Thomas Kattau
“What should we prevent – use, abuse or
addictions?“
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Finn-Czech Media Seminar on Substances “Addicted Society – today
and in the future” – Prague 2010
What should we prevent – use, abuse or addiction?
Presentation by Thomas Kattau
All over Europe and beyond we are facing a big concern about the use of drugs and the harmful
consequences. We all want a happy and safe future for or children living in a as far as possible drug
free world. But this is complicated already when it come to the definition of the term ‘drug’.
A drug, broadly speaking, is any chemical substance that, when absorbed into the body of a living
organism, alters normal bodily function. Pharmacologically a drug is a chemical substance used in
the treatment, cure, prevention, or diagnosis of disease or used to otherwise enhance physical or
mental well-being.
But there is no single, precise definition, as there are different meanings in medicine, government
regulations, and colloquial usage. The drugs we refer to in common language are mainly
psychoactive drugs or psychotropic substance which are chemical substances that act primarily upon
the central nervous system where it alters brain function, resulting in temporary changes in
perception, mood, consciousness and behaviour.
These substances can be found in plants or natural products, medicines, and other chemical
compounds designed for different purposes. As ‘drugs’ they are used:
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for medicinal purposes
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recreationally to purposefully alter one's consciousness,
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as entheogens (agents) for ritual or spiritual purposes,
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as a tool for augmenting the mind, or for therapeutic means (easing pain, depression etc).
Why are drugs used
Drug use is a practice that dates to prehistoric times. There is archaeological evidence of the use of
psychoactive substances dating back at least 10,000 years, and historical evidence of cultural use
over the past 5,000 years. While medicinal use seems to have played a very large role it has been
suggested that the urge to alter one's consciousness is as primary as the drive to satiate thirst,
hunger or sexual desire. Today the use is often connected to the pressures of modern life.
However, several researchers suggest now that the long history of drug use indicates that the drive to
alter one's state of mind is universal. This appears actually not to be limited to humans: it has been
observed that also animals consume different psychoactive plants, berries and even fermented fruit,
thus becoming intoxicated (such as cats after consuming catnip). Some traditional legends of sacred
plants often contain references to animals that introduced humankind to their use. Modern biology
suggests an evolutionary connection between psychoactive plants and animals, these is seen as a
possible explanation as to why these chemicals and their receptors exist within the central nervous
system.
Psychoactive drugs – or simply ‘drugs’ as we refer to them in colloquial language- are often
associated with addiction and dependency. Addiction are commonly divided into two types:
psychological addiction, by which a user feels compelled to use a drug despite negative physical or
societal consequence, and physical dependence, by which a user must use a drug to avoid medically
harmful withdrawal. Not all drugs are physically addictive, but any activity that stimulates the brain's
reward system can lead to psychological addiction.
We all know that in addition to addiction drug use can lead to other severe health problems, for the
drug user but also for public health (HIV/AIDS, hepatitis, STD); as well as high risks for public safety
such as crime and public nuisance. These problems caused governments initially responding to drug
use by banning many drugs, or restricting their availability (prescription drugs) or making their use,
supply and trade a criminal offense and consequently locking up many people involved in drug use.
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Today it is widely acknowledged that illicit drug use cannot be sufficiently stopped through policies
that focus on inter-diction, criminalization and primarily on repression. Consequently there are
indications that the international drug policy approach is in the process of being re-balanced: towards
different forms of social interventions as well as medical treatments and therapies were introduced.
The aspect of prevention in this context is the probably the most crucial aspect in any drug control
policy.
What do we want to prevent?
The first question which needs to be answered is:
What do we want to achieve through prevention?
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Preventing substance use?
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Preventing drug abuse?
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Preventing drug misuse
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Preventing harmful consequences of drug use?
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Preventing substance or behavioural dependence (addiction)?
The problem is that things are somewhat complicated in organising policies with general and farreaching prevention goals; just like creating the ‘drug free society society’. In addition prevention
faces a number of challenges and dilemmas:
A value issue
A drug is a heavily value- and emotion-laded issue. Therefore there is no overall consensus in society
on the question if abstinence or reducing the negative consequences of substances use should be
the overall policy aim. Furthermore people have different culturally rooted opinions about different
substances. This makes is difficult to find a consensus that would allow agreeing on clearly defined
prevention objectives, goals and targets.
