drug addiction thesis introduction

Pathways of Addiction: Opportunities in Drug Abuse Research (1996)

Chapter: 1. introduction, 1 introduction.

Drug abuse research became a subject of sustained scientific interest by a small number of investigators in the late nineteenth and early twentieth centuries. Despite their creative efforts to understand drug abuse in terms of general advances in biomedical science, the medical literature of the early twentieth century is littered with now-discarded theories of drug dependence, such as autointoxication and antibody toxins, and with failed approaches to treatment. Eventually, escalating social concern about the use of addictive drugs and the emergence of the biobehavioral sciences during the post-World War II era led to a substantial investment in drug abuse research by the federal government (see Appendix B ). That investment has yielded substantial advances in scientific understanding about all facets of drug abuse and has also resulted in important discoveries in basic neurobiology, psychiatry, pain research, and other related fields of inquiry. In light of how little was understood about drug abuse such a short time ago, the advances of the past 25 years represent a remarkable scientific accomplishment. Yet there remains a disconnect between what is now known scientifically about drug abuse and addiction, the public's understanding of and beliefs about abuse and addiction, and the extent to which what is known is actually applied in public health settings.

During its brief history, drug abuse research has been supported mainly by the federal government, with occasional investments by major private foundations. At the federal level, the lead agency for drug abuse research is the National Institute on Drug Abuse (NIDA), which supports

85 percent of the world's research on drug abuse and addiction. Other sponsoring agencies include the National Institute of Mental Health (NIMH), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and the Substance Abuse and Mental Health Services Administration (SAMHSA), all in the Department of Health and Human Services; as well as the Office of Justice Programs (OJP) in the Department of Justice. Throughout the federal government, the FY 1995 investment in drug abuse research and development was $542.2 million, which represents 4 percent of the $13.3 billion spent by the federal government on drug abuse (ONDCP, 1996). By comparison, $8.5 billion (64 percent of the FY 1995 budget) was spent on criminal justice programs, 1 $2.7 billion (20 percent) on treatment of drug abuse, and $1.6 billion (12 percent) on prevention efforts.

In 1992, the General Accounting Office (GAO) released a report Drug Abuse Research: Federal Funding and Future Needs, which recommended that Congress review the place of research in drug control policy and its modest 4 percent share of the drug control budget. The report questioned whether the federal commitment to research was adequate, given the enormity of research needs (GAO, 1992), and whether adequate evaluation research was being conducted to determine the efficacy of various drug control programs. In FY 1995, drug abuse research was still little more than 4 percent of the entire drug control budget.

In January 1995, NIDA requested the Institute of Medicine (IOM) to examine accomplishments in drug abuse research and provide guidance for future research opportunities. This report by the IOM Committee on Opportunities in Drug Abuse Research focuses broadly on opportunities and priorities for future scientific research in drug abuse. After a brief review of major accomplishments in drug abuse research, the remainder of this chapter discusses the vocabulary and basic concepts used in the report, highlights the importance of the nation's investment in drug abuse research, and explores some of the factors that could improve the yield from that investment.

MAJOR ACHIEVEMENTS IN DRUG ABUSE RESEARCH

There have been remarkable achievements in drug abuse research over the past quarter of a century as researchers have learned more about the biological and psychosocial aspects of drug use, abuse, and dependence. Behavioral researchers have developed animal and human mod-

els of drug-seeking behavior, that have, for example, yielded objective measures of initiation and repeated administration of drugs, thereby providing the scientific foundation for assessments of "abuse liability" (i.e., the potential for abuse) of specific drugs (see Chapter 2 ). This information is an essential predicate for informed regulatory decisions under the Food, Drug and Cosmetic Act and the Controlled Substances Act. Taking advantage of technological advances in molecular biology, neuroscientists have identified receptors or receptor types in the brain for opioids, cocaine, benzodiazepines, and marijuana and have described the ways in which the brain adapts to, and changes after, exposure to drugs. Those alterations, which may persist long after the termination of drug use, appear to involve changes in gene expression. They may explain enhanced susceptibility to future drug exposure, thereby shedding light on the enigmas of withdrawal and relapse at the molecular level (see Chapter 3 ). Epidemiologists have designed and implemented epidemiological surveillance systems that enable policymakers to monitor patterns of drug use in the population ( Chapter 4 ) and that enable researchers to investigate the causes and consequences of drug use and abuse (Chapters 5 and 7 , respectively). Paralleling broader trends in health promotion and disease prevention in the past 20 years, the field of drug abuse prevention has made significant progress in evaluating the effectiveness of interventions implemented in a range of settings including communities, schools, and families (see Chapter 6 ).

Marked gains have also been made in treatment research, including improvements in diagnostic criteria; development of a wide range of treatment interventions and sophisticated methods to assess treatment outcome; and development and approval of Leo-alpha-acetylmethadol (LAAM), a medication for the treatment of opioid dependence. Pharmacological and psychosocial treatments, alone or in combination, have been shown to be effective for drug dependencies, and treatment has been shown to reduce drug use, HIV (human immunodeficiency virus) infection rates, health care costs, and criminal activity (see Chapter 8 ).

Drug abuse researchers have also made major contributions to knowledge in adjacent fields of scientific inquiry. For example, NIDA-sponsored research was the driving force in the identification of morphine-like substances that serve as neurotransmitters in specific neurons located throughout the central and peripheral nervous systems (Orson et al., 1994). Identification of these substances represents a dramatic breakthrough in understanding the mechanisms of pain, reinforcement, and stress. Additionally, the discovery of opioid peptides as neurotransmitters played a key role in the identification of numerous other peptide neurotransmitters (Cooper et al., 1991; Goldstein, 1994; Hokfelt et al., 1995). These discoveries have broadened the understanding of brain function and now

form the basis of many current strategies in the design of new drug treatments for neuropsychiatric disorders. Additionally, drug abuse research has contributed to the development of brain imaging techniques.

Drug abuse research has also provided a major impetus for neuropharmacological research in psychiatry since the late 1950s, when it was discovered that LSD (lysergic acid diethylamide; a hallucinogen that produces psychotic symptoms) affected the brain's serotonin systems (Cooper et al., 1991). That seminal discovery stimulated decades of research in the neuropharmacological basis of behavior and psychiatric disorders. The impact on antipsychotic research has been dramatic. In addition, stimulants (e.g., cocaine and amphetamine) were found to produce a state of paranoid psychosis, resembling schizophrenia, in some people. The actions of stimulants on the brain's dopamine pathways continue to inform researchers of the potential role of those pathways in the treatment, and perhaps the pathophysiology, of schizophrenia (Kahn and Davis, 1995). Drug abuse research also has had an impact on antidepressant research (e.g., the actions of drugs of abuse on the brain's serotonin systems have provided useful models with which to investigate the role of those systems in depression and mania). Depression is a risk factor for treatment failure in smoking cessation (Glassman et al., 1993) and depression-like symptoms are dominant during cocaine withdrawal (DiGregorio, 1990). Consequently, treatment of depression in nicotine and cocaine-dependent individuals has been an area of interest for drug abuse research.

Some drugs that are abused, most notably the opioid analgesics, have essential medical uses. Since its founding, NIDA has been the major supporter of research into brain mechanisms of pain and analgesia, analgesic tolerance, and analgesic pharmacology. The resulting discoveries have led to an understanding of which brain circuits are required to generate pain and pain relief (Wall and Melzack, 1994), have revolutionized the treatment of postoperative and cancer pain (Folly and Interesse, 1986; Car et al., 1992; Jacob et al., 1994), and have led to improved treatments for many other conditions that result in chronic pain (see Chapter 3 ).

VOCABULARY OF DRUG ABUSE

Ordinarily, scientific vocabulary evolves toward greater clarity and precision in response to new empirical discoveries and reconceptualizations. That creative process is evident within each of the disciplines of drug abuse research covered in various chapters of this report. Interestingly, however, the words describing the field as a whole, and connecting each chapter to the next, seem to defy the search for clarity and precision. Does "drug" include alcohol and tobacco? What is "abuse"? Are use and

abuse mutually exclusive categories? Are abuse and dependence mutually exclusive categories? Does use of illicit drugs per se amount to abuse? Does abuse include underage use of nicotine? Is addiction synonymous with dependence?

These ambiguities have persisted for decades because the vocabulary of drug abuse is inevitably influenced by peoples' attitudes and values. If the task were solely a scientific one, precise terminology would have emerged long before now. However, because the choice of words in this field always carries a nonscientific message, scientists themselves cannot always agree on a common vocabulary.

