Читать книгу The End of addiction - Dr Volker Hitzeroth - Страница 11

To be able to address the challenges posed by drugs and alcohol, we have to clarify the nature and extent of drug and alcohol use. Basic data about the scope of the problem are therefore critical to our ability to intervene and assist drug- and alcohol-using clients and their families. Although it is clear that there is a need for further research and collection of data on drugs and alcohol, collecting data alone poses many problems. It is extremely difficult to ascertain exact figures regarding drug and alcohol use across populations. This is because very few people work within the drug and alcohol addiction field and are able to report such data.

Furthermore, alcohol and drug use can present to the authorities in a number of different ways. We know that drug- and alcohol-related problems could present in a medical setting with infections, bleeding tendencies and neurological problems; in a mental health setting with associated depression, anxiety, psychosis and threats or attempts at suicide; in an emergency setting with seizures, cardiac problems, intoxication syndromes and withdrawal symptoms; as a chronic illness with HIV, hepatitis, liver problems and stomach ulcers; in a non-medical setting such as a criminal court due to drunken driving, assault or theft; or at the place of employment with workers arriving intoxicated and unable to do their work. The variety of drug and alcohol presentations makes it extremely difficult to gather useful information on drug and alcohol use.

In addition, a large part of the drug and alcohol world remains illegal and underground and virtually impossible to monitor. Lastly, those using drugs and alcohol often do not disclose the exact volume consumed. In fact, they spend a large amount of time and effort hiding their drug or alcohol use from their family and friends. When questioned, they are likely to underreport their drug and alcohol use due to fear of stigma and blame.

Traditionally, a number of sources of drug and alcohol information are accessed when clinicians, epidemiologists or policy-makers attempt to estimate the drug and alcohol use within a community:

1 One method of accessing information regarding drug and alcohol use is to have individual interviews with users or their families. Although these are very useful, they are also hampered by the problems of self-reporting, such as honesty, fear, shame and ignorance, which could all result in under- or overreporting.

2 Governments or large organisations also attempt to do general population surveys in which large population groups are surveyed using questionnaires or interviews to assess the drug and alcohol use within that specific population. Such surveys usually provide reasonably accurate information, but are costly and time consuming. Furthermore, they would have to include large numbers of individuals within the population in order to give accurate results because the problem of drug and alcohol use remains relatively rare within the general population. Of course, a general population survey is also likely to neglect marginalised groups, who may actually have high levels of drug and alcohol use and who are thus underrepresented in the general survey. Examples of such groups might include the homeless, the unemployed, commercial sex workers, or gays and lesbians.

3 Another method of acquiring valuable information on drug and alcohol use involves using indirect drug and alcohol indicators. Such indirect indicators are employed as markers for drug and alcohol problems. If accurate data on the problems associated with drug and alcohol use can be gathered, this would be a reflection of the underlying drug and alcohol use itself. Such indicators include, for example, police arrests, border control attachment of drugs and alcohol, liver problems associated with alcohol or hepatitis, as well as admission rates, detox admissions, prescriptions issued, school drug testing or emergency room visits with a drug overdose. All of these contacts are likely to relate to drug and alcohol use in some way. Hence, data on these contacts could be used to estimate drug and alcohol use within a population. Again, numerous problems arise when such indirect markers are used as, by definition, they are indirect indicators of drug and alcohol problems, and therefore not a true reflection of the underlying drug and alcohol problem. Clearly, alternative causes may be relevant. For example, increasing levels of liver problems may not be a reflection of alcohol consumption or hepatitis infection due to intravenous heroin use, but could simply be due to better screening and diagnosing protocols within the health setting. Similarly, an increase or decrease in drug-related crimes does not necessarily reflect an increase or decrease in drug use, but could be due to heightened awareness of crime within a population, additional resources being spent on detection and arrests of criminals, or simply more accurate reporting in the news media. Finally, the number of children within a school setting who have tested positive for drug and alcohol use could be influenced by the implementation of a new drug- and alcohol-testing protocol, or a greater awareness of drug- and alcohol-related problems among the teaching staff.

4 To improve the accuracy of drug and alcohol estimation, a number of statistical calculations and models have been developed, by which data are statistically analysed and reported. Such statistical analysis is usually based on numerous data sets being entered into the equation in order to come up with the most accurate figures.

As can be seen from the above, estimating drug and alcohol use and abuse is fraught with problems. The most accurate information is usually obtained when a number of large studies across populations are combined. It is also usually best practice to combine studies that have used different methodologies and statistical calculations, so as to provide the best and most accurate overview of a drug and alcohol problem within the specified population.

