Substance Use in the Population—A Plea for a Balanced Discussion

The use of psychoactive substances is widespread in the population. Many people consider the at least occasional use of alcohol, nicotine, or medications such as non-opioid analgesics normal. Particularly with regard to alcohol, only a small proportion of the adult population practices complete abstinence. However, the widespread use of psychoactive substances also increases the likelihood of high-risk use or even dependence among some users, making them of considerable relevance in terms of public health and the national economy. The use of nicotine and alcohol in Germany is responsible for 96% of the estimated annual follow-up costs of 160 billion Euros, as well as for the same proportion (96%) of worldwide deaths that are causally related to the use of psychoactive substances (1).

In reality, however, only a small proportion of users suffer damage to their health or other negative effects from the use of alcohol, tobacco, or other substances. Therefore, it is of particular interest to identify those populations that report high-risk substance use in order that the physical and psychological consequences can, if possible, be prevented or treated early on.

Alcohol and nicotine use at a high level

Representative surveys like the Epidemiological Survey of Substance Abuse (ESA) can make an important contribution here. Since the 1980s, the ESA has been recording, at regular intervals, the consumption of alcohol, tobacco, illicit drugs, and medications in the general German population. Between 1995 and 2018, these data showed a decline in the use of nicotine, alcohol, and sedatives for women and men in Germany (2).

Whereas high-risk forms of consumption, for example episodic binge drinking, have likewise steadily declined among men, a slight increase has recently been observed among women. In 2020, for the first time in years, there was an increase in alcohol-related mortality among women and men despite declining consumption (3). Overall, Germany remains one of the countries worldwide with the highest per capita consumption of alcohol, and a proportion of smokers above the European average (4). Moreover, the successes of tobacco prevention in recent decades, particularly among young adults, may be jeopardized by the variety of alternative tobacco and nicotine products now available (5). For example, the ESA data now available show that a significant proportion of young adults use such products. For at least some of these people, the fear is that nicotine use will continue in the long term, meaning that the prevalence of nicotine dependence could rise again in the future.

Rise in cannabis use over the years

In relation to cannabis, here too, there has been a significant increase in its use among the the population. For example, the proportion of consumers more or less doubled between 1995 and 2018, without however, a rise in cannabis-related disorders (2). The figures now available reveal a further rise by 1.7% in the 12-month prevalence of cannabis consumption (1).

Here, the high proportion of cannabis users whose use was interpreted by Rauschert et al. as problematic and “indicating dependence” is surprising. Studies to date suggest that approximately every 10^th person who regularly consumes cannabis exhibits dependence (6). The interpretation of results obtained using the Severity of Dependence Scale (SDS) is clearly responsible for this discrepancy. Equating “problematic use” with “indicating dependence” could be controversial.

Controlled distribution of cannabis

Against the backdrop of the planned regulated distribution of cannabis, how data in epidemiological surveys are gathered and interpreted is not only of academic interest. The risks associated with use are contrasted with the opportunities presented by controlled distribution, for which a framework needs to be carefully set up.

Ultimately, it is precisely the increase in cannabis use among the general adult population observed over the past decade that provides an important argument for the proposed distribution. Health and consumer protection are paramount here, as are improved opportunities for prevention and a more sensible allocation of those resources currently invested in law enforcement. Thus, controlled supply can ensure the quality of the cannabis consumed by what has meanwhile become a significant number of users.

Particular risks are currently linked to the use of synthetic cannabinoids, which a number of users resort to. An example of this is the work, also cited by Rauschert et al., on the risk of triggering psychoses, which points to far greater hazards from synthetic cannabinoids compared to natural cannabis (7). On the other hand, data from Canada suggest that the legalization of natural cannabis there has not led to an increase in cannabis-induced psychoses (8).

Improved access to consumers as part of a legal market will open up additional opportunities to work preventively and promote low-risk use. It is for this reason that the planned controlled distribution of cannabis needs to be accompanied by a nationwide expansion of preventive structures, not least for the purposes of effective youth protection (9).