Consider the case of nicotine; from a pharmacological standpoint, nicotine is functionally similar to other psychoactive drugs. However, many researchers and policymakers choose to exclude nicotine from the category of drug. The same is true of alcohol; for example, other terms, such as ''chemical dependency" or "substance abuse," are often used as generic terms encompassing the abuse of nicotine and alcohol as well as abuse of illicit drugs. This semantic strategy is chosen to signify the difference in legal status among alcohol, nicotine, and illicit drugs. In recent years, however, a growing number of researchers have adopted a more inclusive use of the term drug. In the case of nicotine, this move tends to reflect a policy judgment that nicotine should be classified as a drug under the federal Food, Drug and Cosmetic Act.

In the committee's view, the term drug should be understood, in its generic sense, to encompass alcohol and nicotine as well as illicit drugs. It is very important for the general public to recognize that alcohol and nicotine constitute, by far, the nation's two largest drug problems, whether measured in terms of morbidity, mortality, or social cost. Abuse of and dependence on those drugs have serious individual and societal consequences. Continued separation of alcohol, nicotine, and illicit drugs in everyday speech is an impediment to public education, prevention, and therapeutic progress.

Although the committee uses the term drug, in its generic sense, to encompass alcohol and nicotine, the report focuses, at NIDA's request, on research opportunities relating to illicit drugs; research on alcohol and nicotine is discussed only when the scientific inquiries are intertwined. Because the report sometimes ranges more broadly than illicit drugs, however, the committee has adopted several semantic conventions to promote clarity and avoid redundancy. First, the term drug, unmodified, refers to all psychoactive drugs, including alcohol and nicotine. When reference is intended solely to illicit drugs such as heroin, cocaine, and other drugs regulated by the Controlled Substances Act, the committee says so explicitly. Occasionally, to ensure that the intended meaning is clear, the report refers to "illicit drugs and nicotine" or to "illicit drugs

and alcohol," as the case may be. Additionally, the words opiate and opioid are used interchangeably, although opiates are derivative of morphine and opioids are all compounds with morphine-like properties (they may be synthetic and not resemble morphine chemically).

The report employs the standard three-stage conceptualization of drug-taking behavior that applies to all psychoactive drugs, whether licit or illicit. Each stage—use, abuse, dependence—is marked by higher levels of use and increasingly serious consequences. Thus, when the report refers to the "use" of drugs, the term is usually employed in a narrow sense to distinguish it from intensified patterns of use. Conversely, the term "abuse" is used to refer to any harmful use, irrespective of whether the behavior constitutes a "disorder'' in the DSM-IV diagnostic nomenclature (see Appendix C ). When the intent is to emphasize the clinical categories of abuse and dependence, that is made clear.

The committee also draws a clear distinction between patterns of drug-taking behavior, however described, and the harmful consequences of that behavior for the individual and for society. These consequences include the direct, acute effects of drug taking such as a drug-induced toxic psychosis or impaired driving, the effects of repeated drug taking on the user's health and social functioning, and the effects of drug-seeking behavior on the individual and society. It bears emphasizing that adverse consequences can be associated with patterns of drug use that do not amount to abuse or dependence in a clinical sense, although the focus of this report and the committee's recommendations is on the more intensified patterns of use (i.e., abuse and dependence) since they cause the majority of the serious consequences.

DEFINITIONS AND BASIC CONCEPTS

Drug use may be defined as occasional use strongly influenced by environmental factors. Drug use is not a medical disorder and is not listed as such in either of the two most important diagnostic manuals—the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSMIV; APA, 1994); or the International Classification of Diseases (ICD-10; WHO, 1992). (See Appendix C for DSM-IV and ICD-10 diagnostic criteria.) Drug use implies intake for nonmedical purposes; it may or may not be accompanied by clinically significant impairment or distress on a given occasion.

Drug abuse is characterized in DSM-IV as including regular, sporadic, or intensive use of higher doses of drugs leading to social, legal, or interpersonal problems. Like DSM-IV, ICD-10 identifies a nondependent but problematic syndrome of drug use but calls it "harmful use" instead

of abuse. This syndrome is defined by ICD-10 as use resulting in actual physical or psychological harm.

Drug dependence (or addiction) is characterized in both DSM-IV and ICD-10 as drug-seeking behavior involving compulsive use of high doses of one or more drugs, either licit or illicit, for no clear medical indication, resulting in substantial impairment of health and social functioning. Dependence is usually accompanied by tolerance and withdrawal 2 and (like abuse) is generally associated with a wide range of social, legal, psychiatric, and medical problems. Unlike patients with chronic pain or persistent anxiety, who take medication over long periods of time to obtain relief from a specific medical or psychiatric disorder (often with resulting tolerance and withdrawal), persons with dependence seek out the drug and take it compulsively for nonmedical effects.

Tolerance occurs when certain medications are taken repeatedly. With opiates for example, it can be detected after only a few days of use for medical purposes such as the treatment of pain. If the patient suddenly stops taking the drug, a withdrawal syndrome may ensue. Physicians often confuse this phenomenon, referred to as physical dependence, with true addiction. That can lead to withholding adequate medication for the treatment of pain because of the very small risk that addiction with drug-seeking behavior may occur.

As a consequence of its compulsive nature involving the loss of control over drug use, dependence (or addiction) is typically a chronically relapsing disorder (IOM, 1990, 1995; Meter, 1996; O'Brien and McLennan, 1996; McLennan et al., in press). Although individuals with drug dependence can often complete detoxification and achieve temporary abstinence, they find it very difficult to sustain that condition and avoid relapse over time. Most persons who achieve sustained remission do so only after a number of cycles of detoxification and relapse (Dally and Marital, 1992). Relapse is caused by a constellation of biological, family, social, psychological, and treatment factors and is demonstrated by the fact that at least half of former cigarette smokers quit three or more times before they successfully achieve stable remission from nicotine addiction (Schilling, 1992). Similarly, within one year of treatment, relapse occurs in 30-50 percent of those treated for drug dependence, although the level

of drug use may not be as high as before treatment (Daley and Marlatt, 1992; McLellan et al., in press). Unlike those who use (or even abuse) drugs, individuals with addiction have a substantially diminished ability to control drug consumption, a factor that contributes to their tendency to relapse.

Another terminological issue arises in relation to the terms addiction and dependence. For some scientists, the proper terms for compulsive drug seeking is addiction, rather than dependence. In their view, addiction more clearly signifies the essential behavioral differences between compulsive use of drugs for their nonmedical effects and the syndrome of "physical dependence" that can develop in connection with repeated medical use. In response, many scientists argue that dependence has been defined in both ICD-10 and DSM-IV to encompass the behavioral features of the disorder and has become the generally accepted term in the diagnostic nomenclature. Moreover, some scientists object to the term addiction on the grounds that it is associated with stigmatizing social images and that a less pejorative term would help to promote public understanding of the medical nature of the condition. The committee has not attempted to resolve this controversy. For purposes of this report, the terms addiction and dependence are used interchangeably.

An inherent aspect of drug addiction is the propensity to relapse. Relapse should not be viewed as treatment failure; addiction itself should be considered a brain disease similar to other chronic and relapsing conditions such as hypertension, diabetes, and asthma (IOM, 1995; O'Brien and McLellan, 1996). In the latter, significant improvement is considered successful treatment even though complete remission or cure is not achieved. In the area of drug abuse, however, many individuals (both lay and professional) expect treatment programs to perform like vaccine programs, where one episode of treatment offers lifetime immunity. Not surprisingly, because of that expectation, people are inevitably disappointed in the relatively high relapse rates associated with most treatments. If, however, addiction is understood as a chronically relapsing brain disease, then—for any one treatment episode—evidence of treatment efficacy would include reduced consumption, longer abstention periods, reduced psychiatric symptoms, improved health, continued employment, and improved family relations. Most of those results are demonstrated regularly in treatment outcome studies.