It is also very important to understand precisely what has been assessed. For example, if a study is done on drug and alcohol use, the results are likely to differ from a study on drug and alcohol abuse or even dependence. Which criteria are used to study the population also plays an important role. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, with Text Revision (DSM- IV-TR), published by the American Psychiatric Association (APA), covers all mental disorders and is used extensively within the field of psychiatry. The DSM-IV-TR has specific sets of criteria for alcohol abuse (one of four criteria within the last month) and dependence (three of seven criteria over the last year). However, other diagnostic criteria do exist, and could also be used when such studies are undertaken. This would be particularly relevant when comparing and analysing more than one study, as the study methodologies may differ and the criteria used may relate to a different classification system.

Two important concepts that need to be understood when we estimate the use of drug and alcohol within a population are prevalence and incidence.

1 Prevalence refers to the total number of cases at a particular time point who use, abuse or are dependent on drugs and alcohol. Prevalence is thus usually a cross-sectional count of a specific condition being present. There are different types of prevalence, including point prevalence, which refers to the total number of cases at a specific time point; lifetime prevalence, which refers to the total number of cases within a lifetime, up to the date of the study; and period prevalence, which refers to the total number of cases within a predetermined and well-defined time period.

2 Incidence refers to the number of newly reported cases within a specific and predetermined time period. It is a longitudinal indicator of newly reported cases within a specified time, which is usually defined as a one-year period, but could also be longer or shorter, for example one month or ten years.

Although governments, large organisations, non-governmental organisations and even university departments would like information about drug and alcohol use, accessing these data is costly, cumbersome and time consuming. In South Africa, the situation is complicated further by its being a developing nation that is constrained by a lack of funding, technology and manpower.

United States of America

The United States has access to large epidemiological studies that have estimated the use of drugs and alcohol within their population. Numerous studies by various organisations were done throughout the 1980s, 1990s and early 2000s. These studies sampled many thousands of people across the United States in order to estimate the lifetime prevalence of drug and alcohol use, abuse and dependence.

Depending on which study is analysed, the range of lifetime prevalence for alcohol abuse is between 4.9% and 17.8%, while the lifetime prevalence of alcohol dependence ranges from 5.4% to 14.1%. These average figures do not reflect the significantly higher rate of alcohol abuse and dependence within the male population compared with the relatively lower rate in the female population.

The lifetime prevalence of cannabis abuse and dependence is approximately 11.8%, while the lifetime prevalence for other drug abuse and dependence is relatively low (most studies indicate less than 3.9%, although one study ranged up to 7.9%). The lifetime prevalence of nicotine dependence ranged between 13% and 24%.

South Africa

Although South Africa does not have access to such large studies as the United States, we do have a number of surveys and local studies that have attempted to estimate drug and alcohol use within our country. These studies include authors with various affiliations in different localities, using a range of methodologies and definitions. It is therefore very difficult to provide a comprehensive overview of the drug and alcohol situation within South Africa. The South African studies include a number of household and school surveys, as well as specific studies of commercial sex workers, HIV risk behaviour, drug-injecting patterns, and studies of gay men.

Alcohol in South Africa

Overall, it is clear that South Africa has one of the highest levels of alcohol use in the world. Similarly, this country has one of the most hazardous and harmful patterns of alcohol consumption when compared with other countries worldwide. In this sense, alcohol is associated with a high burden of mortality and morbidity. The lifetime alcohol use is approximately 40%, while the current alcohol use within the last one month is approximately 30%. Approximately 25% to 33% of alcohol users engage in risky drinking, which occurs mostly over weekends. Hazardous and harmful alcohol use in adolescents and young adults ranged from 2% to 17%, with that of adults ranging from 5% to 17%. Such hazardous and harmful alcohol use occurred among men and women in both rural and urban areas, in many provinces and across most racial groups.

When alcohol use among different subpopulations was examined, a number of studies among adolescents found a range of current alcohol use from 21% to 62%, with binge drinking ranging from 14% to 40%. Hazardous or harmful drinking was found to be at 19%. Studies of South African students highlighted a current alcohol use among 22% to 80% of students, with binge drinking in the last month ranging between 6% to 43%, and hazardous or harmful drinking ranging from 17% to 58%.

