Addiction Medicine: Principles and Practice

understood.

Chapter 1

The history of psychoactive substance use and problems and of social responses to them

Robin Room

Psychoactive substances have been used throughout recorded human history (1). The most widely used are alcoholic beverages of one type or another (2). These were commonly used before European contact everywhere except in Australia, Oceania, and North America north roughly of the United States–Mexico border, and even in such areas there may have been some pre-contact use (3). Other psychoactive substances were derived in many cultures from a wide variety of organic materials. Very few human societies have used no psychoactive substances, and in various parts of the world today there are widespread folk traditions of use of leaves of khat, coca, and tobacco, nuts, seeds, and pods of betel, cola, coffee, and opium, and roots of kava.

In village and tribal societies there have usually been rules controlling use, enforced by customary or religious law. Use of a substance might be reserved to a shaman or an elite; use might be constrained to particular times of the year or fiesta days; often there are limits on the context of use. The rules did not necessarily always hold down the rates of problems from the substance use, and there is plenty of historical and ethnographic evidence of serious alcohol and other drug problems in tribal and village societies.

In the period of European expansion and empire-building after 1500, the production, commerce, and use of psychoactive substances were all fundamentally transformed. Trade became global, and psychoactive substances as valuable products were an important trade commodity, and often an instrument of power – they have been described as the ‘glue of empires’ (1). In European home markets, distilled alcoholic beverages came into everyday use after 1600, and the shift to industrial production of beer and spirits was an early stage in industrialisation.

In many countries of northern, western, and eastern Europe, and in their overseas colonies, there were waves of heavy use of psychoactive substances in the 18th and 19th centuries, as industrialised supplies became plentiful and the poor moved out of destitution. The British settlement of Australia came in the latter stages of the ‘gin epidemic’ in 18th-century Britain, as British governments, though dominated by landowners who profited from selling grain for distillation, began to take serious steps to contain the problems (4). Both the heavy drinking habits and the alcohol licensing laws from that period were transferred into early British Australia (5). Later in the 19th century, particularly in Britain and the United States, entrepreneurs generated waves of heavy use of patent medicines containing opiates and cocaine (6). In the same period, the invention of the cigarette-making machine transformed the availability and social acceptability of tobacco smoking, setting off the great smoking epidemic of the 20th century (7).

Eventually, strong alcohol temperance movements emerged in response to the waves of heavy use and the problems they created. Doctors were often prominent among the social reformers in the first reactions at elite levels. Figure 1.1 shows the ‘moral thermometer’ that an American doctor, Benjamin Rush, first put forward in 1784 in his treatise on the adverse effects particularly of distilled spirits (8). But at the heart of the temperance movements, as they emerged in the 1830s and 1840s in English-speaking and Nordic societies, were tradesmen and other workers, meeting together for mutual support in renouncing at first spirits drinking and eventually all alcoholic beverages. While Rush’s treatise is an example of occasional earlier discussions in terms of the ‘progress’ of ‘intemperance’, it was the experience in these temperance groups of frequent relapses from pledges to abstain that played a major role in reconceptualisation of habitual drunkenness in terms of a new concept that was eventually called addiction (9). Towards the end of the 19th century, homes or asylums to treat the disorder, under medical direction or advice, were set up in many countries (10), including Australia (11).

Figure 1.1: Benjamin Rush’s ‘moral and physical thermometer’ of the nature and effects of temperance and intemperance, 1784.

As the temperance movement matured at the end of the 19th and beginning of the 20th century, it turned from moral suasion to coercion, campaigning for prohibition of all alcohol sales. Between 1910 and 1935, such a prohibition was instituted for at least a time in 13 countries (12). The temperance movement expanded its concerns to other psychoactive substances, succeeding for a few years in outlawing sale of tobacco cigarettes in some US states, and campaigning against the availability of opium and cocaine in patent medicines and tonics, and the export of opium from British India to China. Out of these campaigns came an international anti-opium treaty in 1912, the beginning of the international drug prohibition system that still operates today (13).

While prohibition was adopted and has continued globally for other drugs, it failed for alcohol. In the wake of the repeal of alcohol prohibition, alcohol and tobacco were renormalised and conceived quite separately from narcotic drugs, a separation that lasted for most of the 20th century (14). As alcohol prohibition lost its appeal, the alternative put forward was alcohol control – what today would be termed harm reduction (15). Alcohol was to be made available, but under restricted conditions, for instance in terms of the number of sales places and hours of sale, and often with substantial taxes to discourage heavy use. In some places there were rations or limits on purchases, and bans on purchasing for specific individuals. Such systems of alcohol control were widely adopted as an alternative to or to replace prohibition.

