is vitally important to prove that what the addict experiences is not at
all as “he/she thinks”. This is where “Prayer Brotherhood” becomes involved.
Prayer is a direct communication with the transcendent and immanent and when considered, sharing such a communication with someone else is a great generosity. The addressee who wants to get rid of addiction is involved in the prayer chain right after making
this decision, others pray for him/her every day and he/she is asked to pray for others
like himself/herself. So the curative effect of prayer appears. The mind, used to think
negatively, is conditioned to the positive and invites this.
Other methods we apply are the suggestions we make to ensure that the addressee starts
anything with prayer and spares sometime of the day for prayer.
D6. Establishing Common History
We attach a special importance to the participation of the addressees in the thematic
visits we perform together. These visits constitute basis to establish clearer and correct
opinions related to the life and the human. In this sense, the last visits we organized are
“We’re retired from the world” in Alacahoyuk and “Establishment-Ottoman Geography”
in Bursa-Sogut-Goynuk.
Making the decision to undergo treatment-therapy is maybe the most important day of
life for the personal history of the addressee. We also make an effort to act in accordance
with this importance.
First, we organize a symbolic funeral ceremony and we emphasize that it is required to
cancel the “past”. Later, we offer everybody the halva prepared. And after, we give a new
cloth as gift, we perform “groom shave” and lastly we give a new name. We form a social
control network by ensuring that the penitents and the friends of the addressee participate in this ceremonial meeting.
432
Difficulties Encountered on the Field
Difficulty to Situate Oneself
This is a handicap encountered by all civil initiative movements. You are in contact with
parties under intense risk in marginal fields. The simplest question you will be asked is
“Who are you?” and/or “What do you gain from this?”. You can be perceived by official
organizations as more unfavorable, more irritant than the addict you are trying to help.
With regards to the person you are helping, the slightest move or the simplest situation
that will cause you to be misunderstood in the partner relationship you have developed
as a person or an organization will threaten your reliability and the continuation of the
process.
Staff Recruitment and Providing the Continuity of Support
Human resources formed only by volunteers are not sufficient for mid and long termed
studies and problems are encountered in designing studies that can show continuity in
volunteer studies.
Handicaps Resulting from the Treatment Process
The lengthening of the treatment-therapy process causes some setbacks in tracking the
process and acquiring results; our organization that is completely based on voluntarism
is affected by all of these difficulties.
Difficulties of Conducting Methodological Studies
This structure involves some difficulties related to conducting methodological studies,
establishing long-termed corporate relations, creating an inventory and developing modules.
Fund Procurement
Relying on our own resources and on our financial structure which consists of sharing
whatever we have can be insufficient during crisis and we can experience fund procurement problems. The fact that there is currently no suitable place for us to perform our
studies also constitutes an important problem in terms of fund and resource.
433
Conclusion
No social problem can be degraded to only one cause considering its reasons and occurrence. Social problems are formed as a result of the association of many elements that are
either separated from each other or in contact with each other. The difference of reasons
also reveals itself in the context of the results. Seemingly identical reasons may constitute
the basis for unpredicted results and problems.
Substance addiction is also a problem of this kind, in terms of its emergence. The solution of this problem will be possible through methods that are above organizations and
individuals, are multi-disciplinary and have the ability of elasticity and mobilization.
This kind of concept can be realized in the most general sense by getting the opinion of
all parties in the society and by ensuring their representation.
Throughout Turkey, the addiction problem has a considerable amount of addressees and
victims and there are many structures combating for a solution, belonging to different
disciplines and practices. The existence of these structures, most of which cannot be
defined in terms of regulations and are not compatible with the criteria of scientific methodology, brings up many discussions.
Scientific perception is in the habit of approaching the metaphysical and anything that
cannot be measured and defined by its own standards with caution. However, outside
of this context, there is a total that is a party of this problem, that professes solution and
that has an existence which cannot be discussed. We completely trust that this and similar studies will constitute the basis for a meaningful relation between the parties of the
solution, that they will serve as mirror and offer a variety of alternatives for the solution
through mutual opinion and experience exchange.