The idea that drug addiction is a chronic relapsing condition, requiring long-term attention, has been resisted in the United States and in some other countries (Brewley, 1995). Many lay people view drug addiction as a character defect requiring punishment or incarceration. Proponents of the medical model, however, point to the fact that addiction is a distinct morbid process that has characteristics and identifiable signs and

symptoms that affect organ systems (Miller, 1991; Meter, 1996). Characterization of addiction as a brain disease is bolstered by evidence of genetic vulnerability to addiction, physical correlates of its clinical course, physiological changes as a result of repeated drug use, and fundamental changes in brain chemistry as evidenced by brain imaging (Volkow et al., 1993). This is not to say that behavioral, social, and environmental factors are immaterial—they all play a role in onset and outcome, just as they do in heart disease, kidney disease, tuberculosis, or other infectious diseases. Thus, the contemporary understanding of disease fully incorporates the voluntary behavioral elements that lead many people to be skeptical about the applicability of the medical model to drug addiction. In any case, the committee embraces the disease concept, not because it is indisputable but because this paradigm facilitates scientific investigation in many important areas of knowledge, without inhibiting or distorting scientific inquiry in other parts of the field.

IMPORTANCE OF DRUG ABUSE RESEARCH

The widespread prevalence of illicit drug use in the United States is well documented in surveys of households, students, and prison and jail inmates ( Chapter 4 ). Based on the National Household Survey on Drug Abuse (NHSDA), an annual survey presently sponsored by SAMHSA, it was estimated that in 1994, 12.6 million people had used illicit drugs (primarily marijuana) in the past month (SAMHSA, 1995). That figure represents 6 percent of the population 12 years of age or older. 3 The number of heavy drug users, using drugs at least once a week, is difficult to determine. It has been estimated that in 1993 there were 2.1 million heavy cocaine users and 444,000-600,000 heavy heroin users (Rhodes et al., 1995). This population represents a significant burden to society, not only in terms of federal expenditures but also in terms of costs related to the multiple consequences of drug abuse (see Chapter 7 ).

The ultimate aim of the nation's investment in drug abuse research is to enable society to take effective measures to prevent drug use, abuse, and dependence, and thereby reduce its adverse individual and social consequences and associated costs. The adverse consequences of drug abuse are numerous and profound and affect the individual's physical health and psychological and social functioning. Consequences of drug abuse include increased rates of HIV infection and tuberculosis (TB); education and vocational impairment; developmental harms to children of

drug-using parents associated with fetal exposure or maltreatment and neglect; and increased violence (see Chapter 7 ). It now appears that injection drug use is the leading risk factor for new HIV infection in the United States (Holmberg, 1996). Most (80 percent) HIV-infected heterosexual men and women who do not use injection drugs have been infected through sexual contact with HIV-infected injection drug users (IUDs). Thus, it is not surprising that the geographic distribution of heterosexual AIDS cases has been essentially the same as the distribution of male injection drug users' AIDS cases (Holmberg, 1996) Further, the IUDs-associated HIV epidemic in men is reflected in the heterosexual epidemic in women, which is reflected in HIV infection in children (CDC, 1995). Nearly all children who acquire HIV infection do so prenatal (see Chapter 7 ).

The extent of the impact of drug use and abuse on society is evidenced by its enormous economic burden. In 1990, illicit drug abuse is estimated to have cost the United States more than $66 billion. When the cost of illicit drug use and abuse is tallied with that of alcohol and nicotine ( Table 1.1 ), the collective cost of drug use and abuse exceeds the estimated annual $117 billion cost of heart disease and the estimated annual $104 billion cost of cancer (AHA, 1992; ACS, 1993; D. Rice, University of California at San Francisco, personal communication, 1995).

As noted above, the federal government accounts for a large segment of the societal expenditure on illicit drug abuse control—spending more than $13.3 billion in FY 1995 (ONDCP, 1996). About two-thirds was devoted to interdiction, intelligence, incarceration, and other law enforcement activities. Research, however, accounts for only 4 percent of federal outlays, a percentage that has remained virtually unchanged since 1981 (ONDCP, 1996) ( Figure 1.1 ). Given the social costs of illicit drug abuse and the enormity of the federal investment in prevention and control, research into the causes, consequences, treatment, and prevention of drug abuse should have a higher priority. Enhanced support for drug abuse research would be a socially sound investment, because scientific research can be expected to generate new and improved treatments, as well as prevention and control strategies that can help reduce the enormous social burden associated with drug abuse.

THE CONTEXT OF DRUG ABUSE RESEARCH

In the chapters that follow, the committee identifies research initiatives that seem most promising and most likely to lead to successful efforts to reduce drug abuse and its associated social costs. Although the yield from these initiatives will depend largely on the creativity and skill of scientists, the many contextual factors that will also have a major bear-

TABLE 1.1 Estimated Economic Costs (million dollars) of Drug Abuse, 1990

FIGURE 1.1 Federal drug control budget trends (1981-1995). NOTE: Figures are in current dollars. SOURCE: ONDCP (1996).

ing on the payoff from scientific inquiry cannot be ignored. The committee has identified six major factors that, if successfully addressed, could optimize the gains made in each area of drug abuse research: stable funding; use of a comprehensive public health framework; wider acceptance of a medical model of drug dependence; better translation of research findings into practice; raising the status of drug abuse research; and facilitating interdisciplinary research.

Stable Funding

A stable level of funding in any area of biomedical research is needed to sustain and build on research accomplishments, to retain a cadre of experts in a field, and to attract young investigators. Drug abuse research, in comparison with many other research venues, has not enjoyed consistent federal support (IOM, 1990, 1995; see also Appendix B ). The field has suffered from difficulties in recruiting and retaining young researchers and clinicians and in maintaining a stable research infrastructure (IOM, 1995). Society's capacity to contain and manage drug abuse

depends upon a stable, long-term investment in research. The vicissitudes in federal research funding often reflect changing currents in public opinion toward drugs and drug users ( Appendix B ). However, drug abuse will not disappear; it is an endemic social and public health problem. The nation must commit itself to a sustained effort. The social investment in research is an investment in "human capital" that must be sustained over the long term in order to reap the expected gains. An investment in this field is squandered if researchers who have been recruited and trained in drug abuse research are drawn to other fields because of uncertainty about the stability of future funding.

Adoption of a Comprehensive Public Health Framework

The social impact of drug abuse research can be enhanced significantly by conceptualizing goals and priorities within a comprehensive public health framework (Goldstein, 1994). All too often, public discourse about drug abuse is characterized by such unnecessary and fruitless disputes as whether drug abuse should be viewed as a social and moral problem or a health problem, whether the drug problem can best be solved by law enforcement or by medicine, whether priority should be placed on reducing supply or reducing demand, and so on. The truth is that these dichotomies oversimplify a brain disease impacted by a complex set of behaviors and a diverse array of potentially useful social responses. Forced choices of this nature also tend to inhibit or foreclose potentially useful research strategies. Confusion about social goals can lead to confusion about research priorities and can obscure the links between investigations viewing the subject through different lenses.

Some issues tend to recur. A prominent dispute centers on whether preventing drug use is important in itself or whether society should be more concerned with abuse or with the harmful consequences of use. The answer, of course, is that such a forced choice obscures, rather than clarifies, the issues. From a public health standpoint, drug use is a risk factor; the significance of use (whether of alcohol, nicotine, or illicit drugs) lies in the risk of harm associated with it (e.g., fires from smoking, impaired driving from alcohol or illicit drugs, or developmental setbacks) and in the risk that use will intensify, escalating to abuse or dependence. Those risks vary widely in relation to drug, user characteristics, social context, etc. Attention to the consequences of use and to the risk of escalation helps to set priorities (for research and policy) and provides a framework for assessing the impact of different interventions.

From a public policy standpoint, arguments about goals and priorities are fraught with controversy. From the standpoint of research strategy, however, the key lies in asking the right questions (e.g., What influ-

ences the pathways from use, to abuse, to dependence? What are the effects of needle exchange programs on illicit drug use and on HIV disease?) and in generating the knowledge required to facilitate informed policy debate. The main virtues of a comprehensive public health approach are that it helps to disentangle scientific questions from policy questions and that it encompasses all of the pertinent empirical questions, including the causes and consequences of use, abuse, and dependence, as well as the efficacy and cost of all types of interventions. In sum, the social payoff from drug abuse research can be enhanced substantially by integrating diverse strands of inquiry within a public health framework.

Acceptance of a Medical Model of Drug Dependence

Drug dependence is a chronic, relapsing brain disease that, like other diseases, can be evaluated and treated with the standard tools of medicine, including efforts in prevention, diagnosis, and treatment with medications and behavioral or psychosocial therapies. Unfortunately, the medical model of dependence is not universally accepted by health professionals and others in the treatment community; it is widely rejected within the law enforcement community and often by the public at large, which tends to view the complex and varied patterns of use, abuse, and dependence as an undifferentiated behavior rather than a medical problem.