Prohibition had been applied in Australia only to Indigenous Australians – lasting for them until the 1960s – but relatively strict alcohol control was adopted, with half of the pubs in Victoria being bought out and closed between 1900 and 1925, and no sales of alcohol after 6 p.m. in a majority of states (5). In combination with popular temperance sentiment and the effects of the Great Depression, the restrictions meant that Australian per capita consumption of alcohol in the early 1930s was one-quarter of what it is today (16).

In Australia and other countries with a strong temperance history, alcohol consumption stayed low until after World War II, and then rose steadily, levelling off after 1980. Culturally, there was a strong reaction against temperance, and gradually alcohol controls from the early 1900s were swept away. The social contexts of drinking, which had been primarily among males at the pub, expanded to include women and involve restaurants and the home. The dynamic of increased promotion and availability of alcohol was continued by a governing ideology of the free market, in which alcohol was increasingly treated as an ordinary commodity, expressed internationally in trade agreements and in Australia in competition policy (17). The main exception to the trend was the campaigns against drink-driving, in which Australia has been in the forefront in taking effective action.

In terms of the societal response to alcohol problems, in the late 1940s the main institutions for handling alcohol problems in Australia, as elsewhere, were the local lock-up or prison farm, the mental hospital, and to some extent public hospitals (16). In this era Alcoholics Anonymous, a mutual-help group for alcoholics, started its growth, and specialist services for alcoholics, with a mixture of state and non-governmental resources, began to appear in the 1950s and 1960s. This picture for Australia did not differ greatly from developments in other high-income countries, although the associated research effort in this era was greater in Canada and the United States.

Non-medical use of other drugs was generally low in Australia, as in other developed nations, until the 1960s. Part of the countercultural movements of the 1960s was experimentation with a wide variety of psychoactive substances (18). These patterns of drug use shocked older generations, and the response to the growth in use was initially primarily punitive, in Australia as in most of the rest of the world. As with heavy alcohol use, patterns of drug use did not differ greatly between richer and poorer youth, but those who were punished and marginalised were much more likely to be poor. In Australia, the modern era of response to drug problems began with a national Drug Summit in 1985, when infection with HIV and AIDS from shared needles in injection drug use had become an overriding concern. Specialist treatment services for drugs and alcohol grew sharply. Spurred on by doctors and other professionals, harm reduction was set as the official Australian policy, in contrast to more punitive policies, for instance, in the United States and South-East Asia (19).

In recent years, public attention in Australia and globally has been turning back to alcohol problems, as it has been gradually realised that the health and social problems from drinking are far greater than from illicit drugs. But policy changes which respond to this realisation have proved difficult, on the one hand because of the difficulty of changing international drug treaties and the resistance of the drug prohibition establishment, and on the other hand the centrality of alcohol in many Western cultures and the economic interests involved in the alcohol market.

References

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2Blocker JS, Fahey DM, Tyrrell IA, editors. Alcohol and temperance in modern history: an international encyclopedia. 2 vols. Santa Barbara, CA: ABC-CLIO; 2003.

3Brady M. Drug and alcohol use among Aboriginal people. In: Reid J, Trompf P, editors. The health of Aboriginal Australia. Sydney: Harcourt Brace Jovanovich; 1991. p. 173–217.

4Nicholls J. The politics of alcohol: a history of the drink question in England. Manchester, UK: Manchester University Press; 2009.

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8Katcher B. Benjamin Rush’s educational campaign against hard drinking. Am J Public Health. 1993;83:273–280.

9Levine HG. The discovery of addiction: changing conceptions of habitual drunkenness in America. J Stud Alcohol. 1978;39:143–174.

10Baumohl J, Room R. Inebriety, doctors and the state: alcoholism treatment institutions before 1940. In: Galanter M, editor. Recent developments in alcoholism. Vol. 5. New York: Plenum; 1987. p. 135–174.

11Clark C. Contrasting medical models of alcohol problems in Victoria around 1900. Addiction 2012;107(10):1756–1764.

12Schrad ML. The political power of bad ideas: networks, institutions, and the global prohibition wave. Oxford: Oxford University Press; 2010.

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16Room R. The dialectic of drinking in Australian life: from the Rum Corps to the wine column. Australian Drug and Alcohol Review. 1988;7:413–437.

17Room R. The long reaction against the wowser: the prehistory of alcohol deregulation in Australia. Health Sociology Review. 2010;19(2):151–163.

18Manderson D. From Mr Sin to Mr Big: a history of Australian drug laws. Melbourne: Oxford University Press; 1993.

19Hall W, Hamilton M, Ali R. Harm reduction in a prohibition context – Australia. Ann Am Acad Pol Soc Sci. 2002;582(1):80–93.