The benefit of this article for the issues we have stated in the solutions section will be our
most important gain. We express our gratitude to the conducive.
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435
436
Successes and
Challenges
437
438
Bob Keizer*
The Trimbos Institute,
Netherlands Institute of Mental Health and Addiction
ABSTRACT
Developing effective drug policies is extremely complicated. The nature of drug-related problems is constantly changing, reliable data
about these problems and the results of interventions are difficult to collect. Furthermore many sectors and disciplines are involved
(politics, researchers, those who work in day-to-day practice: health workers, police, teachers, media, etc.), and very often the communication and collaboration between these sectors and disciplines is problematic.
The main role of policy makers is to improve the quality of the policy process through collection of data and stimulation of communication and co-operation between these actors. Monitoring and evaluation are essential and indispensable tools for these policy makers.
European drug policies have changed – and improved – significantly in the last 20 years, thanks to the development of national and
international monitoring techniques and evaluation activities.
I shall give a short overview of these developments and the lessons learned. I shall give some examples of the crucial role that monitoring and evaluation have played in drug policy decisions in the Netherlands.
* Bob Keizer is graduated in medical law. He was from 1992-2002 the Head of the Drug Policy Division of the Ministry of Health of The
Netherlands , in charge with coordinating national and international Dutch Drug Policy.
In this capacity he was amongst others the Dutch representative in the Pompidou Group and between 2004-2007 he was the Executive
Chairman of this group.
Furthermore he was for 8 years the Dutch representative in the Management Board of the European Monitoring Centre on Drugs and
Drug Addiction (EMCDDA), and has participated for more than 10 years in all relevant EU and UN drug policy-related developments.
As from 2005 he works as Senior Advisor on international drug policies at the Trimbos Institute, the Netherlands Institute of Mental
Health and Addiction. In this capacity he has been involved in many projects in Europe, North Africa, The Russian Federation, Turkey
and Central Asia (monitoring, policy analysis and evaluation; consultancy and training activities).
439
THE ROLE OF MONITORING AND EVALUATION IN THE POLICY PROCESS
The Role of Monitoring and Evaluation in the
Policy Process:
Some Experiences and Observations
Introduction
In this paper I shall briefly share with you some of my experiences and observations that
I have gathered in the last 25 years when I was working as a drug policy maker, and I
shall pay particular attention to the role that monitoring and evaluation have played in
this process. For more detailed information, I refer to the excellent sources of information that are available on this subject: the publications of the Trimbos Institute within
the framework of the National Drug Monitor (www.trimbos.nl) (see English version:
publications) and of course for the European perspective the website of the EMCDDA
(www.emcdda.org). And feel free to address me personally for more detailed questions.
Characteristics of drug policy and policy making
The first thing I have learned is that developing drug policies is extremely complicated.
The issues at stake are often highly sensitive from a political and public perspective,
there are ongoing changes in the nature of drug related problems, and the input of many
disciplines is needed. Furthermore there is an ongoing development of new methods,
good practices, etc.
And above all particularly in drug policies three different groups of stakeholders are
involved: politicians, researchers and those who are confronted in day-to-day practice
with drug related issues: policemen, nurses, doctors, teachers, parents, etc. However
all three groups have their own characteristics and responsibilities : “politics” tends to
act ad hoc, has little knowledge, is used to think top down, and very often mixes up
emotions and facts. But it also has the responsibility to make sure that the policy can be
carried out in practice and has sufficient scientific backing.
“Science” has always problems with budgeting and programming, and tends to think on
an ivory tower. On the other hand, science has responsibilities too: science will need to
pay more attention to the question of what kind of information politicians need in order
to make good decisions. What is more, science will also need to spend more time considering what kind of research could support the day-to-day practice of drug policy better.
“Practice” has always a lack of capacity, budget and knowledge, but also has a responsibility, in the sense that clear signals must be sent out to policy and to science about the
440
state of affairs “on the shop floor” and about the need for (scientific) support that people
are feeling there; often enough this too is lacking.
