Understanding the problem of substance use

Alcohol and drugs – a development issue

The use of intoxicating substances like alcohol and illicit drugs creates a wide range of health and social consequences which are closely linked to many of the important development issues; poverty, violence against women and children, neglect of children, hiv/aids, crime, accidents, trafficking, street children etc.

Alcohol and drug related problems are closely linked both to poverty and to affluence and economic development. Experience shows that alcohol consumption tends to rise with economic growth, increasing purchasing power and the expansion of a middle class. Consequently, developing societies that succeed in eradicating poverty and creating economic growth, will face new social problems linked to alcohol use, - if prevention of such problems is not integrated into their development strategies.

A social and cultural phenomenon

The development of individuals’ regular alcohol or drug use is above all a social and cultural phenomenon. As individuals we are, in many respects, simply swimming with the tide. We are born into a given culture and adopt other people’s habits, and at the same time our own behaviour influences other people.

Cultural changes, both towards increased and decreased substance use, are long and complicated chain reactions. Therefore it is vital to understand the cultural and social context of drinking and drug taking, as a part of designing prevention strategies.

The most effective way to influence alcohol and drug consumption is, consequently, to change the user environment through targeting larger population groups, rather than targeting the individual users. This includes interventions towards also the larger groups of moderate alcohol users and experimental drug users.

A public health approach

We recommend using a public health approach to alcohol and drug problems:

• To study the general population to understand how and why alcohol and drug problems develop;

• To apply a broad definition of “health” which includes all types of alcohol- and drug-related harm, including harm to others than the users;

• To give priority to prevention of substance use problems rather than on treatment and harm reduction, even if such types of interventions also are an integral and important part of any national alcohol and drug policy;

• To address the larger population with interventions, not only individual problem users or addicts.

The full picture

People often identify alcohol or drug problems as being alcoholism or addiction. Such an understanding captures only a small piece of the problem. Three mechanisms explain harm caused by alcohol or illicit drugs; Intoxication, toxicity and dependence. A broader understanding of harm can be illustrated by this table, which mentions some examples under each category:

Interventions based on best available knowledge

The choice of strategies and interventions should be knowledge based, i.e. based on available scientific findings, together with other types of knowledge and practical experience from the international community of research institutions, NGOs and intergovernmental agencies. If reliable scientific data are not available, which often is the case in many project areas, one has to act on the basis of what is there and information that can be gathered in the preparation of interventions.

We recommend the use of material from the World Health Organization and related institutions and researchers. See literature and links at other places in this web site. The research monograph “Alcohol No Ordinary Commodity” (Babor et al, 2010) gives a summary of existing evidence on effective intervention in the alcohol field.

The WHO Global strategy to reduce the harmful use of alcohol (WHO, 2010) also presents a menu of possible and effective interventions.

Availability – a key determinant

In order to design the most effective interventions against alcohol and drug problems, it is essential to define the determinants behind the problem; i.e. factors that control or influence consumption habits. In other words; to understand the reasons and mechanisms that draw or push persons towards drinking or taking drugs and, in turn, lead to increased consumption.

Some of the determinants will be found in the social and cultural environment, while others rest within the users as biological and psychological mechanisms.

The research monograph “Drug Policy and the Public Good” defines availability as a key driving force: “Finally, we must recognize that availability has enormous implications for the waxing and waning of drug use. Availability refers not only to the supply of drugs (physical availability), but also to their cost (economic availability), their attractiveness (psychological availability), and their social acceptance within the user’s primary reference groups (social availability). In general, the more a drug is physically available, affordable, attractive both as a reinforcer and as a social symbol, and accepted by an individual’s peers, the more likely it is that it will invite experimentation and continued use.” The same logic applies to legal substances like alcohol.

The Prevention Triangle - A comprehensive and balanced prevention strategy

Having defined the determinants behind substance abuse- and selected the most important among them - the next step is to select strategies and activities for prevention of alcohol and drug problems: How can we influence the most important determinants in a resource-effective way?

A comprehensive strategy seems to give the best results; a combination of several interventions and activities. The “prevention triangle” may be a good guide to such a comprehensive strategy:

Control policies: Interventions by governments to reduce the availability of a substance and to guarantee a safest possible production and distribution system; i.e. alcohol regulations and drug laws.

Education: Training of professionals, education of consumers, parents, youth etc and campaigns to raise awareness, challenge and motivate the public and to create an understanding of the need for control policies.

Mobilization: Make alcohol and drug prevention a part of the agenda for social and political movements, link the issue to other key policy issues and involve leadership and members of NGOs in practical activities.

Independence from vested interests

The multinational alcohol corporations have defined developing societies as their new and promising markets. They are termed “emerging markets” for beer and spirits products, and the younger generations of the Global South are seen as potential customers as their level of education and purchasing power increases.

In order to avoid conflicts of interest, government policies should be formulated without interference by vested interests and with promotion of public health as the primary goal. Simultaneously, civil society organisations should not interact with vested interests in policy formulation or receive funding from the alcohol industry.