Commentary on Bischof et al.: Empirical and conceptual paradigms for studying secondary impacts of a person's substance use

Harm from alcohol and other drugs have effects that extend beyond the drinker to their social connections and produce much wider familial and societal impacts. The needs of the relatives, friends, co‐workers and communities affected by the drinking of people in their social networks are seldom voiced, counted or responded to.

Drawing on a national cross‐sectional study in Germany, Bischof et al. [1] measured the health and wellbeing of people living and not living with a family member with a substance use disorder (SUD). Bischof et al. [1] identified two complementary empirical paradigms measuring the harms beyond the substances' impact on individual consumers. They framed these as, first, ‘harm to others’, and including studies of an array of effects from others' substance use in general population surveys [2, 3]. Second, they described qualitative studies of impacts on family members that focused on more severe harm, often among people living with persons with diagnosed SUD [4].

A third way of measuring substance‐related harms beyond the person using substances is to focus on systems. For instance, analyses of substance use treatment systems and a wider variety of service agency responses (including family violence services and emergency departments) can provide societal estimates of the number of people seriously affected (to the degree that they have sought professional help) [3, 5] and associated costs [6]. Data linkage, as often used in Nordic countries, enables links between such systems and provides enhanced surveillance and research [7]. This third perspective adds understanding of how family and clinical problems are managed and measures severity of harm amongst people affected.

To this point, we have largely described empirical models—ways of counting and describing harm, yet what might be more insightful is a model that recognises that these harms, the actors involved and local community responses and influences sit in a much broader context. A confluence of factors is related to the harm and wellbeing of people in a range of social relationships with people who drink. In a public health framing [8], consumption of alcohol causes toxicity, intoxication, dependence and increases the risk of a wide range of harms, particularly intentional and non‐intentional injuries and mental ill‐health, to those that drink and those around them. The individual, family and wider connections form crucial supports. In the background, structural factors related to harm to others operate. These have been identified in the World Health Organization reports on alcohol [9] and violence against women [10, 11] and include intersecting oppressions such as socioeconomic and gender inequality, sexism and colonialism [12].

The authors' contribution is a cross‐sectional national approach to the study of how people might be affected by the drinking of people they are related to. However, caution is needed. The paper, in presenting the millions of people affected in Germany, reports on the prevalence of people living with or related to people who have been identified by the participant as a person with a SUD. This likely generates stigma and could lead to underestimation of the number of people affected (if people decline to acknowledge someone they know is using alcohol or drugs) yet could also lead to overestimation, as not everyone who they know with a SUD will be adversely affecting the participant.

Importantly, Bischof et al. [1] found participants living with an affected family member were at significantly increased odds of experiencing poorer subjective health and depression. Bischof et al.'s [1] study shows an increase in harm—relative to participants who did not report a person affected by an addictive disorder. However, without knowing the baseline level of harm (how many people are categorised as unwell or depressed?) in the unaffected group, we can only conclude participants were at increased odds of being subjectively unwell and depressed. This is an important finding, but not one that shows that millions of people were affected just by being related to a person with a SUD. This and other studies [13] highlight a potential increase in the risk of harm, rather than harm per se. Moreover, Bischoff et al.'s [1] estimates of harms (people living with someone with a SUD) on a percentage basis are much smaller than the estimates produced in the general population studies published [3, 14, 15, 16].

Empirical paradigms measure and highlight that alcohol and other drugs have effects that extend beyond the person drinking or using to their social connections and produce much wider familial and societal impacts. The needs of the relatives, friends, co‐workers and communities affected by the drinking or drug use of people in their social networks are often unvoiced, and few treatment systems exist to manage their specific concerns. These “Harms from substance use to social connections” or “Substances' harm to others” should be counted and responded to.

AUTHOR CONTRIBUTIONS

Anne‐Marie Laslett: Conceptualization.

DECLARATION OF INTERESTS

None.

Laslett A‐M. Commentary on Bischof et al.: Empirical and conceptual paradigms for studying secondary impacts of a person's substance use. Addiction. 2022;117(12):3148–3149. 10.1111/add.16049