Resistance to the medical model takes many forms. One is resistance to pharmacotherapies, such as methadone, that are seen as substituting licit drugs for illicit drugs without changing drug-taking behavior. Conversely, treatment approaches that adopt a rigid drug-free strategy preclude the use of medications for patients with other psychiatric disorders that are easily treated by pharmacotherapeutic approaches. On a subtler level, resistance to the use of pharmacotherapies is evidenced by the routine use of inadequate doses of methadone (D'Aunno and Vaughn, 1992). Finally, for others, all forms of drug abuse signify a failure of willpower or a moral weakness requiring punishment, incarceration, or moral education rather than treatment (Anglin and Hser, 1992).

Resistance to the medical model of drug dependence presents numerous barriers to research. Clinical researchers experience difficulty in soliciting participation by both treatment program administrators and patients, who are sometimes mistrustful of researchers' motives. If research involves a medication that is itself prone to abuse, there are additional regulatory requirements for drug scheduling, storage, and record keeping that act to discourage investigation (see Chapter 10 ; IOM, 1995). The ever-present threat of inappropriate intrusion by law enforcement agents has a chilling effect on treatment research (McDuff et al., 1993). All barri-

ers to inquiry, irrespective of whether they are legal or social in origin, raise the cost of research and discourage researchers from entering the field. Additionally, those barriers diminish the likelihood that a pharmaceutical company will invest in the development of antiaddiction medications (IOM, 1995). 4 Broader acceptance of the medical model of drug dependence would provide an incentive for researchers and clinicians to enter this field of research. Over time, a developing consensus in support of the medical model could facilitate common discourse, help to shape a shared research agenda within a public health framework, and diminish tensions between the research and treatment communities and the criminal justice system.

Better Translation of Research Findings into Practice and Policy

To benefit society, new research findings must be disseminated adequately to treatment providers, educators, law enforcement officials, and community leaders. In the case of prevention practices, it is often difficult for communities to change entrenched policies, particularly when combined with political imperatives for action to counteract drug abuse. In the case of treatment, technology transfer is impeded by the heterogeneity of providers and their marginalization at the outskirts of the medical community (see IOM, 1990, 1995; see also Chapter 8 ). Physicians and psychiatrists are seldom employed by specialized drug treatment facilities (approximately one-quarter employ medical doctors), and treatment is delivered by counselors whose training and supervision vary greatly and who have little access to and understanding of research results (Ball and Ross, 1991; Batten et al., 1993). These factors not only impede the transfer of research findings to the field but also impede communication from the field to the laboratory so that research designs can be modified in response to clinical realities (Pentz, 1994). Thus, there is a real need for bidirectional communication, from bench to bedside and back to the basic scientist (IOM, 1994).

The committee is aware, however, of recent technology transfer efforts in the field such as the Treatment Improvement Protocol Series, an initiative to establish guidelines for drug abuse treatment with an emphasis on incorporating research findings (SAMHSA, 1993), and the Prevention Enhancement Protocol System, a process implemented by the Center

for Substance Abuse Prevention in which scientists and practitioners develop protocols to identify and evaluate the strength of evidence on topics related to prevention interventions. Similar efforts will be invaluable for communicating and integrating research results to the treatment community.

Research frequently results in product development leading to changes in operations and an overall enhancement of the value of the enterprise. For example, in the pharmaceutical industry research often leads to the development of new medications or devices. In the public sector, however, research is often divorced from the implementation of findings and development. Research is often more basic than applied, and the fruits of research are not realized by the government, but by the private sector. Although that approach may be appropriate, it is unfortunately not always the most productive strategy for advancing research, knowledge, and product development. That is particularly true in the development of medications for opiate and cocaine addictions, where there is a great need for commitment from the private sector. However, many obstacles prevent active involvement of the pharmaceutical industry in this area of research and development (IOM, 1995).

A similar problem arises in relation to policymaking. Because debates about drug policy tend to be so highly polarized and politicized, research findings are often distorted, or selectively deployed, for rhetorical purposes. Researchers cannot prevent this practice, which is a common feature of political debate in a democratic society. However, researchers and their sponsors should not be indifferent to the disconnect between policy discourse and science. Researchers should establish and support institutional mechanisms for communicating an important message to policymakers and to the general public. Scientific research has produced a solid, and growing, body of knowledge about drug abuse and about the efficacy of various interventions that aim to prevent and control it. As long as drug abuse remains a poorly understood social problem, policy will be based mainly on wish and supposition; steps should be taken to educate policymakers about the scientific and technological advances in addiction research. Only then will it be possible for policymaking to support legislation that adequately funds new research and applies research findings. To some extent, persisting failure to reap the fruits of drug abuse research is attributable to the low visibility of the field—a problem to which the discussion now turns.

Raising the Status of Drug Abuse Research

Drug abuse research is often an undervalued area of inquiry, and most scientists and clinicians choose other disciplines in which to develop

their careers. Compared with other fields of research, investigators in drug abuse are often paid less, have less prestige among their peers, and must contend with the unique complexities of performing research in this area (e.g., regulations on controlled substances) (see IOM, 1995). The overall result is an insufficient number of basic and clinical researchers. IOM has recently begun a study, funded by the W. M. Keck Foundation of Los Angeles, to develop strategies to raise the status of drug abuse research. 5

Weak public support for this field of study is evident in unstable federal funding (see above), a lack of pharmaceutical industry investment in the development of antiaddiction medications (IOM, 1995), and inadequate funding for research training (IOM, 1995). NIDA's FY 1994 training budget, which is crucial to the flow of young researchers into the field, was about 2 percent of its extramural research budget, a percentage substantially lower than the overall National Institutes of Health (NIH) training budget, which averages 4.8 percent of its extramural research budget.

Beyond funding problems, investigators face a host of barriers to research: research subjects may pose health risks (e.g., TB, HIV/AIDS, and other infectious diseases), may be noncompliant, may deny their drug abuse problems, and may be involved in the criminal justice system. Even when research is successful and points to improvements in service delivery, the positive outcome may not be translated into practice or policy. For example, more than a year after the Food and Drug Administration's (FDA's) approval of levo-alpha-acetylmethadol (LAAM) as the first new medication for the treatment of opiate dependence in over 20 years, fewer than 1,000 patients nationwide actually had received the medication (IOM, 1995). More recently, scientific evidence regarding the beneficial effects of needle exchange programs (NRC, 1995) has received inadequate attention. Continuing indifference to scientific progress in drug abuse research inevitably depresses the status of the field, leading in turn to difficulties in recruiting new investigators.

Increasing Interdisciplinary Research

The breadth of expertise needed in drug abuse research spans many disciplines, including the behavioral sciences, pharmacology, medicine, and the neurosciences, and many fields of inquiry, including etiology, epidemiology, prevention, treatment, and health services research. Aspects of research relating to drug use tend to draw on developmental perspectives and to focus on general population samples in community settings, especially schools. Aspects of research relating to abuse and de-

pendence tend to be more clinical in nature, drawing on psychopathological perspectives. Additionally, a full account of any aspect of drug-taking behavior must also reflect an understanding of social context. The rich interplay between neuroscience and behavioral research and between basic and clinical research poses distinct challenges and opportunities.

Unfortunately, research tends to be fragmented within disciplinary boundaries. The difficulties in conducting successful interdisciplinary research are well known. Funds for research come from many separate agencies, such as the NIDA, NIMH, and SAMHSA. These agencies all have different programmatic emphases as they attempt to shape the direction of research in their respective fields. In times of funding constraints, agencies may be less inclined to fund projects at the periphery of their interests.

Additionally, NIH study sections, which rank grant proposals, are discipline specific, making it difficult for interdisciplinary proposals to ''qualify" (i.e., receive a high rank) for funding. Another problem is that the most advanced scientific literature tends to be compartmentalized within discipline or subject matter categories, making it difficult for scientists to see the whole field. The problem is exacerbated by what Tonry (1990) has called "fugitive literatures," studies carried out by private sector research firms or independent research agencies and available only in reports submitted to the sponsoring agency.

In light of lost opportunities for collaboration and interdisciplinary research, IOM (1995) previously recommended the creation and expansion of comprehensive drug abuse centers to coordinate all aspects of drug abuse research, training, and treatment. The field of drug abuse research presents a real opportunity to bridge the intellectual divide between the behavioral and neuroscience communities and to overcome the logistical impediments to interdisciplinary research.