A study among mine workers revealed that 9.3% used alcohol daily of whom 15.3% were alcohol dependent. A study among farm workers in the Western Cape revealed that 87% were potentially alcohol dependent. A study done at a defence force clinic in Cape Town revealed that 13.3% reported that they engaged in hazardous or harmful drinking. A study in a rural primary outpatient clinic revealed that 19.2% of patients reported that they engaged in hazardous or harmful drinking, while an investigation of a psychiatric hospital clinic’s records found that alcohol abuse was 6.3% among women and 15.1% among men.

Cannabis in South Africa

A number of studies have attempted to estimate the use of dagga in South Africa. Adolescent lifetime cannabis use ranges between 7% and 20%, while current use of cannabis among adolescents ranged between 2% and 9%. Adolescents seem to start using cannabis during their early teenage years. Recent and current cannabis use among adults was found to be approximately 2%, while in a specific study among educators this range was even lower (approximately 0.3%). A study done among mine workers indicated that self-reported lifetime cannabis use was 7.2%, and current cannabis use 2.3%, although urine testing revealed current cannabis use of 9.1%. A further study of arrestees who were tested and interviewed in three major cities in South Africa revealed that only 54% who tested positive for cannabis reported using the drug in the last month.

Heroin in South Africa

A number of household, school and community surveys on drug abuse have been conducted in this country. The results indicate that a range of approximately 1% to 4% of respondents reported using heroin at least once in their life, with between 1% to 3% reporting current use of heroin. Studies done at various rave parties found that between 4.8% and 12% reported using heroin at least once in their life.

A Cape Town study that investigated heroin use and HIV-related risk behaviour interviewed 239 heroin users in Cape Town. This group indicated a large proportion of polydrug use with tobacco, alcohol, cannabis, methamphetamine (tik) and mandrax being the most common other drugs used. The average age of onset of heroin use was 20 years. The majority of those who had tried other drugs prior to heroin began with cannabis and mandrax. Of this sample, 24% had injected heroin in the last month, while 77% of these injectors had injected heroin in the past three days, and 80% had injected heroin daily. The average starting age for injecting heroin was 22 years. Injecting would mostly occur in their homes, their friends’ homes, or their dealers’ homes. No less than 89% of the heroin users who reported injecting in the past month had shared a needle at least once during that period, with either a close friend or their regular sex partner or a casual sex partner. Reusing needles was also common. Among the respondents, 61% had been tested for HIV at least once. Of those, 88% reported that the test had been negative, 6% reported that the test had been positive, and another 6% replied that they did not know the result. Of the respondents, 52% had been tested for hepatitis C, with 7% of these being positive, and 47% had been tested for hepatitis B.

SACENDU

The South African Community Epidemiology Network on Drug Use or SACENDU as it is commonly known, is an alcohol and drug surveillance system that operates throughout South Africa. SACENDU has been operational since 1996 and monitors trends in alcohol and drug use, as well as its associated consequences. The surveys are repeated every six months by analysing information received from drug- and alcohol-treatment centres. SACENDU was established by the Medical Research Council of South Africa in association with various partners, stakeholders and funders. It comprises a network of researchers, practitioners and policy-makers who provide community level public health surveillance data of drug and alcohol use throughout the country. SACENDU therefore measures drug and alcohol trends indirectly by monitoring those who seek treatment at treatment centres across South Africa.

During the Phase 24 SACENDU analysis (June 2008), alcohol remained the most common primary substance of abuse across South Africa, except in the Western Cape, where methamphetamine was the most common drug. The treatment seekers who sought help with an alcohol problem were mostly young to middle-aged males. Cannabis also remained very common, with 11% to 50% of treatment seekers across South Africa reporting cannabis use as their primary problem. Cocaine and crack were the primary drugs of abuse for between 5% and 20% of treatment seekers throughout the country. They were often used in combination with other drugs, and were mostly used by younger adults.

Heroin was used by between 1% and 23% as their primary drug across South Africa. It was found that 11% of heroin users in the Western Cape were injecting, compared with 24% of users in Gauteng. Stimulants such as ecstasy and khat were reported as very low primary drugs of abuse. In the Western Cape however, methamphetamine (tik) was the primary drug of abuse for approximately 36% of treatment seekers. Over-the-counter and prescription medication abuse and dependence was responsible for seeking help in between 1% and 7% of the respondents. Over-the-counter and prescription medication use was mostly combined with alcohol and other drugs.

Having explored the overall scope of the drug and alcohol problem at community level, we can now consider individual patterns of drug and alcohol use.