Chapter 2

The epidemiology of tobacco, alcohol, and illicit drug use and their contribution to the burden of disease

Louisa Degenhardt, Coral Gartner, and Wayne D Hall

INTRODUCTION

The use of psychoactive drugs has received increasing attention worldwide in recent decades because of the significant contribution that alcohol, tobacco, and illicit drug use make to the global burden of disease (Table 2.1) (1,2). Not all psychoactive drugs are under international control: tobacco and alcohol are two obvious and widely used exceptions. Illicit drug use refers to the non-medical use of a variety of drugs that include amphetamine-type stimulants (including methamphetamine, amphetamine, and MDMA (ecstasy)), cannabis, cocaine, and opioids (including heroin). There are many other drugs used, such as gamma-hydroxybutyrate (GHB), ketamine, and d-lysergic acid (LSD), but these are used by comparatively fewer persons in a more limited number of countries, and the nature and extent of harm arising from their use is less well documented. This chapter focuses upon alcohol, tobacco, and the four major illicit drug classes used in Australia.

This chapter reviews evidence on the extent of use of drugs, and the population health burden that their use causes in developed countries. We discuss alcohol, tobacco, and the major illicit drug types used, the epidemiology of their global use, and the natural history and burden of disease related to these different drug types.

WHY DO PEOPLE USE DRUGS?

People use psychoactive drugs for a range of reasons, but most users begin and continue to use these drugs because they produce effects that the user enjoys. Alcohol is commonly used in social settings because of its disinhibiting effects, which increase sociability. Methamphetamine increases energy and arousal, including sexual arousal, lowers inhibitions, and increases self-confidence. Drug use may also serve more practical ends; for example sex workers and night-shift workers may use methamphetamine to enable them to work for longer hours.

Table 2.1: Estimated mortality attributable to illicit drug use, alcohol, and tobacco, globally in the 2000 Global Burden of Disease comparative risk assessment

Note: Extracted from.³ Cannabis was not included in these estimates.

Dependent drug users may use these drugs for more complex reasons: in addition to experiencing drug effects that are increasingly attenuated as tolerance develops, they also seek to avoid the withdrawal symptoms that follow abrupt cessation of drug use.

HOW DO WE ESTIMATE THE NUMBER OF PEOPLE WHO USE DRUGS?

There are major challenges in producing credible estimates of the prevalence of an illegal and often stigmatised behaviour like illicit drug use (1,4). There is no ‘gold standard’ method for producing credible estimates; the best strategy is to look for a convergence of estimates produced by ‘direct’ and ‘indirect’ methods of estimation. No single method is ideal for all drugs or countries; the lack of consistency in measurement and potential biases poses challenges to cross-national comparisons.

‘Direct’ methods

General population or ‘household’ surveys

In surveys of the general population, people are asked if they have used various drugs in the past month, the past year, or in their lifetime (referred to as ‘monthly’, ‘past year’, and ‘lifetime’ prevalence). This approach enables a straightforward calculation of prevalence that is accurate if: (i) a representative population sample was obtained; (ii) people honestly disclosed their drug use; and (iii) drug users were spread equally around the country. Its major limitations are that marginalised groups with high rates of drug use are often missed, and such drug use is often geographically concentrated in large cities. Also, the expense of doing these surveys limits their use in developing countries. Surveys underestimate the prevalence of the most harmful and stigmatised forms of illicit drug use, such as opioid and injecting drug use (5). It is also possible that the extent of underreporting varies across countries and cultures, although this has never been investigated.

School surveys

In these surveys, school-attending children/young people (typically in high school) are asked whether they have used various licit and illicit drugs. The benefits and limitations of this approach are shared with those of general population surveys, with the additional limitation that they exclude young people who have left school, who are also more likely to have used illicit drugs. This may be a large proportion of young people in some countries.

‘Indirect’ methods

These methods use different sources of data to estimate of the total number of drug users indirectly (6). A simple approach is the multiplier method, which involves (for example) multiplying (i) the number of people who receive drug treatment in a year (an indicator) by (ii) an estimate of the proportion of all drug users who receive treatment in a year (the multiplier) to estimate the total size of the drug-using population. Other indirect methods include capture–recapture and back-projection estimates. The capture–recapture method requires collection of two or more data sources and identification of how many people are captured in both sources of information. This overlap is used to estimate the total number of problem drug users. Back-projection estimates have been used in other areas (for example to model HIV epidemics); in this context, it can involve combining data on the number of (for example) heroin overdoses, with likely rates of entry into and cessation of heroin use, and rates of overdose among heroin users, to estimate the number of drug dependent people over time (7).

