Addiction 98:713-716, 2003. Commentaries and a response published on pp. 717-723.
My aim in this paper is to take advantage of the broadened perspective which comes from thinking about alcohol, tobacco and other drugs together, and to suggest some rethinking of how communities and societies can go about controlling their use so as to minimize the harms which potentially come along with the use.
In dealing with alcohol, tobacco, and other drugs, our field deals with behaviours which are intensely personal. At the level of choices about using, and of the experience of habitual use which we call addiction or dependence, the great advances in neurobiological research have something to teach us. But the lesson I draw from this research is different from that drawn, for instance, by Alan Leshner (Kessler, 2001). It turns out that the psychoactive substances all have their effects of bringing pleasure or relief from pain in common pathways in the brain which are affected also by many other daily or occasional experiences -- by eating food, by having sex, by many other pleasures and peak experiences.
So the neurobiological research, on the one hand, has given us an understanding at a new level of what is in common between the substances we have called “psychoactive”. But, on the other hand, it has also taught us that they are not so special after all -- that the biological mechanisms by which they have their psychoactive effect are mechanisms widely shared with other activities. The common ideological response to this, in the context, say, of the U.S. National Institute on Drug Abuse, has been to distinguish between some highs defined as “natural” and others defined as “artificial”, and to talk in terms of the “artificial” highs from drugs as “hijacking” the brain. But this is a distinction which is in the end aesthetic rather than scientifically based. We readily accept artificial aids in a circumstance which we define as an illness -- opiates for intractable pain, for instance, or Viagra for male impotence. We also rely on artificial means for many everyday pleasures: we do not ban roller-coasters or forbid swings to children, or banish television, because they are an artificial source of pleasure.
In the end, then, I believe that the result of the neurobiological research, as its implications trickle into our consciousness, will be a convergence in our frames for understanding psychoactive substance use -- a convergence, furthermore, which normalizes the use of psychoactive substances as just one segment of the spectrum of activities by which humans get pleasure or relief from pain -- activities which all, to a greater or lesser extent, often become habitual.
Our attention then will tend to be refocused on the dimensions of substance use which hold direct implications for public health. In the first place, there are the dimensions which primarily affect the user him- or herself. These include the short-term and chronic effects on the user’s body -- the possibilities of overdose, affected both by characteristics of the psychoactive substance itself and by the form and route in which it is taken, and the long-term bodily effects like cirrhosis and lung cancer so familiar to those working on alcohol and tobacco. The ease with which dependence gets established, for the particular formulation and in particular social circumstances, is also a potential consideration.
But such a list of consequences of substance use for the user of course does not exhaust the list of relevant consequences for public health. What we do even in private often affects others. More crucially, psychoactive substance use itself is often a social act, something done in the company of and together with others. Around the use of particular substances and modes of use, subcultures, customs, and even institutions build up. I have only to mention to you the neighbourhood tavern, shooting galleries, wine-tastings, the work-break known as a “smoko” in my native Australia, and the phrase “Here’s looking at you, kid”, to conjure up some of the cultural associations and customs which become part of the meaning of psychoactive substance use.
Sometimes, as with second-hand smoke from cigarettes, the effects of the substance use on others is direct toxicity. But more important, in terms of the total health burden, are the effects due to the changes in thinking and actions induced by the psychoactivity itself. In terms of present-day patterns, the most important substance here is alcohol. The interference with physical coordination from a few drinks, for instance, produces many casualties, whether from motor-vehicle collisions, from falls, or otherwise. The interference with judgement and reasoning from drinking lies at the heart of alcohol’s role in violence.
Also important, but much less adequately measured, are the adverse effects which can result from a substance user’s default of major social roles -- in the family, in friendships, and in the workplace.
Setting aside these social problems,
and accounting just for the disease and disability attributable to psychoactive
substance use, the new Burden of Disease estimates for 2000 from the World
Health Organization find that a net of 8.9% of the disability-adjusted
life-years lost on a global basis are due to the use of psychoactive
substances. In the subregion that is
nine-tenths composed of the population of the
Once the list of potential adverse
effects is totted up, the impulse easily becomes to ban one or another
psychoactive substance altogether. We
live every day, in the modern world, with the consequences of the
Though the prohibitory system can show some successes, primarily with synthesized medications, we are also living with the daily object lesson of its larger failures. So far, we have been unwilling to live in a society sufficiently authoritarian to make the prohibition system workable. This object lesson seems to have been sufficient to deter the public health community, for instance, from calling for prohibition of tobacco. And any comprehensive public health approach to reducing the health burden from psychoactive substance use has to take account of the fact that the drug control systems do not cover the two substances, alcohol and tobacco, which together account for 91% of the death and disability attributable to psychoactive substances, according to the Global Burden of Disease estimates (Ezzati et al., 2002).
