Global public health objectives need to address substance abuse in developing countries

Substance addiction is a large and growing problem for developing societies. A new study that surveyed reports on modalities for treating addiction and their effectiveness in the developing world calls on policymakers to use this information to support the design of programs that meet known population needs. The study also encourages looking at ways to adapt the Alcoholics Anonymous (AA) model to fit different cultural norms. The findings are published in the Annals of Global Health.

15 aug 2014--The World Health Organization has indicated that alcohol and illicit drugs pose multifaceted dangers to millions of people, from the psychological damage of addiction to a range of physical health problems. A recent report highlights the need to address a broad spectrum of mental health issues, including substance use disorder (SUD), in order to achieve global public health objectives. This led to a call by policymakers to improve access to treatment for SUD in developing nations. Resources to address SUD in the developing world are severely limited, however, and some 34% of low- and middle-income nations have not yet developed a substance use policy.

"It is difficult to assess the extent of SUD. This is, in part, because of the limited capacity of these countries' governments to conduct national surveys, but it is also due to underinvestment in mental health care in these countries and to underutilization of mental health services in resource-poor settings," says Craig L. Katz, MD, of the Departments of Psychiatry and Medical Education, Icahn School of Medicine at Mount Sinai, New York. "The poorest nations allocate the smallest portion of their already strained public budgets to mental health."

These challenges provided the impetus for a review of the current literature on SUD treatment in the developing world, with the aim of informing future program development and research. Investigator Jasleen Salwan, MD-MPH Candidate, Icahn School of Medicine at Mount Sinai, identified 30 relevant studies published in 1994 or later. The treatment methods included pharmacological approaches, intervention studies to prevent, detect, and reduce harm, the AA-style or Minnesota/Therapeutic Community Model, and multimodal approaches. Two studies compared treatment approaches between two different countries: China with Germany, and El Salvador with Puerto Rico. Other studies looked at access to treatment and resources for providers.

"An important finding is that what works well in one setting may not work well in another," notes Salwan. "Existing research highlights the need to provide secular alternatives to the dominant faith-based treatment approach in El Salvador, to improve access to harm reduction programs for crack cocaine users in Brazil, and to ensure the availability of safe havens for recovering addicts in China to avoid being treated as criminals."

Although comprehensive overviews of treatment models were markedly absent from the literature surveyed, the studies highlight specific areas of need within developing countries, building on existing awareness of general barriers to treatment in those countries. "Policymakers can use this information to design programs that meet known population needs and avoid providing extraneous services," adds Katz.

The investigators recommend that future research should blend inquiry with practice. "Although further investigation is clearly needed in order to better understand the specific needs of developing world populations, assisting those populations should be a primary goal of all endeavors. Conversely, service-oriented planning for addressing SUD in the developing world should be done with a mandate to study the effect of interventions in order to establish program efficacy," comments Katz.

Finally, the authors suggest further evaluation of the AA model. There were mixed results in the literature regarding implementation of the AA model in developing countries that invite further exploration, ideally in more systematic and comprehensive ways.

"Although there is reason to question whether a model that relies so heavily on self-revelation and sharing will work in all places due to cultural and privacy concerns, the AA model has great appeal for developing countries that lack financial resources to create more comprehensive substance use treatment programs. Finding successful ways to adapt the AA model in different settings therefore may not only be a cost-effective way to scale up services, but also help foster a culture of awareness of substance use issues that can in turn spark greater investment in medicalized resources beyond what AA can offer," Katz concludes.

More information: "A Review of Substance Use Disorder Treatment in Developing World Communities," by Jasleen Salwan, MD-MPH Candidate, and Craig L. Katz, MD, DOI: dx.doi.org/10.1016/j.aogh.2014.04.010, Annals of Global Health, Volume 80, Issue 2 (2014)

Provided by Elsevier

Severe mental illness tied to higher rates of substance use

People with severe mental illness such as schizophrenia or bipolar disorder have a higher risk for substance use, especially cigarette smoking, and protective factors usually associated with lower rates of substance use do not exist in severe mental illness, according to a new study funded by the National Institute on Drug Abuse (NIDA), part of the National Institutes of Health.

05 jan 2014--Estimates based on past studies suggest that people diagnosed with mood or anxiety disorders are about twice as likely as the general population to also suffer from a substance use disorder. Statistics from the 2012 National Survey on Drug Use and Health indicate close to 8.4 million adults in the United States have both a mental and substance use disorder. However, only 7.9 percent of people receive treatment for both conditions, and 53.7 percent receive no treatment at all, the statistics indicate.

Studies exploring the link between substance use disorders and other mental illnesses have typically not included people with severe psychotic illnesses.

"Drug use impacts many of the same brain circuits that are disrupted in severe mental disorders such as schizophrenia," said NIDA Director Dr. Nora D. Volkow. "While we cannot always prove a connection or causality, we do know that certainmental disorders are risk factors for subsequent substance use disorders, and vice versa."

