A new integrated vision of how to prevent harmful drug use
The medical community has important roles in reducing harm from alcohol and other drugs
A contemporary vision of how to prevent harmful alcohol and drug use is emerging, at a time when a new approach is vitally needed. In 1998 (the most recent year for which mortality data on all recreational substances are available), substance use killed some 23 000 Australians.1 Licit drug use accounted for 96% of these deaths, with tobacco the leading cause. In the same year, drug use cost the Australian community $34.7 billion, representing almost 2% of GDP for alcohol, 1.71% for tobacco and 1.76% for illicit drugs.2 Rates of tobacco and alcohol use have increased over the past decade among adolescents and young adults.
Although the problem is of large scale,3 there have been major recent advances in the understanding of how to prevent much harmful drug use. One such advance is the “developmental pathways” approach, emphasised in Australian mental health4 and crime prevention5 strategies. This approach draws on life-course development research, community epidemiology and preventive intervention trials.6,7 Studies have demonstrated that from early in life similar developmental, social-risk and protective factors lead to a range of problem and risk behaviours in adolescence and young adulthood, including problematic substance use.8 Attention to these underlying factors is an essential element in preventing problematic substance use. Hence, we need to consider how these forms of prevention can be integrated into Australia's existing harm-minimisation framework.
Recent evidence also warrants an increased acknowledgement of the significant and influential role regulation and legislation play in prevention,9 including the symbolic role of law in reinforcing social norms against harmful drug use.10 The challenge is to integrate this new knowledge while accepting that there have also been clear advances through the use of harm-reduction strategies for people who are unable or unwilling to abstain from risky drug use .11
In recognition of the need for these different approaches to prevention to be integrated into national drug policy, the Australian Department of Health and Ageing commissioned a major review of Australian and international literature. The review was recently published as a monograph, The prevention of substance use, risk and harm in Australia.12,13
As part of the focus of integrating different prevention approaches, 159 preventive interventions were reviewed. The highest level of evidence for effectiveness was found for eight interventions (Box).
Eight interventions with the highest level of evidence to prevent harms associated with substance use
- Tobacco taxation to create and maintain price disincentives
- Enforcement of environmental tobacco smoke regulations
- Alcohol taxation based on alcohol content of drinks
- Random breath testing of drivers
- Brief interventions by primary healthcare providers in relation to alcohol and tobacco use*
- Treatment for dependent alcohol and other drug use*
- Needle and syringe distribution programs
- Hepatitis B vaccination*
* There is a role for the medical profession in these three interventions.
What can the medical profession do to assist?
Interventions for families and adolescents
A number of effective interventions for families and adolescents are implemented predominantly by healthcare professionals:
- Antenatal and postnatal home visiting by nurses to support high-risk parents in effectively meeting the child's basic needs and to encourage healthy bonding;
- Early identification of fetuses or infants at risk of manifesting the effects of drug exposure, including early intervention to encourage reduction of harmful maternal drug use, particularly smoking;
- Child development support for families with problems associated with alcohol and drug use;
- Assistance for parents and families in developing skills and gaining support to enhance healthy child development and prevent substance use beginning at an early age or occurring regularly during adolescence;
- Identification of training and evaluation strategies to improve the preventive screening and health promotion offered to adolescents by primary healthcare professionals.
Interventions within the general community
As well as specific medical interventions, the medical profession plays an important role in supporting the development of evidence-based alcohol and other drug policy.14,15 Evidence attests to the value of interventions in the general community which prevent the sale of tobacco to minors,16 encourage responsible alcohol marketing and distribution,17 integrate treatment and harm reduction services18 and reduce the availability of illicit drugs.19
Behavioural risk factors for a variety of health issues can be managed in general practice using initiatives such the Smoking, Nutrition, Alcohol and Physical activity (SNAP) Framework to address cardiovascular health.20 Brief interventions by general practitioners appear effective for reducing both smoking and early-stage alcohol problems.21 Despite this, GP uptake of brief interventions has been poor, and many GPs fail to detect individuals at risk of developing alcohol and other drug problems.22 Professional support for GPs can improve rates of screening and brief interventions. Practice nurses should also be considered as alternative service delivery agents.22
There is a solid research base to show that treatment for a range of drug and alcohol problems is effective and can improve mental and physical health and social functioning. Treatment is an essential aspect of prevention, having population-level effects on levels of crime and disorder. Treatment of families minimises the intergenerational transmission of substance-use problems. However, most treatment programs engage only a small proportion of the people with drug and alcohol dependence. Including advice from a GP, only one in three people with an alcohol problem will receive any kind of treatment from a healthcare professional in a 12-month period.23
Conclusion
An integrated vision of prevention brings together action from many areas, including health, with a common goal of creating healthy social environments. Healthcare providers play a critical role and are encouraged to see the provision of services to drug- and alcohol-dependent individuals as a core responsibility.24,25 The evidence supports an increase in the capacity of mainstream healthcare providers to provide brief and early interventions and treatment. Further funding for drug-dependency services, training for healthcare practitioners in managing drug-dependent patients, improved access for GPs to specialist support, and the recognition of medical practice in the drug-dependency field as a legitimate medical specialty have all been recommended.24
GPs are ideally placed to identify children at risk of developing psychosocial problems because of their family backgrounds, particularly where adults and children present with problems associated with substance use by parents. Early identification of these children and appropriate treatment or referral of both the child and the parent may help to prevent the intergenerational transfer of alcohol and drug problems within families.
Finally, advocacy by the medical and healthcare professions for effective non-medical interventions such as taxation, law enforcement and harm reduction is vital to ensure their wider and more effective application.