This mixture of characteristics makes it difficult for a policy maker to develop efficient
drug policies.
A policy maker has -or should have- several tools at his or her disposition, like Strategies
and Action Plans, Coordination mechanisms, research and innovation structures, etc.
But most of all, monitoring and evaluation are crucial policy tools. Monitoring is essential in order to assess the actual situation in practice, and is the basis for evaluation.
And evaluation is necessary for assessing the results of policy measures and identifying
inter-relationships of these measures, and is the basis for innovation, research, and formulating future policy.
My main observation in this regard is that a good policy maker is primarily a manager
and communicator. The main task of a policy maker is to raise awareness amongst politicians, scientists, practitioners of their interdependencies and responsibilities, to improve
communication and co-operation.
Monitoring and evaluation in the Netherlands
Dutch drug policy
The main characteristic of our drug policy, which was formulated in the mid-seventies,
is that Dutch policy does not moralize, but is based on the assumption that drug use is a
fact and must be dealt with as practical as possible. The most important objective of our
drug policy is therefore to prevent or to limit the risks and the harm associated with drug
use, both to the user himself and to his environment. A wide range of care and prevention facilities have been available since the seventies including methadone prescription
and needle exchange programs. Furthermore, dealing in small quantities of cannabis,
through the outlets known as coffee shops, is since 1976 tolerated under strict conditions. This tolerance is a typically Dutch policy instrument which is based on the power of
the Public Prosecutor to refrain from prosecuting offences. This principle is formulated
in the law and is called the “expediency principle”. The small-scale dealing carried out in
the coffee shops is thus an offence from a legal viewpoint, but under certain conditions
it is not prosecuted.
The Netherlands’ drug policy is characterized by a high degree of collaboration between
the different parties concerned, such as the health care, judicial and public administration authorities. Our country is also highly decentralized, and consequently there is
always close collaboration between the national and local levels.
Another Dutch characteristic is that we try to treat the drug problem as rationally as
possible, and we mainly look for practical solutions. Because of these characteristics, we
441
regard data collection and processing as extremely important. Research, monitoring and
evaluation have therefore played a permanent part in formulating an “evidence-based”
drug policy, right from the start.
Criticism on the Netherlands
In the mid-nineties, however, an extra boost was given to these activities. At that time,
both national politicians and local populations in this country were expressing more
and more doubts about the value of the Netherlands’ own specific approach to the drug
problem. This was also connected to the fact that our policy came under heavy fire from
other countries at that time. Germany, France, Sweden and the US all put heavy pressure on us to modify our policy (that is, to make it much more restrictive). The criticism
focused on two main areas. There were well-founded complaints –about trans-border
drug trading, for example– but also complaints about the underlying philosophy of the
Netherlands’ policy. Some countries felt that we had the wrong attitude and that we were
setting the wrong example to the world.
At one point, when President Chirac of France came under attack because of the French
atomic tests in the Pacific, he remarked that the damage caused by the nuclear tests was
negligible in comparison with the disastrous effects of the Netherlands’ drug policy.
The question of re-evaluating the Netherlands’ policy was discussed at length in 1995/96,
both in Parliament and among professionals in the field. These discussions led to a number of modifications, but no fundamental changes. This was largely because the available
data provided no proof that Dutch policy was producing worse results than that of other
countries: indeed, in many respects we were actually doing better. One outcome of this
debate, however, was a clearer recognition of the importance of collecting and processing good, reliable data and the need to give high priority to further expansion of our
monitoring and evaluation activities. The Minister of Health decided in 1997 to create a
National Drug Monitor (NDM), to be managed by the Trimbos Institute.
It is only a slight exaggeration to say that we can mainly thank our foreign critics for our
present high-quality data collection system.
The National Drug Monitor:
The NDM is not a new, supplementary monitor, or an all-embracing system to replace
all these existing sources. Rather, the NDM operates on the assumption that the Netherlands has enough monitors already, and its job is to promote quality and cohesiveness
between all these information sources, to improve planning, and to publish a number
of products at regular intervals designed to meet the different information needs that
exist. It publishes the NDM Annual Report, which is submitted to the Parliament each
year, and other reports on the drug situation in the Netherlands. Another important
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NDM activity is producing reports for the European Monitoring Centre on Drugs and
Drug Addiction (EMCDDA) and also other regular reports for the UN and the WHO.