In the current study, 9,142 people diagnosed with schizophrenia, schizoaffective disorder, or bipolar disorder with psychotic features, and 10,195 controls matched to participants according to geographic region, were selected using the Genomic Psychiatry Cohort program. Mental disorder diagnoses were confirmed using the Diagnostic Interview for Psychosis and Affective Disorder (DI-PAD), and controls were screened to verify the absence of schizophrenia or bipolar disorder in themselves or close family members. The DI-PAD was also used for all participants to determine substance use rates.

Compared to controls, people with severe mental illness were about 4 times more likely to be heavy alcohol users (four or more drinks per day); 3.5 times more likely to use marijuana regularly (21 times per year); and 4.6 times more likely to use other drugs at least 10 times in their lives. The greatest increases were seen with tobacco, with patients with severe mental illness 5.1 times more likely to be daily smokers. This is of concern because smoking is the leading cause of preventable death in the United States.

In addition, certain protective factors often associated with belonging to certain racial or ethnic groups – or being female – did not exist in participants with severe mental illness. "In the general population, women have lower substance use rates than men, and Asian-Americans have lower substance use rates than white Americans, but we do not see these differences among people with severe mental illness," said Dr. Sarah Hartz, from the Washington University School of Medicine in St. Louis and first author on the study. "We also saw that among young people with severe mental illness, the smoking rates were as high as smoking rates in middle-aged adults, despite success in lowering smoking rates for young people in the general population."

Previous research has shown that people with schizophrenia have a shorter life expectancy than the general population, and chronic cigarette smoking has been suggested as a major contributing factor to higher morbidity and mortality from malignancy as well as cardiovascular and respiratory diseases. These new findings indicate that the rates of substance use in people with severe psychosis may be underestimated, highlighting the need to improve the understanding of the association between substance use and psychotic disorders so that both conditions can be treated effectively.

More information: JAMA Psychiatry. Published online January 01, 2014. DOI: 10.1001/jamapsychiatry.2013.3726

Provided by NIH/National Institute on Drug Abuse

Hispanic drug use rises in US culture

CORVALLIS, Ore. – Substance abuse increases among recent Hispanic immigrants as they replace their traditional cultural beliefs with those of white Americans, according to new research presented today by Oregon State University assistant professor Scott Akins at the American Sociological Association’s Annual Meeting in New York.
The study surveyed 6,713 adults in Washington – of which 1,690 persons identified themselves as “Hispanic.” It is the first of its kind in the Pacific Northwest.
Previous research on the effect of acculturation on drug use has been conducted in states with larger Hispanic enclaves such as California, Florida and the Southwest. In these states Hispanics are more likely to live in heavily concentrated ethnic communities, which may slow their acculturation or assimilation.
The results were striking. Acculturated Hispanics were nearly 13 times as likely to report using illegal drugs as non-acculturated Hispanics. Acculturation involves the adoption of new cultural information and social skills by an immigrant group, which often replaces traditional cultural beliefs, practices and social patterns.
“In general, recent Hispanic immigrants are more family-oriented and have less tolerant views of drug and alcohol use,” Akins said. “Although acculturation and assimilation will provide some migrants with benefits such as wealth and job stability, immigration and acculturation can be a difficult process which has negative consequences as well.”
The study shows that 6.4 percent of whites reported using illicit drugs in the previous month, compared to 7.2 percent of acculturated Hispanics. However, less than 1 percent of non-acculturated, Spanish-speaking Hispanics reported use in the same time period.
“Their percentage/general patterns of substance use are very similar to white patterns of use, which is what we would expect given an acculturation/assimilation model,” Akins said. “When Hispanics acculturate to dominant American society their substance use behavior appears to mimic that of whites, the culture they are acculturating to.”
The research also showed that acculturated Hispanics were almost twice as likely as non-acculturated Hispanics to report current binge drinking and more than three times as likely to report drinking continuously for days in a row without sobering up, also known as bender drinking.
“When people immigrate to the U.S., their patterns of illegal drug use and alcohol abuse increase over time,” Akins said. “In states such as California, you have large Hispanic enclaves that have a protective buffering effect for new residents. But we wanted to find out what was happening in Washington, a state with a relatively small Hispanic population (only 9 percent statewide), which is disproportionately rural and dispersed.”
The study controlled for a number of factors, including marital status, education level, poverty, and rural residence, among other variables.
Akins is the lead author on the research, along with Clayton Mosher of Washington State University, Chad L. Smith of Texas State University and Jane Florence Gauthier of University of Nevada Las Vegas.
Akins said the researchers hope to find new ways to maximize the protective effects of low-acculturation, such as the emphasis on family in traditional cultures, as Hispanic immigrant populations will naturally acculturate over time.