Indirect methods are less expensive and technically challenging than surveys because they use existing administrative data. Their major limitations are uncertainty about the quality of the indicator data and the validity of commonly used multipliers. These problems are usually addressed by making multiple indirect estimates using different indicators of illicit drug use (e.g. deaths, number in drug treatment, arrests, and treatment for complications of drug use) and different multipliers and methods of estimation. Often a combined estimate from different sources is used.

ESTIMATES OF THE PREVALENCE OF SUBSTANCE USE IN AUSTRALIA

In Australia, surveys of representative samples of the general population have been carried out since 1985 to assess prevalence of use of a range of licit and illicit substances in the general population (Box 2.1 and Table 2.1). These surveys have consistently found that alcohol is the most commonly used psychoactive substance, followed by tobacco, and that cannabis is the most commonly used illicit drug. The 2010 Australian National Drug Strategy Household Survey (NDSHS) estimated that around 9 in 10 people aged 14 years and over had used alcohol at some point in their lives, with 83% having done so in the past year (8). One in five people aged 14 years and over (18%) reported use of tobacco within the past year, with 42% reporting lifetime use (8). A little over one-third (35.4%) of persons aged 14 years and over reported having used cannabis at some point in their lives, with 10.3% reporting having used it within the past 12 months. Smaller proportions of Australian adults reported having used amphetamines, cocaine, heroin, and sedatives within the past year (4). Over the past decade, there have been variations in the levels of illicit drug use, with ecstasy (MDMA) increasing, methamphetamine peaking in the mid-2000s and then falling again, and cannabis decreasing from a peak of 18% past year use in 1998, declining to 9% in 2007, and then increasing to 10.3% in 2010 (4). Clearly, in terms of the numbers of people reporting use of psychoactive substances, alcohol, tobacco, and cannabis are those that are the most widespread.

Box 2.1: The burden of disease attributable to illicit drugs, tobacco, and alcohol in Australia

The disease burden attributable to opioids, amphetamines, cocaine, and cannabis in Australia (Table 2.2) is of international relevance, because Australia has good data on mortality and rates of most types of illicit drug use (cocaine excepted) are similar to those in other high-income countries. A 2003 study examined more consequences of drug use,⁹ permitting some assessment of the extent to which current global estimates underestimate disease burden.

In 2003, illicit drug use in Australia was responsible for levels of disease burden similar to those for alcohol (2· 0% vs. 2·3%).⁹ More deaths were attributed to illicit drugs than to alcohol, on the assumption that moderate alcohol use reduced cardiovascular heart disease (CHD) mortality in middle- aged adults. Injecting drug use and opioid and polydrug use accounted for over half of the contribution of illicit drugs to disease burden. Cannabis dependence, psychosis, suicide, and motor vehicle accidents accounted for 0–2% of the total disease burden and 10% of the burden for all illicit drugs. The inclusion of cannabis use, hepatitis C virus, and hepatitis B virus produced an estimate that was 1.6 times greater than one based on the more limited risks included in the 2000 Global Burden of Disease estimates.

Table 2.2: Burden of disease attributable to illicit drugs, alcohol, and tobacco in Australia, 2003

Note: Adapted from (9)

These patterns of use are similar to those globally. Tobacco is widely used throughout the world in both smoked (e.g. cigarettes, cigars, pipe tobacco, kreteks, bidis) and non-smoked forms (e.g. oral and nasal snuff, chewing tobacco). Manufactured cigarettes account for the vast majority (96%) of global sales and are responsible for the majority of tobacco-related harm (10). Around one billion, or just over 20% of adults worldwide, smoke cigarettes, and nearly six trillion cigarettes are smoked each year (10,11). Smoking prevalence among men peaked in high-income countries in the 1950s, when more than half of men smoked. Smoking among women in these countries peaked in the 1960s with over 30% of women smoking (12). As smoking prevalence has declined in high-income countries, male and female smoking prevalence has converged with between 15% and 20% of adults smoking. Smoking prevalence is still increasing in low- and middle-income countries, where the majority of the world’s smokers live (10,11).

Cannabis is the most widely used illicit drug and is used in every region of the world. In 2012 between 119 and 224 million people (an estimated 2.6–5% of the global population aged 15–64 years) were thought to have used cannabis in the previous year, an increase on estimated rates of global use in the mid-1990s (13). Patterns of cannabis use have been most extensively studied in developed countries, such as the United States, Canada, Australia, and Europe. Europe generally has lower rates of use than Australia, Canada, and the United States (14). The limited data from low- and middle-income countries suggest that with exceptions (e.g. South Africa) rates of cannabis use are much lower in Africa, Asia, and South America than in Europe and English-speaking countries (14).

