A time for everything: changing attitudes and approaches to reducing substance abuse

John S. Millar, MD

CMAJ 1998;159:485-7

Reprint requests to: Dr. John S. Millar, Office of the Provincial Health Officer, 3rd Floor, 1810 Blanshard St., Victoria BC V8V 1X4; fax 250 952-0877; john.millar@hnet.moh.hnet.bc.ca

© 1998 Canadian Medical Association

• Canada's drug problem: time to get serious: Letter 1, Letter 2

Substance abuse is an enormous problem in Canada. Its total costs have been estimated at $18.4 billion and its direct costs at $6.6 billion annually.¹ But the nonmonetary costs are even more important.

• Tobacco use continues to be the leading lifestyle-related cause of death in Canada.
• Alcohol abuse causes high rates of disease, disability and death from cirrhosis, various types of cancer, injuries and congenital defects.
• In some jurisdictions in Canada, narcotics overdose has become the leading cause of death among adults aged 30­49 years. The leading risk factor for new cases of HIV infection in BC is injection drug use, which is also responsible for current epidemics of hepatitis B and C.^2,3

These problems are not new. So why have we been unable to implement strategies to reduce the widespread health impacts of substance abuse that are consuming so many tax dollars and leaving so many people sick or dead? Several factors have been working against the efforts that have been made. For example, we now know that the tobacco companies have intentionally targeted their marketing efforts toward young people and that these efforts have been effective in attracting new recruits to tobacco addiction from among young people. Furthermore, some policies, such as reduced tobacco taxation, appear to have increased tobacco use among the young. Epidemics of heroin and cocaine use have occurred because of the combined influences of cheap prices and increased supplies, along with inadequate prevention and treatment services.

So what can be done?

A change in public attitude

First, there must be a fundamental change in public attitude and political will. We must recognize that a person with a substance abuse problem has a chronic medical condition that merits effective prevention programs and good medical care, not a prison sentence. We must also realize that as well as causing much avoidable death, suffering and expense, injection drug users in particular represent a large and growing pool of infectious disease that poses a threat to everyone.

A better understanding of addiction

We now know that there is a biological or genetic propensity for substance abuse,^4,5 just as there is for other chronic diseases such as diabetes, hypertension and asthma. All of these chronic conditions, including substance abuse, are also characterized by clinical management difficulties arising from deficiencies in diagnosis and treatment. There is often poor compliance with recommended life-style changes. Compliance with treatment regimens for these chronic conditions is hampered by social and economic circumstances such as poverty, chronic mental illness, unemployment and homelessness.

In the case of injection drug users, outcomes are often further compromised by societal attitudes and policies that relegate these people to inadequate housing and other social services and may even force them into criminal activity.

Primary prevention of substance abuse

Children

Children who are abused and neglected are far more likely to have poor coping and learning skills, school readiness and performance; they are more likely to drop out of school and to become dependent on financial assistance; and they are more likely to experience teen pregnancy and engage in criminal activity. In addition to experiencing these poor socioeconomic outcomes, people who have been abused and neglected as children often have serious substance abuse problems. There is now very good evidence that programs to assist families in circumstances that increase the risk of inadequate early childhood care can substantively reduce the likelihood of these poor outcomes.⁶ Moreover, such programs are cost-effective and generate cost savings in terms of government expenditures: it has been estimated that as much as $7 can be saved for each $1 spent on such programs.⁷

Mental health services

Many substance abusers have a concurrent mental illness of some type, and prevalence studies of mental disorders have shown that substance abuse is common among people with mental illness.⁸ Because there is considerable overlap in clients seen by mental health and addiction treatment services, specific interventions for substance abuse will not be truly effective unless adequate and coordinated mental health services are in place.

Social and environmental conditions

For many chronic substance abusers, poverty, homelessness and repeated incarceration constitute a way of life. Without stability and support in their lives, any interventions to deal with substance abuse will have limited effectiveness.

Interventions to treat substance abuse

Tobacco

On the basis of current evidence, we know that several measures are effective in reducing tobacco use, including legislated approaches that restrict sales to minors, improved warning labels on tobacco products and prohibition of tobacco advertising and sponsorship. Media campaigns educating the public about the dangers of tobacco use and about the deliberate attempts of tobacco companies to attract new addicts from among young people are well received, and school-based programs to educate students about the dangers of tobacco, the advertising efforts of tobacco companies and ways to resist peer pressure have all shown good results. Other approaches include measures by governments and businesses to limit exposure to environmental tobacco smoke, as well as regular monitoring of smoking rates to measure the success of anti-tobacco programs (and to allow changes to the programs if appropriate) are also effective. Smoking cessation treatment has been shown to be cost-effective.⁹ Physicians and other health care professionals need to explore ways to optimize the provision of cessation interventions.

Alcohol

There is good evidence that active case-finding and counselling by physicians is effective for detecting and treating problem drinking.¹⁰ However, there continue to be major challenges in encouraging and monitoring the provision of these services by physicians.

The detection and treatment of drinking during pregnancy is also effective.¹¹ Fetal alcohol syndrome and its effects are a major cause of poor health, and we must improve delivery of effective services to prevent these tragic cases.

Injection drug use

Several recent studies have suggested that to adequately address the problem of injection drug use, we need a comprehensive strategy, implemented through an integrated service delivery system.¹² The measures described here will be effective only if resources are also made available to provide adequate mental health services and adequate housing and social services.

The first measure is to adopt a harm-reduction approach and philosophy that accepts as the principal aim of treatment the reduction of harmful health and societal effects without requiring abstinence. This approach necessitates such services as needle exchanges, provision of condoms for injection drug users and sex trade workers, and street outreach programs for youth, aboriginal people and other marginalized groups.

Comprehensive methadone treatment services for users of heroin (alone or in combination with cocaine or other drugs) must be expanded. Methadone programs, in combination with counselling and other appropriate supportive services such as social, housing and mental health services, are highly cost-effective in reducing injection drug use and criminal activities, allowing a return to employment and reducing dependence on financial assistance.¹³

Even when methadone is fully available, some heroin injection drug users do not respond satisfactorily to treatment.¹⁴ For these addicts, there is evidence that medically supervised heroin maintenance is a cost-effective harm-reduction strategy.¹⁵ The federal government must cooperate with provincial and local governments to establish the pre-conditions for an evaluation of medically supervised heroin maintenance in Canada.

Other pharmaceutical agents that may be effective in reducing the harmful effects of heroin, cocaine and other injection drugs must be explored.

For injection drug users of substances other than heroin, there is an array of effective treatment services, including detoxification facilities, residential treatment and rehabilitative counselling. These, too, need to be expanded.

The Addiction Research Foundation Division of the Addiction and Mental Health Services Corporation is to be applauded for providing regular survey data on drug use in Ontario. It is only by regularly measuring our progress (or lack thereof) that interventions can be evaluated. Data such as those reported by Adlaf and Ivis should be collected regularly on a national basis. Their study shows that we are not making the desired progress in reducing the use of tobacco, alcohol, cocaine and injection drugs. This lack of progress is costing us heavily as a society both in human suffering and waste and in government expenditures. The time has come to recognize that substance abuse is a chronic medical illness for which there are effective prevention programs and treatments. Let's stop treating addicts and substance abusers as criminals and begin treating them as patients who deserve respectful, effective care.

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