If we are not to ban the substances, then how may the public health burden be minimized? As we rethink this question, we have a wealth of practical experience, stretching back decades and in some places centuries, to draw on. The general answer seems to me to be a policy of selective discouragement, sometimes robust and sometimes gentle. To the extent possible, the measures of discouragement should be mundane and built into the social fabric, rather than being fraught with drama and thus offering an attractive target for generational rebellions. And as much as possible the policies should be adapted to local circumstances, rather than being imposed nationally or globally.
In terms of criteria for selectivity in the discouragement, there is substantial room for action in how the substance is formulated and taken. While prohibitions tend to push a substance into its most concentrated form, if only for ease of concealment and carrying, a controlled market in the substance can favour more dilute forms. There are often at least some public health advantages from use of more dilute forms. One can die of an overdose of spirits, but it would be extremely difficult to die of an overdose of the 3.5% beer which is most readily available to Swedish teenagers. The way in which the substance is taken is often even more crucial to public health. The minor potential health harms from nicotine itself, to take the most pressing example, are insignificant next to the health harms from the tars and carbon monoxide when the nicotine is taken in by smoking a cigarette. Smoking heroin carries fewer risks than injecting it. We know from practical experience with tobacco and alcohol that differentially favouring less harmful forms and concentrations of the substance, by such means as relatively greater availability and lower taxes, can quickly become a relatively unobtrusive way of influencing the rates of public health harm.
A crucial part of any control policy is an active control over the markets in psychoactive substances. One conclusion which can be drawn both from human history and from laboratory experiments is that psychoactive substances create their own market; in view of the potential adverse consequences, further stimulation of demand with advertising and promotion is socially dysfunctional. In this area the American constitutional tradition, particularly in the hands of the current Supreme Court, is creating a real problem for public health (Weissman, 1998). The court decisions are moving towards the posing of a stark dichotomy: either sale of a commodity is prohibited, or else governments cannot limit its advertising and promotion. The idea of full First Amendment protections for “commercial speech” about tobacco or alcohol, that governments cannot limit promotion of products with adverse public health effects, seems to me an extremely problematic and retrograde development.
Government control of the market, of
course, needs to go beyond limiting or disallowing advertising and
promotion. One characteristic of licit
markets for psychoactive substances, well recognized for alcohol in the first
part of the 20th century, is that they are potentially highly profitable, and
that the long-term trend is towards greater and greater concentration in their
production and distribution. Those
profiting from the sales of psychoactive substances have the potential to wield
great political power, and their incentive to do so becomes greater as the
government exercises more control over their conditions of operation. One historical solution to this in the
alcohol field was for the private profit interest to be eliminated, by the
state itself taking over all or part of the production or distribution of the
product (Room, 2000). This was a major
consideration behind setting up systems of state or provincial liquor stores,
for instance, in 18
Other measures have often been taken to limit the power
and concentration of commercial interests in markets for psychoactive
substances. For instance, “tied-house
laws” at federal and state levels in the
In the present world, these powers
of local and national governments to control the market in licit psychoactive
substances are under sustained attack from trade agreements and disputes. Prompted by their beer industries, both the
Many of the most poignant adverse effects of psychoactive substances are experienced and dealt with at the local level -- by family, friends or community emergency services. There is good reason therefore for the local level to have substantial powers to set policies on the details of psychoactive substance availability. The limited geographic reach of local jurisdictions does place some limits on these powers; these days, there is not only the sales outlet just across the boundary, but also the website seller, to contend with. But to some extent these issues can be dealt with by state or federal legislation supporting the powers of local authorities to control the market.
Reflecting the concrete and vivid experience of adverse effects at the local level, local action and option were the hallmark historically of the temperance movement, just as local ordinances have been a key strategy in recent decades in the movement to strengthen tobacco controls. To counter the potential impact of these local decisions, commercial interests have often pushed for pre-emption by higher levels of government, for instance by placing alcohol control decisions at the state level in California after Repeal, or by pre-emptions of local tobacco control decisions at the state or federal level. The most favorable position for commercial interests often is that one level of government, usually the local level, is bearing the costs and picking up the pieces from substance use problems, while another level of government pre-empts the control system, often also reaping the benefits from any taxation. Until recently this dynamic primarily played out between local and state governments, or between state and federal. Now the dynamic is also occurring at the supranational level. The ability of nations, or of their subunits, to impose controls is limited and potentially pre-empted by the existing structure of trade agreements and disputes, and still more by the proposed General Agreement of Trade in Services (GATS) (Griueshaber-Otto & Schacter, 2002). Ensuring that communities and local government are not hamstrung at state, national or supranational levels from responding to their local problems is thus a more and more pressing issue. It is counterproductive and even cynical to assign communities the responsibility for preventing the problems while denying them the policy tools needed for effective action.
In rethinking control of alcohol, tobacco and other psychoactive substances, we need a public health vision of the problems which is comprehensive and global. But experience teaches us that sweeping visions and actions once and for all are of less use in countering and limiting the problems. Recourse to psychoactive substances as sources of pleasure and relief of pain is intertwined through all of human history. Building effective and sustainable systems of control which limit attendant harms is an important task for public health, but it is a task which, as with much else in public health, requires sustained attention to detail and above all perseverence.
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