The term amphetamine-type stimulants (ATS) refers to a range of drugs related to amphetamine. Methamphetamine and amphetamine are the major ATS available worldwide, followed by 3,4-methylenedioxymethamphetamine (MDMA, or ‘ecstasy’ as it is commonly known) (15). The diversion of prescription stimulant drugs such as dexamphetamine has been reported, but this is less of a problem than illicitly produced ATS. Use appears to be increasing in many parts of the world, but many countries have scant or no data on prevalence, routes, and forms of use. Problematic use of amphetamines appears more prevalent in East and South-East Asia, North America, South Africa, New Zealand, Australia, and a number of European countries (16,17).

Cocaine is reportedly the least widely used of the illicit drugs: between 13 and 19.5 million people aged 15–64 years were thought to have used cocaine in 2012, with use heavily concentrated in North America, Latin America, and some European countries (13). The reported prevalence of cocaine use in other high-income countries is typically much lower than that in the United States (17).

Illicit opioids are the third most common form of illicit drug use. Globally, illicit opioids were estimated to have been used by between 26 and 36 million people in 2012 (13). In high-income countries, estimates of dependence are typically below 1% of adults aged 15 or more (18). Most research on the epidemiology and natural history of opioid use focuses upon dependent users. The distinction between use and dependence is an important one that is briefly discussed below.

EPIDEMIOLOGY OF DRUG USE

In general, males are more likely than females to use most psychoactive substances and more likely to become regular users. There are indications, however, that this gender difference in rates of use may be smaller in more recent birth cohorts (19,20). Substance use (particularly illicit substance use, but also alcohol and tobacco use) is strongly associated with a person’s age. Young people aged 18–25 are most likely to report using psychoactive substances within the past year. Recent use (e.g. use within the past year) typically declines in adulthood, reflecting the adoption of roles such as child-rearing, marriage, and employment.

Some research has suggested that socioeconomic factors may be related to alcohol and tobacco use. Tobacco use has been related to a number of indicators of lower socioeconomic status, such as lower levels of education and a greater likelihood of being unemployed. Research has also found that education is related to involvement with alcohol use: the better educated drink more often but are probably less likely to drink at risky levels; the least well- educated often drink least, but if they do drink, they are more likely to drink in a risky way. Individuals with dependent alcohol use have also been found to be more likely to be unemployed.

Similarly, illicit substance use has been correlated with a number of sociodemographic factors. Low levels of education are typically found among illicit drug users, and general population studies have found that lower education levels are associated with reporting more use of illicit drugs. People who have used illicit drugs such as cannabis, amphetamines, and heroin are more likely to be unemployed and less likely to be married or in a de facto relationship than those who have not used illicit drugs.

SUBSTANCE ABUSE AND DEPENDENCE

Most people who use psychoactive substances do so without experiencing any problems related to their use, but a minority do develop problems. Efforts have been made on an international level to classify the behaviours or symptoms associated with drug use that may cause problems to the user and require treatment or other interventions. Conceptualisation and measurement of these problems has undergone considerable change over the past three decades, with the emergence of the concept of a substance dependence syndrome, influenced by Edwards and colleagues’ work on alcohol dependence (21).

Edwards and colleagues suggested that alcohol dependence could be conceptualised as a cluster of symptoms that occurred in heavy drinkers and could be distinguished from alcohol-related problems. Seven factors were regarded as major symptoms of alcohol dependence:

•Narrowing of the behavioural repertoire

•Salience of drinking (alcohol use given priority over other activities)

•Subjective awareness of a compulsion (experiencing loss of control over alcohol use, or an inability to stop using)

•Increased tolerance (using more alcohol to get the same effects, or finding that the same amount of alcohol has less effect)

•Repeated alcohol withdrawal symptoms (fatigue, sweating, diarrhoea, anxiety, trouble sleeping, tremors, stomach ache, headache, hallucinations, fever)

•Relief or avoidance of withdrawal symptoms by further drinking

•Reinstatement of dependent drinking after abstinence.

The concept of a dependence syndrome has since been extended to cannabis, tobacco, amphetamines, opioids, and sedatives. Another category of problematic substance use has also been developed: the concept of substance abuse. This was developed in an attempt to classify persons who experienced clinically significant problems associated with their substance use but did not use the substance in a way that met criteria for dependence.