INVESTING WISELY IN DRUG ABUSE RESEARCH

This report sets forth drug abuse research initiatives for the next decade based on a thorough assessment of what is now known and a calculated judgment about what initiatives are most likely to advance our knowledge in useful ways. This report is not meant to be a road map or tactical battle plan, but is best regarded as a strategic outline. Within each discipline of drug abuse research, the committee has highlighted priorities for future research. However, the committee did not make any attempt to prioritize recommendations across varied disciplines and fields of research. Prudent research planning must respond to newly emerging opportunities and needs while maintaining a steady commitment to the

achievement of long-term objectives. The ability to respond to new goals and needs may be the real challenge for the field of drug abuse research.

Drug abuse research is an important public investment. The ultimate aim of that investment is to reduce the enormous social costs attributable to drug abuse and dependence. Of course, drug abuse research must also compete for funding with research in other fields of public health, research in other scientific domains, and other pressing public needs. Recognizing the scarcity of resources, the committee has also considered ways in which the research effort can be harnessed most effectively to increase the yield per dollar invested. These include stable funding, use of a comprehensive public health framework, wider acceptance of a medical model of drug dependence, better translation of research findings into practice and policy, raising the status of drug abuse research, and facilitating interdisciplinary research.

The committee notes that there have been major accomplishments in drug abuse research over the past 25 years and commends NIDA for leading that effort. The committee is convinced that the field is on the threshold of significant advances, and that a sustained research effort will strengthen society's capacity to reduce drug abuse and to ameliorate its adverse consequences.

ORGANIZATION OF THE REPORT

This report sets forth a series of initiatives in drug abuse research. 6 Each chapter of the report covers a segment of the field, describes selected accomplishments, and highlights areas that seem ripe for future research. As noted, the committee has not prioritized areas for future research but, instead, has identified those areas that most warrant further exploration.

Chapter 2 describes behavioral models of drug abuse and demonstrates how the use of behavioral procedures has given researchers the ability to measure drug-taking objectively and to study the development, maintenance, and consequences of that behavior. Chapter 3 discusses drug abuse within the context of neurotransmission; it describes neurobiological advances in drug abuse research and provides the foundation for the current understanding of addiction as a brain disease. The epidemiological information systems designed to gather information on drug use in the United States are identified in Chapter 4 . The data collected from the systems provide an essential foundation for systematic study of

the etiology and consequences of drug abuse, which are addressed, respectively, in Chapters 5 and 7 . Chapter 6 addresses the efficacy of interventions designed to prevent drug abuse. The effectiveness of drug abuse treatment and the difficulties in treating special populations of drug users are discussed in Chapter 8 , while the impact of managed care on access, costs, utilization, and outcomes of treatment is addressed in Chapter 9 . Finally, Chapter 10 discusses the effects of drug control on public health and identifies areas for policy-relevant research.

Specific recommendations appear in each chapter. Although these recommendations reflect the committee's best judgment regarding priorities within the specific domains of research, the committee did not identify priorities or rank recommendations for the entire field of drug abuse research. Opportunities for advancing knowledge exist in all domains. It would be a mistake to invest too narrowly in a few fields of inquiry. At the present time, soundly conceived research should be pursued in all domains along the lines outlined in this report.

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Drug abuse persists as one of the most costly and contentious problems on the nation's agenda. Pathways of Addiction meets the need for a clear and thoughtful national research agenda that will yield the greatest benefit from today's limited resources.

The committee makes its recommendations within the public health framework and incorporates diverse fields of inquiry and a range of policy positions. It examines both the demand and supply aspects of drug abuse.

Pathways of Addiction offers a fact-filled, highly readable examination of drug abuse issues in the United States, describing findings and outlining research needs in the areas of behavioral and neurobiological foundations of drug abuse. The book covers the epidemiology and etiology of drug abuse and discusses several of its most troubling health and social consequences, including HIV, violence, and harm to children.

Pathways of Addiction looks at the efficacy of different prevention interventions and the many advances that have been made in treatment research in the past 20 years. The book also examines drug treatment in the criminal justice setting and the effectiveness of drug treatment under managed care.

The committee advocates systematic study of the laws by which the nation attempts to control drug use and identifies the research questions most germane to public policy. Pathways of Addiction provides a strategic outline for wise investment of the nation's research resources in drug abuse. This comprehensive and accessible volume will have widespread relevance—to policymakers, researchers, research administrators, foundation decisionmakers, healthcare professionals, faculty and students, and concerned individuals.

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• Study Protocol
• Open access
• Published: 16 May 2024

Developing practical strategies to reduce addiction-related stigma and discrimination in public addiction treatment centers: a mixed-methods study protocol

• Maryam Khazaee-Pool   ORCID: orcid.org/0000-0002-2587-3460 1 ,
• Seyed Abolhassan Naghibi 1 ,
• Tahereh Pashaei 2 &
• Koen Ponnet 3  

Addiction Science & Clinical Practice volume  19 , Article number:  40 ( 2024 ) Cite this article

Metrics details

People with substance use disorders (SUDs) have restricted engagement with health-care facilities and describe repeated experiences of stigma, discrimination, and mistreatment when receiving care at health-care and public addiction treatment centers (PATCs). The purpose of the current study is to design practical cultural-based strategies to reduce addiction-related stigma and discrimination at PATCs.

Methods/design

The present study will use a mixed-methods design with an explanatory sequential approach. Phase 1 of the study will combine a cluster sampling technique combined with a cross-sectional survey of Patients with Substance Use Disorders (SUDs) in Mazandaran, Iran. A total of three hundred and sixty individuals with SUDs will be selected to assess their experiences of stigma and factors predicting stigma. Phase 2 will involve qualitative study aimed at exploring participants’ perceptions regarding the aspects and determinants of their stigma experience. The participants will include two groups: people with SUDs and staff/health-care providers at PATCs. Participants for Phase 2 will be purposively sampled from those involved in Phase 1.Qualitative data will be collected using in-depth semi-structured interviews and focus group discussions and analyzed using content analysis with a conventional approach. Phase 3 will focus on the development of new strategies to reduce the experiences of stigma among people with SUDs at PATCs. These strategies will be formulated based on the findings derived from the qualitative and quantitative data obtained in Phases 1 and 2, a comprehensive review of the literature, and expert opinions gathered using the nominal group technique.

This is one of the few studies conducted within the domain of stigma pertaining to individuals who use drugs within the context of Iranian culture employing a mixed-methods approach, this study aims to develop culturally sensitive strategies to reduce such problems from the perspective of Iranian people who use drugs. It is anticipated that the study will yield evidence-based insights and provide practical strategies to reduce the stigma and discrimination experienced by people who use drugs at PATCs. Such outcomes are important for informing policymaking and designing healthcare interventions tailored to the needs of individuals grappling with substance dependency.

Introduction

Substance use disorders (SUDs) represent complex illnesses that disrupt brain activity and function resulting in significant personal and societal repercussions [ 1 , 2 , 3 , 4 ]. Recognizing the detrimental impact of SUD-related stigma, The National Institute on Drug Abuse has prioritized efforts to understand and diminish this stigma [ 5 ]. Research on mental illness stigma has consistently revealed its association with adverse outcomes, including exacerbated symptoms and impaired social functioning [ 6 ]. With the increasing prevalence of SUDs within the general population [ 1 , 2 , 3 , 4 , 7 ] and the necessity to inform policymakers and allocate legislative resources effectively [ 8 , 9 ], it becomes crucial to raise awareness about the stigma surrounding SUDs in society. Studies investigating SUD-related stigma have documented various forms of prejudice and discrimination experienced by people who use drugs, particularly from healthcare providers, which are correlated with detrimental health outcomes, including mental health disorders and compromised physical health [ 10 , 11 , 12 , 13 , 14 ].

Part of the stigmatization faced by healthcare providers stems from the inaction of public health leaders [ 15 ], while another part arises from the lack of training among healthcare workers in SUD treatment [ 16 , 17 ], both of which contribute to inadequate implementation of effective remedies. Numerous studies have demonstrated the persistent and entrenched nature of stigma, often rooted in the misconception that drug addiction reflects a personal choice, indicating a lack of self-control and moral failure. Stigma and discrimination levels are notably high both within the general population and among professions that interact with individuals with SUDs, such as the healthcare industry. Some studies have demonstrated that stigma and prejudice harm SUD patients’ health and cause delays in the delivery of high-quality care in venues for public addiction treatment. Individuals with SUDs frequently encounter stigma and discrimination across all levels of care at public addiction treatment centers (PATCs) [ 17 , 18 , 19 , 20 , 21 , 22 ].

