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Reducing the harm done by substances: key strategies

The most recent data on life expectancy for the United States show stagnation over the past three years. This stagnation has happened at a time when the most important causes of death, such as cardiovascular diseases or cancers, have decreased.

So, what causes of death are responsible for the stagnation in life expectancy? This can best be seen in the sub-population of middle-aged white non-Hispanics who have experienced increasing mortality rates and decreasing life expectancy for some time now. In this sub-population, the major causes of death on the increase are overdose, suicide, and liver cirrhosis: three killers which are all clearly linked to substance use.

This example is a poignant reminder of the importance of substance use for our societies. Since all harm from substance use is theoretically avoidable, the reminder is also for better substance use policies. This blog comes out of the work of a multi-year project involving more than 200 scientists, the Addiction and Lifestyles in Contemporary Europe Reframing Addictions Project (ALICE RAP), co-financed by the European Commission, and summarized in a six-book series on the governance of addictive substances and behaviours.

It is suggested that from an evolutionary biology viewpoint, humans have a biological predisposition for seeking out and ingesting drugs. These biological predispositions argue against simple policies like prohibition. The history of the last decades show a clear failure of such polices for illegal drugs.

Back to the original example: what policies should be adopted to reduce substance-related mortality?

First, policies should be conceptualized and integrated across all psychoactive substances. The situation in the United States was largely caused by legal recreational substances such as alcohol and prescription drugs dispensed in the medical system. Both alcohol and prescription drugs causally impact on overdoses: prescription opioids and benzodiazepines as the most frequent categories of overdose deaths in the United States; alcohol via alcohol poisoning and being a common contributory factor in prescription overdoses. In addition, prescription opioids and alcohol have been shown to cause suicides, and alcohol is also the major underlying causal factor for liver cirrhosis. In addition, illegal recreational drugs, such as heroin, also contribute greatly to these causes of death.

Unfortunately, currently in most societal decisions, substance policies are reactive and based on singular substances. For example, policies about overdoses have not included prescription drugs for a long time, although such drugs now cause the largest percentage of overdose deaths in North America.

Why prohibition is not the best solution

A second lesson from ALICE RAP concerns the framing of such drug policies. They should be oriented towards maximizing individual and societal well-being, and this can rarely be achieved by criminalizing the use of psychoactive substances. As a consequence, the long-term legalization of the use of all drugs could be suggested.

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This does not mean that substances should be legalized without regulation. On the contrary, as well as strong limitations on the marketing of such substances, there should be availability restrictions, and such restrictions should be commensurate to the size of the potential harm done by substances. One major contribution of the ALICE RAP project summarized has been the conceptualization of a toxicology-based approach to conduct a comparative assessment on the risk of different substances as they are currently used in our societies. The standard application of such an approach would avoid some of the more ideology-based classification of drugs in our society which have led to policies driven by moral knee-jerking.

Preventive aspects of policies to reduce the harm done by substances are vital, particularly for young people and developmental processes.

Drug prevention

Any economic analyses to date have shown that only a very small fraction of the costs of substances in our societies is spent on prevention (less than 1%), much less than on law enforcement or treatment. Current prevention programs, however, are a mixed bag: they are often based on good intentions and hope, rather than on solid empirical evidence.

One concrete proposal, derived from the work of ALICE RAP aims to improve this situation, through the establishment of a European Prevention Agency, which, similarly to the European Medicines Agency, would evaluate and disseminate evidence-based prevention programs according to standardized, objective and rigorous scientific criteria.

A final point to highlight concerns the concepts of addiction and substance use disorders, often posited as distinct categories of behaviour (outside the normal) and characterized by changes in the brain. This concept has contributed hugely to a sharp division of those who use drugs into ‘addicts’ versus the rest, as illustrated by the extensive stigmatization that all of our societies place on substance use disorders, even among health care workers who treat these problems.

The fact is that substance use behaviours constitute a continuum, where there is no clear threshold between normal and addictive behaviours. And the changes of the brain are associated with long-term heavy use, without the necessity to introduce concepts which label ‘addict’s as different. As a consequence, ALICE RAP proposes reconceptualising substance disorders as heavy use over time, and conceptualizing interventions for heavy use similar to interventions for high blood pressure.

The truth is, it is the consequence of fragmented policies, often reacting to perceived crises of select substances and fixated on disease and criminality instead of optimizing well-being that exacerbate this attributable harm. Key strategies are needed to reduce the current level of harm attributable to substance use in our societies, and these strategies should be known by policy decision makers.

Featured image credit: Smoking by Unsplash. CC0 public domain via Pixabay.

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