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COMMENTARY 3.4
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Drug Misuse – Lessons
Learned Through
the Modern Science
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This commentary discusses the three chapters – ‘Epidemiology of Drug Abuse: A Global
Overview’ by Maria Elena Medina-Mora, Tania Real, Rebeca Robles; ‘Drugs: Prevention’
by Vladimir Poznyak, James White and Nicolas Clark, and ‘Drugs: Treatment and Management’ by Fabrizio Schifano. These chapters represent several of the major perspectives
in this emerging and exciting area of addiction science and practice. Each text approaches
specific issues in the enormously large area of drug and alcohol misuse and addictive behaviour in ways that are distinctive, comprehensive and interesting. Although each chapter
addresses a separate theme, all together they cover the major components of addictive
behaviour – biological interventions, psychological vulnerabilities and socioenvironmental
factors through epidemiological analysis. They also have several commonalities – a broad
view of addiction science, deep knowledge of the current research, thoroughness and
presentation that is understandable to and applicable by practitioners.
In reviewing the texts it is important to mention the social context in which current
addiction science is unfolding. Drug and alcohol use, misuse and dependence produce dramatic costs to society in terms of lost productivity, a myriad of social consequences, and,
of course, multiple and serious health care issues. In response, there has been increased
interest in the development and expansion of prevention and treatment programs as a way
of dealing with problems directly or indirectly related to drug and alcohol use. Yet, while
the large proportion of the public is demanding greater availability and more funding for
prevention and treatment, there are others, particularly in governments, insurance industries, health care and the general public who question the efficacy of these activities, and
whether or not they are ‘worth it’. Such a variety of opinions appears to relate to core
public perceptions about substance use in general, and about what would constitute an
‘effective’ intervention, regardless of its type. Some believe that drug addiction is primarily
a ‘social problem’ requiring a social-judicial solution, rather than a ‘health problem’ requiring prevention and treatment. This perception is quite understandable considering the
extent and significance of the social problems caused by drug and alcohol abuse. Thus,
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Substance Abuse Disorders Edited by Hamid Ghodse, Helen Herrman, Mario Maj and Norman Sartorius
C 2011 John Wiley & Sons, Ltd
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it is not surprising that many in the policy-making arena and in the public at large rely
mostly on law enforcement and interdiction efforts instead of public-health efforts to correct the drug problem. This perception is also related to the widespread scepticism about
the effectiveness and value of prevention and treatment for substance use disorders. Many
people believe that treatment-orientated approaches send an uncomfortable message that
the view of addiction as an illness suggests that the addicted person is not responsible for
the disease, nor the addiction-related problems and behaviours. Also, many in the public
believe that neither prevention nor treatment ‘work’. Specifically, many do not believe
that any treatment can get addicted persons ‘off drugs and alcohol’ and keep them off.
This is a view that is apparently shared by many physicians, despite scientific evidence
supporting neuronal mechanisms, heritability, treatment responses and a characteristic progressive clinical course of substance use disorders. It has been repeatedly documented over
the past three decades that a majority of physicians do not screen for signs of alcohol or
drug dependence during routine examinations. The ‘failure’ of substance-abuse prevention
and treatment to reliably produce long-standing abstinence is often seen as confirming the
suspicions about the need to continue both efforts. But are these perceptions true? Is there
a role for addiction prevention and treatment in public policy aimed at reducing demand
for drugs and reducing the social harms and costs associated with drug abuse? If treatment
was considered a wise public investment, what treatment –behavioural interventions, medications, or combinations – should be provided? Finally, is there evidence that prevention
and treatment can be effective and valuable – not just to the affected patient – but to the
society that is expected to support those activities?
One of the important first steps in answering these and many other questions is to get a
reliable and comprehensive picture of the extent of the problem both locally and globally.