The most recent operationalisation of substance use disorders is DSM-5 (22). DSM-5 substance use disorder criteria require a pattern of substance use that is causing clinically significant distress or impairment, with three levels of severity (mild, moderate, and severe). Symptoms include:

•tolerance to the effects of the substance

•a withdrawal syndrome on ceasing or reducing use

•craving for the drug

•using the substance in larger amounts or for a longer period than intended

•a persistent desire or unsuccessful efforts to reduce or cease use of the substance

•a disproportionate amount of time spent obtaining, using, and recovering from substance use

•social, recreational, or occupational activities are reduced or given up due to substance use

•a failure to fulfil role obligations due to substance use

•substance use in hazardous situations

•continuing substance use despite knowledge of physical or psychological problems caused by such use.

PREVALENCE OF SUBSTANCE ABUSE AND DEPENDENCE

The health risks of illicit drug use generally increase with frequency and quantity of drug use (23). Those who ever use any illicit drug and do not persist in using have, at most, a very small increase in mortality that is not easily detected in epidemiological studies. In estimating the health burdens of drug use it is most relevant to consider the effects of problematic drug use (abuse or dependence).

US research suggests that 20% of people who ever use an illicit drug will meet criteria for dependence at some point (24). Similar proportions have been found in Australia (25). The difference in dependence risk between drugs reflects a combination of their pharmacological effects (e.g. drugs with a rapid onset and shorter duration of effect have a higher dependence risk) and route of administration (the dependence risk is higher if drugs are smoked or injected). Proportionally more heroin users (who typically inject) meet dependence criteria than do intranasal users of cocaine and amphetamines, or cannabis smokers (26). Those who inject or smoke amphetamines or cocaine have a higher risk of dependence than those who use either drug intranasally (27,28).

The National Comorbity Survey (NCS) found that approximately 14.1 % of adults met criteria for alcohol dependence at some point in their lives, with another 9.4% meeting criteria for alcohol abuse (26,29). Within the past 12 months, 2.5% of persons met criteria for DSM-III-R alcohol abuse and 4.4% for dependence (29). Approximately one in four persons (24%) met criteria for nicotine dependence at some point in their lives, while 7.5% met criteria for other drug dependence, and 4.4% for other drug abuse (26,29). The most common illicit drug of dependence was cannabis, with 4.2% meeting lifetime criteria for cannabis dependence, followed by cocaine (2.7%), stimulant (1.7%), and sedative (1.2%) dependence (26). Lifetime dependence upon heroin was reported by 0.7% of the population (26).

CORRELATES OF SUBSTANCE ABUSE AND DEPENDENCE

Males are more likely than females to meet criteria for alcohol and other substance use disorders. While male and female tobacco smoking prevalence has converged in some high-income countries, in most countries more men smoke tobacco than do women. Substance use disorders also decline significantly with age, with young people by far the most likely to meet criteria for all substance use disorders.

As with illicit substance use, illicit substance use disorders are strongly associated with a number of indicators of social disadvantage. Persons meeting criteria for illicit substance use disorders have a higher likelihood of being unemployed than do those who do not meet such criteria. They are more likely to have completed fewer years of education than are persons who do not meet criteria for substance use disorders. They are also less likely to be married or in a de facto relationship.

Alcohol and tobacco use disorders are also associated with these sociodemographic characteristics (26). Persons with alcohol use problems are more likely than those who do not have such problems to be separated or divorced. Research has found that less-educated persons have an increased risk of developing alcohol abuse and dependence. Individuals with heavier alcohol use, and those who meet criteria for alcohol use disorders, have been found to be more likely to be unemployed. Similarly, an association has been shown between tobacco dependence and lower education levels and socioeconomic status, and a lower likelihood of being currently employed (30,31).

Those at highest risk may have a history of poor academic achievement, deviant behaviour in childhood and adolescence, non-conformity and rebelliousness, poor parental relationships, and a parental history of drug and alcohol problems. There is increasing evidence of a substantial genetic contribution to the likelihood of using and developing dependence upon cannabis.

THE NATURAL HISTORY OF DRUG USE

Transitions in life roles such as entry into full-time employment, getting married, or having children, are associated with reductions in or cessation of use for many people. The largest decreases are seen in cannabis use among males and females after marriage, and especially during pregnancy and after childbirth in women. Few studies have documented the natural history of psychostimulant use, in sharp contrast to the literature on cannabis and even opioids. Our current understanding derives largely from cross-sectional studies, typically involving convenience samples, or treatment or prison settings. US prospective studies have suggested that relapse following treatment for psychostimulant dependence is common. The concentration of work in treatment or prison populations makes it difficult to draw inferences about amphetamine use in the general population, since most users will never come into contact with treatment or law enforcement agencies. As a result, little is known about the aetiology and consequences of psychostimulant use that does not come to the attention of police or treatment services. This is an area where much more needs to be known, given the increases thought to be occurring in use of these drugs.