The World Health Organization is working with several countries to train medical professionals in screening, brief intervention, and referral to treatment (SBIRT) [ 23 , 24 , 25 , 26 , 27 ]. SBIRT is a treatment strategy that encourages all medical professionals to identify patients who are taking drugs at statistically dangerous levels, provide brief interventions to promote drug use reduction, and then refer patients who meet criteria for drug use or addiction for more intensive treatments. According to some studies, screening and brief interventions (SBI) have the greatest effect on reducing the use of psychoactive substances [ 20 , 23 , 26 , and 28 ]. SBI is a simple, quick advisory intervention that stresses several types of specific behavior. It may be used by professionals in a variety of situations [ 29 ].

Unfortunately, societal acceptability of evidence-based initiatives does not always come easily [ 30 ]. The allocation of healthcare interventions is influenced by various factors, including the novelty of characteristics, healthcare worker attitudes, and the stigma associated with a health condition. Research has consistently demonstrated that negative attitudes among healthcare professionals can impede the adoption of innovative practices, the quality of services provided, and clients’ adherence to preventive and therapeutic measures [ 31 , 32 , 33 , 34 , 35 , 36 ]. Therefore, education and training programs should prioritize the modification of attitudes and beliefs among healthcare providers to promote the uptake of SBI for drug addiction [ 37 , 38 ].

Research in health has linked stigma from service providers at care or treatment centers with poor utilization of preventive programs and reduced accessibility for stigmatized individuals to access effective interventions [ 39 , 40 ]. Efforts to mitigate stigmatization are underway, particularly for individuals living with mental health conditions [ 40 , 41 ]. Studies have identified three main approaches: (i) providing educational interventions to dispel misconceptions about mental illnesses, (ii) facilitating interactions between individuals with mental illnesses and the community to challenge community attitudes, and (iii) exposing stigmatizing beliefs and behaviors in the hope of eliciting public condemnation and reducing their acceptance [ 41 , 42 , 43 ]. Although anti-stigma strategies are sometimes inaccessible or unproven, the aforementioned techniques aim to change community perceptions of people facing such circumstances [ 39 , 41 ].

To reduce the stigma associated with mental illness, several national and international strategies have been developed, and the range of programs continues to expand. However, stigma and discrimination against individuals with SUDs remain poorly understood [ 44 , 45 ]. Moreover, there has been limited research investigating the creation and execution of practices or interventions aimed at reducing SUD-related stigma and discrimination among people who use drugs by PHC professionals [ 46 , 47 , 48 , 49 , 50 ]. When developing anti-stigma strategies, it is essential to consider the cultural norms and different behaviors of specific groups, including healthcare professionals, youth, police, and policymakers [ 14 , 38 , 40 , 45 , 49 ].

For many years, stigma related to SUDs has posed challenges in Iran [ 51 , 52 , 53 ]. One of the most significant obstacles to improving the well-being and health of individuals with SUDs is the stigmatization and discrimination they face within the healthcare system [ 52 , 54 ]. This results in disparities in healthcare facilities, including limited availability, accessibility, and quality of services for individuals with SUDs [ 54 ]. Stigmatization negatively impacts help-seeking behavior from official healthcare facilities, leading to poorer outcomes and perpetuating the misconception that SUDs are untreatable. individuals with SUDs may be more prone to engaging in unhealthy behaviors, refusing treatment, non-compliance with prescription instructions, weakened immune systems, and experiencing adverse consequences [ 55 ].

Comprehensive plans for the promotion, prevention, treatment, and recovery of individuals with substance use disorders (SUDs) should consider numerous socioeconomic variables. Adopting a “health-in-all policies” approach is crucial in addressing these challenges. Strategies to increase access to treatment and reduce stigma and discrimination towards individuals with SUDs may involve integrating SUD care and fostering collaboration between primary care clinicians and other healthcare providers [ 22 , 38 , 39 , 40 , 53 ]. International efforts to combat addiction-related stigma have emphasized the importance of lowering barriers to a variety of health treatments for individuals with SUDs. Despite this emphasis and the widespread consensus that reducing stigma associated with SUDs is important, progress in this area has been slow [ 40 , 49 , 56 , 57 , 58 ]. While strategies to reduce SUD-related stigma have gained traction in Western industrial nations in recent years [ 59 , 60 ]. They remain largely absent from national and government policies, information, and healthcare plans in many parts of the world [ 40 , 42 , 44 , 53 , 58 , 61 ].

Longitudinal data on behavior changes in response to stigma and discrimination related to SUDs in Iran are lacking, making it challenging to develop effective strategies to reduce such stigma, especially in PATCs. The most widely recognized solutions are those that are acceptable, suitable, and adaptable across cultural contexts. Further research and needs assessments are required to identify additional strategies for addressing addiction-related stigma [ 42 , 47 , 56 ]. To address the stigma associated with addiction, it is necessary to study the effectiveness and feasibility of stigma-reducing interventions [ 55 , 58 , 62 ].

In Iran, as in many other countries, there is a lack of comprehensive strategies aimed at reducing stigma related to SUDs. Additionally, there is a dearth of studies providing practical strategies, both quantitative and qualitative, to address addiction-related stigma and discrimination specifically within PATCs for individuals with SUDs in Iran. Mixed-method analyses focusing on this issue are also lacking. While there have been some studies conducted in Iran to explore stigma toward individuals with SUDs, none have offered strategies or methods to mitigate stigma within public treatment settings. Although limited, existing data from small-scale qualitative studies in Iranian healthcare settings indicate the prevalence of discriminatory attitudes toward people with SUDs, manifesting as care refusal, substandard care, excessive precautions, physical distancing, humiliation, and blame [ 30 , 51 , 52 , 55 , 62 , 63 , 64 ].

Iran’s unique cultural characteristics [ 65 ] including demographic factors [ 66 ], cultural norms [ 67 ], ethnic identity [ 68 ], social customs, traditions, peer relationships, and poverty [ 69 ] shape the societal landscape and perceptions surrounding behaviors, including those related to SUDs. Consequently, addressing addiction-related stigma and its impact on individuals who use drugs in Iran requires sensitivity to these cultural nuances [ 64 , 70 ]. In Iran, SUDs are not solely viewed as medical issues but also as a socio-cultural problem. This perspective can lead to delays in treatment and pose significant challenges for patients and their families. Consequently, reducing stigma and discrimination associated with the rising prevalence of addiction among Iranians has been identified as a pressing priority within the healthcare system [ 70 ].

In Iranian society, plays a significant role in shaping perceptions and experiences of SUD across various demographic groups, including differences related to age, gender, socioeconomic status, and education level [ 64 ]. Research in Iran has extensively explored how cultural influences manifest in SUDs, examining factors such as demographic characteristics, regional prevalence patterns, gender dynamics, religious beliefs, and the stigma associated with drug use. These studies highlight the complex interplay between cultural norms, individual behaviors, and societal attitudes toward SUDs within the Iranian context [ 66 , 67 , 68 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 ].

Of course, the stigma surrounding drug addiction in Iran exhibits variations based on factors such as gender, the specific type of drug used, and residential location [ 81 , 82 ]. Interestingly, a study examining literary works in Iran reveals a historical acceptance of opium as a medicinal remedy by prominent Iranian poets. Opium has been portrayed positively, with references to its purported benefits such as regulating blood pressure and relieving pain [ 83 ]. This cultural perspective reflects a nuanced view of drug consumption in Iranian society, indicating that stigma surrounding certain drugs may not be uniform. Rather, stigma appears to evolve dynamically within social contexts, presenting new challenges that may differ from those associated with more entrenched forms of stigma.

Although previous qualitative studies have provided valuable insights into the experiences of individuals with SUD interacting with healthcare professionals, our understanding of SUD-related stigma within the Iranian healthcare system remains limited. A comprehensive, multiphase study employing a mixed-methods approach is needed to systematically assess the experiences of Iranian people who use drugs regarding stigma and to develop evidence-based guidelines and strategies for reducing stigma and discrimination against individuals with SUDs at PATCs. The importance and the impact of stigma and discrimination related to SUDs within Iranian culture as well as the influence of cultural differences on patients’ healthcare-seeking attitudes and the support services provided by the healthcare system, form the foundation of this mixed-method study. Given these considerations, it is imperative to address cultural factors associated with substance use disorders and the stigma stemming from substance consumption in Iranian society. This is because the cultural, economic, and social variations across different societies warrant an examination of human experiences within each unique cultural context. Therefore, the aim of this study is to explore comprehensive and culturally sensitive strategies in order to reduce addiction-related stigma and discrimination at PATCs.