The chapter on epidemiology written by Prof. Dr. Medina-Mora and her collaborators offers
the reader exactly that – a comprehensive epidemiological picture of the problem, thus it
sets the stage for other chapters and the rest of the book. Although drug and alcohol abuse
is definitely a global problem, most of the epidemiological analyses have largely been
those of the most affluent and developed countries – United States, Canada, Australia, UK
and some other Western European countries. The chapter by Dr. Medina-Mora provides
us with very recent data from virtually the entire world. While extremely rich in data and
information, there are three very important and unique contributions that I would like to
mention. First, the entire epidemiology as science is reviewed from multiple contextual,
foundational and cultural perspectives, which largely explains the differences in scientific
approaches between different countries, and, quite importantly, emphasizes the issue of
scientific tolerance and compatibility between different models. Secondly, the authors
emphasize the lesson learned by the entire international community, that in order to better
understand the problem and to be more effective in addressing it, an integrated global drug
epidemiology information system is essential. Thirdly, it gives a significant rationale for
departure from the ‘static’, ‘linear’ way of thinking (‘works – doesn’t work’, ‘effective –
ineffective’, etc.), to a more ‘circular’ conceptual approach considering cultural differences
and the circular nature of the drug problem with epidemic rises, periods when drug use is
stable or is reduced, followed by a new rise.
The initiation of substance use is primarily an adolescent phenomenon, occurring within
the context of great physical and psychological change. During adolescence, individuals typically experiment with a wide range of behaviours and lifestyle patterns as part
of the natural process of separating from parents, developing a sense of autonomy and
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DRUG MISUSE – LESSONS LEARNED THROUGH THE MODERN SCIENCE
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independence, and acquiring some of the skills necessary for functioning effectively in
the adult world. Profound cognitive changes occur during the beginning of adolescence
that significantly alter the adolescent’s view of the world and the manner in which he/she
thinks. Also, adolescents tend to have a heightened sense of self-consciousness concerning their appearance, personal qualities and abilities. Furthermore, as children approach
adolescence, there appears to be a progressive decline in the impact of parental influence
and a corresponding increase in the impact of influence from peer networks. Finally, teens
often perceive that they are not susceptible to the hazards presented by risk-taking and
health-compromising behaviours. These and other developmental changes occurring during this period increase adolescents’ risk of yielding to various direct and indirect pressures
to smoke, drink, or use drugs. The authors of the chapter on prevention share the public
concern over the issue of drug abuse amongst children and adolescents and present a good
review of the science on ways of deterring or delaying onset of this behaviour. This chapter
reviews the empirical evidence on the efficacy of substance-abuse prevention efforts and
addresses a number of interrelated critical questions: What scientific evidence supports the
efficacy and effectiveness of drug-abuse prevention programs and policy in schools, the
workplace and communities? What are the associated costs? Are the programs and policies
beneficial to those receiving them? How can the practice of prevention be improved by the
emerging science of drug-abuse prevention? Practitioners and administrators in the field
of drug-abuse prevention programs are seeking science-based answers to these questions
in order to plan and implement programs that are high-quality, empirically supported, and
cost efficient. These interventions go beyond a simple demonstration of the health consequences of alcohol and drug abuse. They are theoretically based in the fundamental science
of human developmental and behavioural psychology. Historically, drug-abuse prevention
programs have been founded on the theoretical assumption that children and adolescents
used drugs because they are ignorant of the consequences of such use. Failure to recognize
negative consequences resulted, according to this theory, in neutral or even favourable
attitudes regarding experimentation and/or regular use. During the 1960s, drug-education
programs focused on providing information. These programs frequently contained ‘feararousal messages’ regarding the health and social consequences of such use. Available
evidence indicates that teaching only about the extreme negative consequences of substance abuse is of marginal value as a prevention strategy. Traditional health-education
approaches have been found largely unsuccessful in reducing rates of drug abuse, although
certain types of knowledge about the use of tobacco, alcohol and drugs may be a useful
component of substance abuse prevention programs. More encouraging results are reported
from research studies based on psychosocial models of behaviour from the 1970s, when
social scientists had begun to address interpersonal and intrapersonal factors that influenced drug-abuse behaviours amongst children and adolescents. Several studies found drug
abuse was associated with attitudes, beliefs and values, as well as other personality factors
such as feelings of self-esteem, self-reliance and alienation. These findings have stimulated
the development of other approaches to prevention – rather than focusing on drug-abuse
behaviours, effective education focused on the factors associated with use, attempting to
eliminate the reasons for using drugs by creating a school climate that was supportive of
students’ social and emotional needs. These programs frequently focused on training the
students in effective decision-making skills. Because perceived risk is an important determinant of drug experimentation, the danger of drugs should be conveyed accurately and
credibly to our youth. Schools provide a natural setting for these interventions and have
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the means to identify youth with higher risk. The authors are right in their conclusions
that education designed to prevent addiction should be well integrated into our schools and
should be further developed with research-based interventions.