Cohort studies of dependent opioid users have suggested that users may continue to use opioids for decades, with periods of use interrupted by time spent in treatment, prison, and, for some, extended periods of abstinence. Such cohort studies have largely been conducted in high-income countries – in Asia, for example, the context of opium (and more recently, heroin and pharmaceutical opioids) use is quite different from that in the United States, and we know much less about the natural history of opioid use in Asian countries. Nonetheless, the evidence available to date suggests that opioid- dependent persons may struggle to control their use for significant portions of their lives. Data from the United States have suggested that one in four persons who use opioids illicitly may develop dependence upon them. Although opioids are used by far fewer people than cannabis, opioid dependence in particular is associated with substantial mortality and morbidity that appears to far exceed that of cannabis use or dependence. Reviews have suggested that opioid-dependent persons may be 13 times more likely to die than peers of the same age and sex. Multiple reasons exist for this: drug overdose, accidents and trauma, suicide, the consequences of blood-borne viral infections such as HIV and hepatitis C, and generally poorer physical health contribute to shorter life expectancy and poorer quality of life for this group. Although heroin has typically been thought to be the primary opioid accounting for problems related to opioid dependence, in many countries (particularly in the United States, South Asia, and Eastern Europe) dependence upon pharmaceutical opioids is an increasing problem.

THE BURDEN OF DISEASE ATTRIBUTABLE TO ALCOHOL, TOBACCO, AND ILLICIT DRUGS

In the first Global Burden of Disease estimates (1990 and 2001), there was good evidence that mortality related to injecting drug use and dependent use of opioids, cocaine, or amphetamines had increased globally (32). The next iteration of these estimates was extended to include cannabis, given its high prevalence of use and stronger evidence that some users were harmed by its use. The global burden of disease attributable to tobacco smoking (including second-hand smoke) increased between 1990 and 2010 from 6.1% of total DALYs to 6.3% (5.5–7.0%) (33). This is more than the global burden of disease due to both alcohol and illicit drugs combined (4.8% of DALYs in 2010) (33).

The best evidence that illicit drug use is a cause of premature death comes from cohort studies of illicit drug users, which have limitations. It is likely that the estimates of disease burden to date have been underestimated because we simply have too little data on the nature and magnitude of harms related to different drugs, and because even where we know drugs cause harm, too few studies have estimated the course of drug use and associated harm over time and across different country contexts. Existing estimates could not estimate morbidity and mortality related to cannabis use; more recently, evidence increasingly suggests that cannabis may increase risks of some cancers (related to smoking of the drug) and motor vehicle accidents.

Comparative burdens of alcohol, tobacco, and illicit drugs

Although far from perfect, the existing Global Burden of Disease estimates provide a common metric to compare harms caused by alcohol, tobacco, and illicit drugs regionally and globally, while taking account of differences in prevalence and harms. Table 2.3 reveals that, globally: illicit drugs are used by many fewer people than alcohol (roughly one-tenth of the number who use alcohol); estimated levels of problem use of opiates/cocaine/amphetamines are one- to two-thirds those of alcohol use disorders (0.4–0.8% vs. 1.2%); tobacco use is far more widespread and its contribution to disease burden the greatest; attributable deaths and DALYs were much higher for alcohol use disorders than for problem illicit drugs (3.8 and 4.5% for alcohol and 0.4% and 0.9% for illicit drugs). The higher number of years of life lost (YLL) from illicit drug use (2.1 million vs. 1.3 million for alcohol) reflects the concentration of illicit drug deaths among younger people, whereas alcohol and tobacco deaths occur in middle-aged and older adults.

Table 2.3: Comparison of global use and burden of disease for illicit drugs, alcohol, and tobacco

Adapted from.¹ For details of sources see.¹

SUMMARY AND IMPLICATIONS

The discussion above has attempted to provide a broad overview of the epidemiology of four major drug types. Although we have some data on the scope of the problem, the illegal nature of such drug use means there is much that we do not understand about the extent, context, and natural history of illicit drugs, particularly in low- and middle-income countries where drug use seems to be increasing. Even in countries such as Australia, we still have much to learn about the extent of drug use and the nature and magnitude of harms that may result.

Although much remains to be understood about illicit drug use, based upon what we do know several things are certain: there is considerable and possibly increasing demand for drugs in the general population; demand for and consumption of drugs is dynamic, with current trends suggesting increasing demand for stimulant drugs; drug supply may both respond to and drive demand for drugs; and responses to drug use must reflect these drivers.

In high-income countries, regular household survey data on tobacco smoking has been collected for several decades, giving a good picture of the cigarette epidemic in these countries (11,12). In low- and middle-income countries, similar data is now becoming available via the WHO Global Adult Tobacco and Global Youth Tobacco Surveys (11,12).