Problems of systematic categorisation
This is actually reflected in the categorisation of drugs, which is political and not based primarily on
health risk and other dangers. This causes serious systematic problems: some substances are legal
and unrestricted, some are legal but restricted and others are illegal. These different categories
prescribe different legal frameworks policy can react within:
With legal substances only the prevention of abuse is opportune
With restricted substances only the prevention of misuse is possible
With illegal substances the prevention of all use is imperative
In terms of addiction/dependency prevention this is often counter productive in so far as the different
legal categorisations prescribe different approaches and interventions that are not coherent but, from
a therapeutic perspective, create contradictions.
A lack of Credibility
As a consequence of different categories of drugs, prevention messages are different, depending on
the legal status of a substance. Incoherent or even conflicting messages are the result. This seriously
challenges the credibility of prevention efforts, particularly when they take an angle on healthprotection and healthy life-styles. The discussion about the gravity of health problems resulting from
some legal substances (alcohol, nicotine) compared with those of some illegal drugs (cannabis,
cocaine) exemplifies this well.
But the credibility problem in drug prevention is aggravated further by more contradictions. Today we
face a situation in many societies where the use of some drugs is actively discouraged, while the use
of other drugs is increasingly promoted. Many people would like to see a drug free society but as
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consumers happily go for any new and promising drug on offer. From Viagra to Ritalin, the market for
performance enhancing drugs and lifestyle drugs is a major growth market.
Drugs which offer quick-fix solutions for depression, attention-deficiency, relaxation, sexual
performance, weights loss and emotional stability are increasingly in demand.
The lifestyle drugs market was worth a phenomenal €20 billion already in 2007. To boost its value,
pharmaceutical companies are actively searching for new lifestyle products and conditions. Most
profits by the associated industries are these days made with these types of drugs and not with
prescription drugs. And the market is rapidly growing not only thanks to new drugs but mainly
because of increasing consumer demand and not yet met desires for more pharmaceutical and herbal
quick fixes.
Communication
Current messages about drug prevention are often designed to please politicians and voters but don’t
always register with the kids and their parents we need to reach. Many drug prevention messages are
delivered based on what politicians and adults think are the issues in drug abuse. For many young
people these messages are simply boring. ‘Just say No campaigns’, for example, please politicians
and voters but in general only appeal to a minority of young people –most of them not really at riskand scare parents.
A long-term effort
The quick-fix attitude today poses a further dilemma for drug prevention. While treatment and law
enforcement interventions usually lead to some immediate or at least mod-term result, effective
prevention is a long term effort. It is not just one intervention but rather a series of programmes and
interventions throughout childhood and adolescence by a variety of actors (parents, peers, teachers,
doctors, social workers, psychologists). Research suggests that outcomes of prevention programmes
can only be measured, if at all, with a time delay of 5 – 10 years. But unfortunately in time of quick-fix
solutions society, and therefore also politicians, expect results within much shorter periods of time.
Since effective prevention takes long-term efforts in different life contexts and situations according to
the developmental stages of the target groups, it must be a multifaceted and multi-disciplinary affair
requiring the action and involvement of many stakeholders. But research shows that there is a
widespread lack of the capacity to manage networks and resources across sectors, as well as being
able to ensure coordination and continuity, among the professionals who are charged with
implementing prevention programmes. In addition there is often a low level of professionalism in view
of the evaluation of success.
Measuring success
In general measuring success is complicated in drug prevention. As already outlined assessing the
impact of prevention programmes requires rather long-term empirical research, and because of the
multifaceted nature of the matter the number of variables makes it difficult to attribute success to a
specific programme or intervention.
Assessing the impact of prevention is further complicated by the fact that the effective elements of
prevention are soft skills, which these are hard to assess in general. In addition positive results
constitute most the time synergy effects that are related to many other aspects than just the
prevention intervention but may have positively inter-acted with it.
It should be borne in mind however that it is not only difficult per se to assess success of prevention,
but that there is also a ‘weak ‘culture of reflection’ across Europe. As a consequence there is a wide
absence of measuring at least some proxy indicators that can be derived from known protective
factors and risk factors.
Furthermore the setting unrealistic success indicators by politicians (such as a drug free society or the
reduction of drug use in the population of children whose parents have undergone a prevention
programme by 30 %) set up many prevention efforts from the very beginning. Such goals are simply
not suitable to guide rational and sustainable drug policies. If such goals were defined for other areas
of public policy this would lead to disbelief and cynicism.
