Comorbidity and concurrence of problems: Overlooked, not under-researched

Mental health and substance use-related problems tend to gather and become part of greater problem nexuses. Researchers of different traditions have tried to devise ways to capture this circumstance. In comorbidity networks, human diseases are mapped broadly in entire populations (e.g., Chmiel, Klimek, & Thurner, 2014), while social epidemiology, for example, attempts to identify structural circumstances by formulating indicators and determinants. An attempt to grasp problems as intertwined is that undertaken by the European PARADISE consortium, which has launched a medical “horizontal epidemiology” (PARADISE, 2010). It challenges previous approaches that look for separate disease trajectories. Instead, horizontal epidemiology is meant to capture the fact that psychosocial difficulties, such as sleep disturbances, emotional instability and difficulties in personal interactions, and their environmental determinants are often related and share commonalities in the brain (Cieza et al., 2015). For people suffering from addiction, this may help to frame their problems as entangled – even if only in the diagnostic and medical sense.

In grasping interconnected factors in the social seating of problems, Meier, Warde, and Holmes (2018) argue for a social practice theory that sees the social meaning, settings, and the nature of health-related activities as integrated in people’s daily lives. When practices are conceptualised as routine types of human activity that are made up of, and can be recognised by “the coming together of several interwoven elements” (Meier et al., 2018, p. 206), the authors see that alcohol research can shift its attention away from individuals and recognise contexts that have been neglected, especially in quantitative research.

Within its social scientific scope, Nordic Studies on Alcohol and Drugs has sought to keep up to date with the multi-problems framing. In December 2018, we published a thematic issue on polydrug use, in which the guest editors Kataja, Tigerstedt, and Hakkarainen (2018) point out that, while the volume of publications dealing with the theme has certainly increased, a great gap remains in understanding such mixed use as a social question. With contributions from Sweden, Norway, and Finland, the present issue can be seen as following up on the poly-use and multi-problems theme. The articles discuss concurrent substance use, experience of different kinds of use by others, and risky habits of pre-loading, sexual behaviour, and driving.

Use of different substances

The fact that problems accumulate and gather, propelling heavy users into the risk zone of comorbidities and marginalisation is unfolded by the Swedish alcohol researcher Mats Ramstedt (2019). He has studied the concurrent use of addictive substances – tobacco, illicit drugs, and non-prescribed use of analgesics and sedatives – among different kinds of alcohol drinkers in the Swedish general population. The study is able to show that those who drink the most are more likely to use other addictive substances than are non-drinkers, and that such concurrent use becomes more common the more alcohol is consumed. Ramstedt’s conclusion is that the screening for concurrent use of different kinds of addictive substances is important for healthcare providers to identify the nature of the patient’s problem picture.

A population survey among 16–64-year-olds serves as the data for perceptions of others’ use of alcohol, cigarettes, and illegal drugs in a Norwegian study by Moan, Bye, Storvoll, and Lund (2019). It appears that the closer you are to the person the more harm you are likely to experience. This likelihood also increases if you are a user yourself. Women and younger persons were more likely to report harm from others’ alcohol and cigarette use.

Intoxication and risk

The ways in which we combine habits as suggested in social practice theory could also serve for figuring out (changing) youth consumption and use patterns. Swedish university students’ alcohol intoxication and hazardous alcohol use is studied by Elgàn, Durbeej, and Gripenberg (2019) in the setting of eight student parties. Breath alcohol concentration, background data, and responses to the AUDIT-C were gathered, implicating that drinking at pre-parties is likely to lead to a pattern of heavier intoxication. This is not a marginal question, since a great majority of the students (91% among the respondents) drink before arriving to university parties.

If the pre-loading study by Elgan and colleagues maps youngsters’ risky intoxication habits at the beginning of party nights, the study by Strandberg and colleagues (2019) could in a sense be seen as looking at the results. Among visitors at youth health clinics in Stockholm county, risky alcohol consumption is associated with risky sexual behaviour outcomes.

In the study on driving fitness among patients with alcohol problems in hospitals in Finland, authors Kalsi, Tervo, and Tervo (2019) point out the worrying circumstance that the evaluation of the heavy alcohol users’ driving fitness is often neglected. The study shows that their driving fitness was significantly reduced, and the health requirements of the driving licence were not met. Still, heavy alcohol users’ capability to drive is seldom tested (only in 24% of the cases).

Last but certainly not least

In order to really acquire insights into the complex and unique events that may lead to a life spent with addiction, I recommend to readers Willy Pedersen’s account of an in-depth interview with a woman born in the early 1920s, who developed a heavy morphine addiction (Pedersen, 2019). In the course of the interview, she gradually reveals the ways in which her husband and physicians played key roles in the development of her addiction over time. Pedersen points out that this story serves not only as an interesting illustration of how women from the upper strata of society with close links to male physicians may have been at particular risk of opioid misuse in the period before 1960, but also as a parallel to the recent prescription opioid drug crisis in the United States. Prescription drug use can develop in intimate and psychologically complicated relationships with physicians. The story can also be read as educative for understanding what is hidden behind the statistics in our research. No indicator list is long enough and no social epidemiologist is skilful enough to account for the story of this fatal attraction-based opioid addiction.

In the summer of 2019, our impact factor has increased to 0.875. Although this measurement has significant flaws for arguing a journal’s quality, we still welcome this news, since we work hard to maintain a high standard. At the editorial office, we hope that the journal’s accessibility, quality, and range of topics will appeal to and be useful for as many readers as possible.