The NDM’s products are accessible to everyone at the following internet address: www.
trimbos.nl (see English version – publications).
The NDM covers a wide range of subjects (drugs, alcohol, tobacco, trafficking, production and possession of illegal drugs, drug users in the criminal justice system, etc.),
and it makes use of a variety of sources, like national prevalence studies, international
sources like ESPAD and HBSC, regional and urban alcohol and drug monitors, school
surveys, NEMESIS (mental health), public opinion polls, Central Methadone Registration, LADIS (outpatient addict care), registration of national clinical mental health care,
HIV/AIDS/ TB/other infectious diseases registration, DIMS (drugs market monitor),
Trend monitors, Justice data: violation Opium Act, drug seizures, addiction problems
in prisons, etc.
Stimulating international activities
As mentioned above, right from the beginning the Netherlands’ Ministry of Health has
funded more or less on a regular basis a number of monitoring and research activities on
drug related issues. Consequently we had in the eighties quite a number of highly specialized researchers at our disposition, and the Ministry has encouraged them to participate
in international activities.
A very important achievement in this regard was the role that Dutch researchers have
played in the development of the so-called key epidemiological indicators in the framework of the Pompidou Group. These indicators were a set of standards and protocols
in order to harmonize the collection and comparability of data from various countries.
Indicators were developed regarding drug use in the general population, problem drug
use, treatment demand, drug related deaths and infectious diseases.
These indicators formed the basis of the activities of the EMCDDA that became operational in 1995. Since then the EMCDDA has succeeded in developing itself into a well-respected authority in the field of drugs data collection and monitoring.
The input of the EMCDDA in the EU Strategies and Action Plans (mainly by providing
comparative, reliable, overviews of the drug situation in the EU) has in its turn led to the
situation that national authorities are relying more and more on these data when formulating their own drug policies. And this would have been unthinkable 20 years ago, when
the European drug debates were dominated by unreasonable and unfounded arguments.
Some observations and conclusions:
Needless to say, we have gained a great deal of experience with monitoring and evaluation as the basis for evidence based policy, which, incidentally, is still in development.
443
Probably our experiences will be of interest to other countries, too. Here are a few observations and conclusions, in no particular order
Monitoring and evaluation must be regarded as indispensable elements of evidence based
drug policy.
By collecting data and by improving the quality of the data, and, above all, by evaluating
policies we have achieved considerable progress in this complex field. It took time, money and political will. But all these investments in monitoring, evaluation and research
have resulted in fundamental changes in approach of the drug problem in Europe in the
last 20 years.
We have succeeded in elevating drug policy from a blind faith into a science, and that is
a great achievement.
The choice of evidence-based policy does not mean in my view that there should be no more
room for opinions which are not evidence-based. It is inherent to political decision-making that opinions about ethics, morality, the relationship between the government and
the public, and issues such as individual freedom and personal responsibility are also
interwoven into that decision-making. These are all elements which cannot be substantiated with “evidence”. Evidence-based policy does not mean that there will no longer be
room for these elements, as long as we separate clearly the opinions from the facts.
Monitoring is not cheap, and what is more, monitoring is only worthwhile when carried out
as a structural activity.
Developing the monitors, and above all structuring the process of co-ordination and
streamlining, is something that takes many years to achieve. Only then can trends be
measured and policies evaluated.
But it also pays off. It improves the quality of policy because it can be evaluated much
more broadly and thoroughly. It is particularly true in the field of drug policy that every
measure also produces side-effects. By identifying the inter-relationships, we can gain a
better understanding of this causality.
Monitoring and evaluation policy cannot exist without sufficient political support, if only
because of the need for structural funding. At the same time, a strict distinction must be
made between mon

Drug Policy and Public Health - ids

Transcription

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