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Towards addiction prevention
So the question is: How to pursue drug prevention goals under such complicated conditions?
In view of the outlined difficult and the unsatisfactory results from the past, some countries have now
changed their policies from different prevention policies (for legal substances, illegal substances,
internet, gambling) to an overall addiction prevention policy. Preventing negative effects of drug use is
usually a major component of these integrated addiction prevention policies. In this way they are
more far reaching than traditional approaches. The aim of such policies is to prevent addiction to
substances (psychological and physical dependence) and non-substance related addictions
(behavioural dependencies).
Preventing adverse effects of drug use
An important element of these policy is the prevention of adverse effects of substance use (health,
social, public safety and nuisance etc.) as a way to avoid a development from casual use to addiction
(secondary prevention); as well as to open gateways into treatment (tertiary prevention).
In general the elements of the pillar of addiction prevention policies combine the most widely used
tools and interventions of what is known as ‘harm reduction’ and ‘risk reduction methods’. In the field
of illegal drugs (needle exchanges, consumption rooms, heroin treatment, drug testing etc.) as well as
in the field of legal drugs (smoke free environments, alcohol self-testing, etc.)
Most of these measures would be targeted prevention towards specific groups.
Preventing drug use or delaying the onset of use
As for the level of general prevention (primary prevention) the most promising approaches also turn
away from a substance oriented approach towards an addiction and harm/risk reduction perspective,
such as Life Skills Training programmes (LS).
Life skills training
The Life Skills Training approach has been yielding the most promising prevention results. Life Skills
Training is a social skills training. It is actually the only prevention methodology whose impact has
been researched over a long period showing a significant positive impact. The study, conducted in 6
countries, showed that the LS concept is adaptable to and functional in different countries and
cultures, yielding the same positive results:
significantly increasing the number of 10 – 14 year olds who do not use drugs at all
substantially delaying the onset of first use of alcohol, nicotine and cannabis among those who
chose to try drugs
Thus, at present time this type of social training is the most promising strategy in general primary
prevention.
The research on LS Training has shown however that the effectiveness of the method greatly
depends on the setting it is applied in.
Different environments were tested for LS programmes: home/family, peer group/leisure time, and
school. The results showed clearly that by far the most effective environment to achieve lasting
impact with LS Training was in the school with teachers as facilitators.
Life Skills Training is based on the idea of training teenagers about addictions, substances and health
risks, and ways how to resist the negative influence of their schoolmates, adults, mass media and the
environment encouraging the use of narcotics (legal and illegal). It focuses on the following
educational goals:
decision making and problem solving.
creative thinking and critical thinking
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communication skills and interpersonal skills
self-awareness and empathy
coping with emotions and coping with stress
However we must be aware: Life Skills Training is no silver bullet that will reach all. In particular when
it comes to hard-to-reach risk groups, highly vulnerable people or people with mental conditions the
impact of Life Skills Trainings is probably very limited. And these groups are probably the most
important to focus on since they are most likely to become those that cause the majority of problems
in doing harm to themselves and society around them. For these special groups intensive, targeted
and more tailor-made, efforts in secondary prevention are necessary.
The way forward
Programmes that have shown a positive impact, such as life-skills trainings or programmes reaching
parents, need to be implemented more consequently on broader scales to have significant impact in
numbers in society. Simultaneously resources should be withdrawn from programmes that have
proven to have no or little effect and then be re-allocated to those that have shown to impact.
More focus on secondary prevention, targeting highly vulnerable and risk groups, needs to be
implemented if we want to reduce the negative social and health effects of addictions and substance
use.
In summary you could argue that:
wanting to prevent drug use is wishful thinking,
preventing drug abuse is extremely difficult
as for addiction prevention it looks as if the jury is still out on this one
BUT treatment/tertiary prevention actually has proven to impact and make a difference in respect to
drug consumption. Therefore and in following the concept of evidence based policies, decision
makers have some clear guidance here for the future.
But we must be careful that we don’t end up in a dead end street. Future efforts should first of all
adequately take into account that the world and perceptions of young people have changed
dramatically over the last years. Most young people live in the middle of the information technology
revolution. Information for them is the world of the mobile phone, the internet and the blog. Actors in
prevention need to acknowledge that and have to make prevention programmes available in a way
that the young are most likely to access them. These new technologies have opened up the gateway
towards many promising new methods in prevention and treatment.
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