The study aims

This mixed-methods study aims to identify strategies to reduce stigma and discrimination against Iranian people who use drugs at PATCs. The specific objectives of the study can be categorized into three phases as follows:

To measure the perceived stigma score among people with substance use disorders (SUDs) who were referred to PATCs in Mazandaran, Iran.

To evaluate professionals’ attitudes towards people with SUDs receiving treatment at PATCs in Mazandaran, Iran.

To measure the social distance score towards people with substance use disorders seeking treatment at PATCs in Mazandaran, Iran.

To examine the relationship between socio-demographic characteristics and perceived stigma among individuals with substance use disorders.

To investigate the relationship between perceived stigma, social distance, and professionals’ attitudes toward people with SUDs.

To explore the perspectives and experiences of people who use drugs concerning the various aspects and determinants of stigma and discrimination stemming from the community, healthcare centers, or PATCs due to drug use.

To examine healthcare providers’ perspectives on stigma against individuals who use drugs.

To develop evidence-based cultural strategies aimed at diminishing stigma and discrimination at PATCs against Iranian people who use drugs faced health challenges.

Study design

This study will employ a mixed-methods technique with an explanatory sequential approach for data collection and analysis. Grounded in pragmatic principles and logic, the mixed-methods paradigm combines quantitative and qualitative methodologies to provide a comprehensive understanding of the research questions. In this methodology, the researcher first gathers quantitative data to identify patterns or trends requiring further exploration. Subsequently, qualitative data are collected from individuals who can offer insights to enhance the understanding and interpretation of the quantitative findings [ 84 ]. According to this paradigm, merging qualitative and quantitative methods results in a deeper comprehension of the issue [ 85 , 86 ].

This study will be conducted in three phases. The first phase will be a quantitative study, during which, quantitative data will be gathered. The second phase of this project will be a more detailed exploratory qualitative study of participants’ experiences regarding SUD-related stigma toward and discrimination against people who use drugs at PATCs. At the end of the second phase, the qualitative and quantitative findings will be integrated. The third phase of the study will involve the development of evidence-based and culturally sensitive strategies based on a literature review, the results of Phases 1 and 2, and experts’ opinions using the nominal group technique (NGT) (Fig.  1 ). Full explanations of each part of the study are provided below.

Study visual diagram

Phase 1: quantitative study

The quantitative phase will be a descriptive-analytic cross-sectional study conducted among Iranian people with SUDs living in Mazandaran, Iran. In this phase, we will assess perceived stigma experiences and their relationship with social distance, perceived dangerousness, experts’ discrimination or acceptance, and sociodemographic characteristics among the participants. The target population will consist of people who are referred to PATCs in Mazandaran, Iran. The Perceived Stigma of Addiction Scale (PSAS), Health Professionals’ Attitude Towards Substance Abusers Scale (HPA-SAS), and Social Distance Scale (SDS) will be used. These scales will be validated for use among Iranian people.

Sample size and sampling method

There is no shortage of research on stigma toward and discrimination against people with SUDs at PATCs and other health-care settings in Iran. Therefore, the sample size is calculated based on Matsumoto’s study [ 87 ]. Following Matsumoto et al. [ 87 ], the calculated sample size is 240, based on the largest standard deviation related to the sub dimension of stigma (SD = 12.39), with a precision (d) of 0.05 around the mean (m = 35.01), and α = 0.05. In most cases, the design effect’s numerical value is about 1.5–2. In this study, we will apply 1.5, and the final sample size will be increased to 360 substance users, based on cluster sampling.

For this project, fifteen PATCs in Mazandaran will be selected. A cluster sampling method will be employed, with each cluster comprising a comparable number of respondents. Mazandaran will be divided into three areas (west, central, and east). All PATCs within these areas will be enumerated, and five PATCs will be randomly chosen from each area. Individuals with SUDs who are referred to the PATCs will be invited to participate in the project.

The participants will be offered comprehensive explanations of the goals and methods of the research. The sociodemographic questions, the PSAS, HPA-SAS, and SDS will be administered in a “quiet setting” [questionnaire will be presented while maintaining patient privacy] by a research group member and then collected in person. The investigator will fill out the scales to ensure that the same data collection method is used for all individuals. Informed consent will be obtained from the individuals prior to the data collection.

Inclusion criteria

Individuals will be eligible for the current project if they are adults (aged 20 years or older), reside in Mazandaran province, have a history of any kind of substance use, and have no severe mental difficulties that prevent them from answering the items in the questionnaires.

Exclusion criteria

The exclusion criteria for participants will be: having a mental disability, having psychiatry history like active bipolar disease, depression with psychosis, or schizophrenia, being deaf or mute, showing unwillingness to continue participating in the study, and not fully completing the questionnaires.

Questionnaires and data collection

Quantitative data will be collected utilizing sociodemographic variables and the PSAS, HPA-SAS, and SDS scales. The sociodemographic section will include questions on age, gender, occupation, duration of employment, and education. The PSAS comprises eight items to measure the perceived stigma towards individuals with substance use disorders. Initially developed and validated among patients undergoing treatment for substance use–related issues in the United States [ 88 ]. he items were adapted from a study conducted by Link and colleagues on perceived discrimination-devaluation processes, Content validity was established through review by stigma professionals in the substance use field the PSAS was related to adopted shame, self-concealment, adopted stigma, and depression [ 89 ]. The PSAS employs a four-point Likert scale ranging from “strongly disagree” to “strongly agree” for participants to rate their agreement or disagreement with each item. Scores range from 8 to 32, with higher scores indicating greater perceived stigma. The PSAS has demonstrated good reliability, with a Cronbach’s alpha of 0.71 and a reliability coefficient of 0.79 based on the test-retest method in American society [ 88 ]. In an Iranian study, the reliability of the PSAS was found to be 0.85, with a test-retest correlation coefficient of 0.81 [ 90 ].

The HPA-SAS consists of 10 items, with questions addressing the attitudes and/or views of health professionals toward people with SUD, their knowledge of addiction, and their training in substance use. The constructs of attitudes will focus on discrimination and acceptance towards people who use drugs. The HPA-SAS was developed utilizing a Likert scale format, with each item offering four response options: (1) strongly disagree (2), disagree (3), agree, and (4) strongly agree, resulting in total scores ranging from 10 to 40. The validity and reliability of the HPA-SAS were established through research conducted by a team of psychological counseling and medical care professionals. The overall Cronbach’s alpha of the original HPA-SAS has been reported as 0.79 [ 91 ]. In this study, the validity and reliability of the questionnaire were assessed prior to data collection with a sample of Iranian people who use drugs. The overall Cronbach’s alpha of the HPA-SAS was found to be 0.76, and the test–retest correlation coefficient of this scale was 0.74.

The seven-item SDS, which was created by Bogardus et al. (1925) [ 92 ] and then modified by Link et al. (1987) [ 89 ], measures the social distance that interviewees wish to keep toward a person with a particular condition (diverse social, ethnic, or racial backgrounds). This scale focuses on respondents’ willingness to engage in a relationship with someone who is dependent on illegal substances. In particular, it measures people’s willingness to take part in a variety of social contacts with a particular group. The SDS consists of seven items presented as multiple-choice questions, which assess social distance by probing the respondent’s willingness to engage in various social interactions with stigmatized individuals: These interactions include scenarios such as being a sub-lessee, neighbor, co-worker, spouse of a family member, caretaker of one’s child, and member of the same social group. Participants will be asked to rate their level of willingness or unwillingness for each item using a four-point Likert scale with the following options: (0) definitely willing [ 1 ], willing [ 2 ], unwilling, and [ 3 ] definitely unwilling. The total score ranges from 0 to 21; scores higher than the mean identify higher social distance. The overall Cronbach’s alpha of the original SDS is 0.75 [ 89 ]. The Iranian version of the SDS has found to have a Cronbach’s alpha value of 0.92. The test–retest reliability coefficient for the SDS was 0.89, and the content validity coefficient was 0.75 [ 90 ].

Data analysis

The data from the first phase of the study will be analyzed using SPSS Statistics Version 26.0 for Windows (IBM Inc., Armonk, NY, USA). In the cross-sectional phase, descriptive statistics will be applied to describe the sociodemographic factors and perceived stigma of addiction, experts’ attitudes toward people with SUD, and social distance. Univariate analytical statistics will be used to test the correlation between the sociodemographic variables and perceived stigma, experts’ attitudes toward people with SUD, and social distance. Variables with a correlation of p  < 0.1 in the univariate analysis will be included in the multivariable logistic model. All statistical tests will be two-tailed, and a p -value < 0.05 will be considered statistically significant. To ensure data quality during this phase of the study, measures such as double data entry and range checks for data values will be implemented.

