The role of psychiatrists in prevention of psychoactive substance use and dependence: beyond clinical practice

Regrettably, psychoactive substance use and substance use disorders are still on the periphery of attention of psychiatrists and mental health professionals in many parts of the world. Separation of psychiatric and substance abuse treatment services and research institutions, existing, for example, in USA and Russian Federation, complicates the problem even further. And this is in contrast with the evidence of the burden associated with psychoactive substance use and the potential of psychiatrists and their professional associations to contribute to reduction of this burden.

According to the World Health Report 2002 (1), 8.9% of global disease burden expressed in disability adjusted life years lost (DALYs) is attributed to psychoactive substance use. Tobacco and alcohol are responsible for a major part (8.1%) of the disease burden, with alcohol being the top risk factor for health in low mortality developing countries. Tobacco, alcohol and illicit drugs are responsible for 12.4% of all deaths worldwide. In some countries of Europe, like Scotland and Spain, deaths related only to opioid use account for as many as 25-33% of deaths in young (15-39 years) males (2). Negative social consequences of alcohol and drug use, like crimes, violence or traffic accidents, make the total burden on the societies even higher. Injecting drug use, often associated with drug dependence and particularly opioid dependence, is a driving force of HIV/AIDS epidemics in many countries of Europe, Asia, the Middle East and Americas, with a number of injecting drug users worldwide estimated to be around 13.2 million (3). Between 1990 and 1998, injecting drug users were the largest group among diagnosed AIDS cases in Western Europe, and since 2001 by far the largest group in the Eastern European Region (4). Often epidemics of drug use were followed by HIV epidemics, and successful and timely prevention of drug use could possibly prevent dramatic developments with HIV/AIDS. Prevention of psychoactive substance use and associated disorders becomes one of the top public health priorities.

However, as Medina-Mora correctly points out, while nobody argues about the importance of prevention, it is not easy to find consensus on the prevention strategies, particularly when evidence for effectiveness of some most popular preventive approaches, like abstinence-oriented school-based interventions, is not very compelling (5), and some effective strategies, like regulation of physical and economic availability of alcohol, are not being widely implemented for different reasons (6).

Developing comprehensive, effective and sustainable strategies of prevention of substance use and dependence requires strong involvement of health care professionals. Psychiatrists, dealing with most severe health consequences of psychoactive substance use and co-occurring psychiatric disorders, by professional training know the effects of substance use and mechanisms of dependence and their prevention and management. That gives them an advantage among health care professionals and determines their potential in the area of prevention of substance use and dependence. The role of psychiatrists in secondary prevention, aiming at early identification and management of substance abuse and dependence, or tertiary prevention, aiming at rehabilitation of substance dependent individuals, is quite straightforward. Regarding primary prevention of substance use disorders, it is worthwhile to mention that prevention of acute intoxication is a legitimate objective, as acute intoxication is a diagnostic category included in both ICD-10 and DSM-IV. This is particularly relevant regarding alcohol, taking into account the burden associated with acute alcohol intoxication. Preventing of drinking to marked intoxication, i.e. changing patterns of drinking in the individuals and populations at large, is an important objective of primary prevention of alcohol use disorders.

With a limited number of trained psychiatrists in many less-resourced countries, it is imperative to go beyond clinical practice to achieve significant public health impact on the scope of substance-related problem. It is critical for psychiatrists to be strongly involved in education, training and support of other health professionals, and first of all in primary health care, to increase their ability to identify and manage substance use disorders among their clientele. Health care professionals have also an important role in communicating the risks associated with psychoactive substance use or its specific patterns to the population, and psychiatrists have an important role in that as well.

Medina-Mora underlines a crucial role of psychiatrists in rational use of dependence-producing medicines. There are other areas where psychiatrists and their professional associations can contribute to prevention of substance use and dependence. One of them is the promotion and development of evidence-based concepts of substance use disorders and effective preventive and treatment strategies, guided by research evidence, which are not limited to management of substance dependence, but incorporate a wide range of preventive interventions, including those which are beyond the health care sector and those that aim at reduction of harm associated with continued substance use.

The role of psychiatrists and their professional associations in the reduction of the burden of substance use disorders has still to be realized.