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Chapter 3

Behavioural science and addiction

Robert West and Michael Farrell

INTRODUCTION

Behavioural science is a cross-disciplinary approach to understanding and predicting behaviour as a basis for developing successful behaviour change interventions. It draws on many disciplines including psychology, sociology, economics, anthropology, and neuroscience. It involves a large number of models and theories of behaviour that focus on different levels of analysis and domains of interest (1). Models of behavioural economics focus on the role of costs and benefits (not exclusively financial). Models in neuroscience focus on neurotransmitters and brain circuitry. Psychology focuses on models and theories relating to mental processes and their interaction with the environment. Sociology focuses on groups, societies, and social structures. Integrating these different perspectives is important to obtaining an adequate understanding of behaviour.

Addiction has been defined in numerous ways over the decades, and even today there are many different perspectives. As a socially defined construct, no single definition can be claimed to be ‘correct’, but some are more useful than others. Thus, a definition that sees addiction purely as a ‘brain disease’ leads to a focus on clinical approaches to management at the expense of broader population-level strategies that have been found to be effective, such as control of price (2). Conversely, a definition that regards addiction in terms of ‘choices’ fails to capture the very important neurobiological mechanisms that underpin it. A behavioural science perspective has to be sufficiently broad to capture both of these and other aspects of the problem that can help to shape research and practice to provide optimum solutions.

A definition of addiction that appears to meet this objective is: ‘Addiction is a chronic condition in which there is recurrent powerful motivation to engage in a behaviour, acquired through experience, to an extent that is maladaptive’ (2). This covers smoking, alcohol dependence, addiction to illicit drugs, and gambling. In principle, it could also cover other behavioural addictions such as excessive internet use, including internet gaming disorders. It is important to appreciate that this still requires decisions to be made about whether the strength of motivation and/or degree of harm are sufficient to warrant inclusion in the definition, and such decisions must be made on the basis of the prevailing societal conditions and opportunities for intervention. For example, some people consider overeating as a form of addiction, while others argue otherwise. The issue is best resolved by analysis of the advantages and disadvantages of applying the term addiction (3). The diagnosis should add significantly to the process of addressing the problem.

The terms addiction and dependence are often used interchangeably, and that is how they will be used in this chapter. Some people use the term physical dependence to refer to neural adaptation to a drug that results in ‘withdrawal symptoms’ during abstinence, and psychological dependence as powerful motivation to use a drug or engage in a particular behaviour. While this distinction has some heuristic value, separating out these two components is generally misleading given how intimately intertwined they are: withdrawal symptoms are subject to psychological influences, and clearly motivation has a physical basis.

Although it is common practice to talk about the prevalence of addictions, it is not meaningful to do so without making clear the thresholds being set for the strength and chronicity of the disordered motivation and/or the degree of harm associated with this. In principle, DSM and ICD criteria are believed to do this (4,5), but there is considerable potential variability in the interpretation of the criteria and their application, and often a failure to appreciate that these are highly context-dependent and relative.

The situation with DSM has been made more problematic with publication of DSM-5, which combines harm from alcohol use and severity of the disorder of motivation in terms of need to drink into a single diagnosis. While the two are highly correlated in practice, they are conceptually distinct and a failure to preserve that distinction can produce misleading conclusions.

UNDERSTANDING BEHAVIOUR

Understanding addiction requires a sufficiently broad model of behaviour to be able to capture its essential features. One such model is termed COM-B, standing for capability, opportunity, motivation, and behaviour (Figure 3.1). This model sees behaviour as part of a system of which the other components are all essential features (6,7). Thus, for any behaviour to occur the individual must be (i) capable of doing it, both physically and psychologically, (ii) have the opportunity to do it, both in terms of physical access and resources and the social milieu, and (iii) must be more motivated to engage in that behaviour than other potentially competing behaviours – with such motivation including self-conscious choices and intentions (reflective motivation), as well as feelings, impulses, and inhibitions (automatic motivation).

Figure 3.1: The COM-B model of behaviour. Behaviour is seen as part of an interacting system involving physical and psychological capability, physical and social opportunity, and reflective and automatic motivation (6,7]

These elements operate as a system; increasing ability or opportunities to engage in a behaviour can increase motivation to engage in it, and enacting a behaviour can change the other elements of the systems (e.g. practice increasing capability).

UNDERSTANDING MOTIVATION

Motivation lies at the heart of addiction; it is worth elaborating on the motivational part of the COM-B model. The PRIME theory of motivation does this by integrating the diverse theories and models of