In addition to epidemiology and prevention science, research on the neurochemical,
molecular and cellular changes associated with drug dependence has led literally to volumes of remarkable findings over the past decade. There is now clear evidence that most
addictive drugs have well-specified effects on the brain circuitry that is involved in the
control of motivated and learned behaviours. This evidence originated from studies in animals, and with recent developments in brain-imaging techniques, has been confirmed in
humans. It is likely that both the direct and sustained physiological changes produced by
the drugs themselves and the acquired effects produced by conditioned cues are involved in
the ultimate explanation of the continued vulnerability to relapse even amongst motivated
and abstinent drug-dependent individuals. The chapter by Dr. Schifano is focused on medications currently available for use by physicians in the treatment of nicotine, alcohol and
opioid dependence, and for the treatment of co-morbid psychiatric disorders associated with
all forms of substance dependence. These have been tested in multiple trials and have been
shown to be effective. Pharmacological strategies are emerging that target specific clinical
components of addiction, including drug-induced euphoria, hedonic dysregulation, craving
and even denial. The chapter by Dr. Schifano presents a very elegant comprehensive review
of the most recent data on a variety of pharmacological options in addiction treatment. It
highlights the area of addiction research that illustrates brain involvement and brain dysregulation as one of the core components of substance use disorders, and will definitely stimulate
public interest because it is conveyed in a clear and understandable fashion. Furthermore,
presented pharmacological options that dramatically improve clinical outcomes should reverse social stigma and justify an expanded care-delivery system. The clinical impact of new
treatments also depends on their translation into clinical practice. Even when effective treatments for addiction have been identified, as illustrated by Dr. Schifano’s review, they have
not always been adequately translated into clinical practice. This can be explained partly by
the public attitude toward the problem, briefly mentioned above. Another possible reason
is the complexity of neuropharmacological research that is often difficult to understand, let
alone apply, even for trained practitioners. So, the author is correct in concluding that there
is a need for additional studies on the appropriate use of these medications in ‘real-world’
treatment of drug-dependence disorders, as well as more translational research. The chapter by Dr. Fabrizio Schifano offers a great example of bridging the gap between academic
science and clinical practice by providing clear treatment guidelines and algorithms for
different clinical situations, including emergencies. This is particularly important in view
of the obvious need for better integration of addiction treatment into mainstream medicine.
The role of primary-care physicians and practitioners is essential in both treatment and
prevention and they should be provided with the most recent science-based knowledge and
skills in pharmacological and nonpharmacological treatment approaches.
The chapters mentioned in this commentary provide a comprehensive scientific analysis
of several critically important areas in addiction science. Although very important, perhaps
this is not the biggest contribution made by the authors. What is really impressive is the
authors’ ability to effectively bridge the gap between highly academic science and the
realities of daily operations by frontline treatment practitioners. Therefore, I am confident
that the entire book will serve the needs of professionals far beyond universities and research
laboratories. This will be a great addition to the existing literature in the field.
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