Phase 2: qualitative study

In Phase 2, an exploratory qualitative study will be conducted utilizing a conventional content analysis method to explore the experiences of people who use drugs regarding stigma and discrimination stemming from the community, health-care centers, or PATCs as a result of drug use. Additionally, this phase will aim to gain insight into healthcare providers’ perspectives on stigma against people who use drugs in greater detail. Given the objectives of the project’s qualitative phase, employing this method will enable the investigator to gain a comprehensive understanding of the situation, facilitating the clarification of the impact of stigma and discrimination on Iranian people who use drugs at PATCs.

Participants and sampling method

A purposive sampling approach will be used in the second phase of the study. The target population will consist of two groups of people, namely, those who have experienced drug use and staff members at PATCs. The first group of participants (people who use drugs) will be selected from those willing to participate in the quantitative phase of the study and will be based on the mean total score of the stigma experience, which will be collected in Phase 1 of the study. People with 10% upper and lower stigma experience scores will be selected as extreme cases, and will be retained for the next phase. We will seek to interview people with either a stigma or discrimination experience in order to collect more comprehensive information about their stigma experiences and its related factors. Efforts will be made to have variety in terms of gender, level of education, religion, age, socioeconomic situation, and the use of different types of drugs.

The second group of participants will consist of health-care workers and providers at PATCs. This sample will include agents from (i) PATC management, (ii) clinical and medical teams, (iii) health-care program teams and (iv)others according to the setting (e.g., finance). Health-care workers will be enlisted using purposive sampling methods. Four of them will be contacted through education programs with a specific focus on staff involved in drug treatment. The retained persons will be invited to register, and a member of the research team will be in touch to schedule an interview. Health-care workers in specific treatment centers will also receive direct invitations from the investigation team.

Data analysis will commence after the first interview, focusing on elucidating the intricacies and interactions among key concepts and categories derived from the exploration of the primary data. Consequently, the selection of participants will persist until theoretical saturation is achieved, ensuring a comprehensive understanding of the relationships between the study concepts and components [ 93 ]. In the current study, sampling will continue until the investigator determines that no further data can be garnered through data analysis and coding, signifying theoretical saturation. However, it is recommended by experts that a minimum of 12 participants be interviewed for a qualitative study to ensure a robust and comprehensive analysis [ 94 ].

Data collection

Data will be collected by two methods: in-depth interviews with individuals with SUDs and focus group discussions with PATC staff members.

Semi-structured, in-depth interviews

Individual, in-depth, semi-structured interviews featuring open-ended questions will be employed to gather data. These interviews will focus on exploring participants’ perspectives and experiences related to stigma and discrimination against individuals with (SUDs within healthcare settings. The target group for this part of the study will consist of people who use drugs who have been referred to PATCs in Mazandaran, Iran. Before the qualitative phase of the study, the interview protocol questions will be prepared based on the results of the first phase of the study as well as the literature review. Interviews will be held in locations, such as clinics, where respondents will feel safe and relaxed. All individual in-depth interviews will be recorded using a digital tape recorder after the applicant’s permission. In addition to the audio recordings, the interviewer will take notes. If participants decline to be audio-recorded, only notes will be employed for data gathering. Furthermore, non-verbal cues, such as facial expressions, tone of voice, and the respondents’ state, will also be noted by the interviewer, together with the date and place of the interview.

All interviews will be conducted by the first author of this study, who is familiar with qualitative research methods and the topic, and who has conducted similar studies on addiction,. Participants will be encouraged to discuss their experiences related to strategies to reduce addiction-related stigma and discrimination in public addiction treatment centers. Further, they will be encouraged to discuss sociocultural and ecological components that might have had an effect on the level of using these strategies in this regard.

The interviews will be focused on the following three main questions:

How was the experience with stigma toward and discrimination in health-care settings?

What strategy and procedure have they applied to reduce and cope with stigma and discrimination in health-care settings?

How have the strategies and procedures affected their coping strategies in this regard?

Based on the responses to these questions, follow-up questions will be asked. After each question, participants will be invited to explain more thoroughly their answer, by probing questions such as “What do you mean?” or “can you explain this more”.

Interviews will be performed during a single meeting with each participant and is estimated to last between 40 and 60 min, although this can differ slightly based on the experiences of each participant. The investigator will start with explaining the significance of the study in order to gain their confidence. All interview questions will be reviewed after the first interview, and all interviews will be taped. Data collection will be continued until saturation is reached.

Focus group discussions

Following semi-structured interviews, the principal researcher (first author), who is an expert in qualitative studies, an expert in qualitative studies, will conduct focus group discussions with staff members at Patients with Substance Use Disorders Treatment Centers (PATCs), which comprise the second target group of this phase of the study. These focus group discussions aim to validate the emerging themes from the individual interviews and gain deeper insights into the identified themes. The focus group discussions will be guided by the two main research questions: (i) What is providers’ understanding of stigma towards and discrimination against persons with SUDs? and [ 2 ] What are the providers’ opinions regarding a response to stigma and discrimination? Furthermore, more detailed investigative questions will be incorporated, such as: What types of SUDs do your clients typically present with? Are there any other community-level factors that could influence experiences of stigma and discrimination against individuals with SUDs?

Immediately following data collection, the coding process will be initiated, and the data will be analyzed. The main themes will be identified using a conventional content analysis method of Graneheim and Lundman [ 95 ], in which themes and subthemes are identified to reveal participants’ perceptions and experiences toward stigma and discrimination against Iranian people who use drugs at PATCs. This process will employ inductive reasoning, which introduces concepts and categories via a detailed exploration of the data by the researcher.

In Graneheim and Lundman’s method, qualitative content analysis addresses the obvious content of an interview, along with explanations of content that can be construed or added from the interview but are not obviously detailed in the transcript [ 95 ]. Further, coding classifications are derived directly from the transcription data. Without laying on preset themes or prior theoretical opinions to categorize extracted codes from interviews, the conventional content analysis method is a suitable technique for advancing coding categorizations from the raw interview transcripts.

In this method, data analysis begins with a comprehensive reading of the entire text to ensure a thorough understanding. Subsequently, the text is examined word by word to extract codes, initially identifying specific words that may encapsulate the main concepts. These texts are derived from notes documenting the initial opinions of the interviewees and the preliminary analysis conducted. Codes that are indicative of more than one main thought are tagged and then categorized based on their dissimilarities and similarities. The greatest benefit of a conventional content analysis is attaining data directly from the study without imposing preplanned and defined categories, themes, or theories. However, one problem with this kind of analysis is that it interjects with other qualitative methods (i.e., grounded theory or phenomenology). While these approaches share similarities with initial analysis, they are emphasized for their relevance to theory advancement. Additionally, they hold significance for model development. To evaluate the trustworthiness of the results in this phase of the study, four criteria —reliability, portability, credibility, and verifiability— will be employed [ 96 ]. MAXQDA software will be used for data processing.

Phase three: integration of quantitative and qualitative data and the development of strategies

In this phase, cultural evidence-based strategies aimed at reducing stigma and discrimination associated with substance use of Iranian people at PATCs will be developed This will involve integrating insights from the literature review, the findings of the preceding study phases, and input from experts. The target group for this aspect of the study will comprise PATC experts residing in Mazandaran, Iran.

Upon completion of the second phase of the study, the quantitative and qualitative results will be merged to glean additional insights that will inform the design and implementation of appropriate strategies to mitigate stigma and discrimination against individuals with SUDs at PATCs. Three techniques can be employed to integrate the quantitative and qualitative findings: combining the data into a discussion, utilizing a matrix for combination, or employing a side-by-side display and transformation. n this study, the data will be combined into a discussion format. Some researchers often commence this approach with a section outlining the quantitative findings, followed by a section detailing the qualitative findings. Alternatively, researchers may present the quantitative findings while substantiating claims with quotes extracted from them. Another less common technique involves initially presenting the quantitative results and subsequently confirming and validating them with descriptive qualitative findings [ 97 , 98 ].

To develop strategies for reducing stigma and discrimination against people who use drugs at PATCs, the research team will start with formulating guidelines after a comprehensive review of the available literature. Systematic review and interventional studies will be conducted to find approaches. The search will encompass English-language databases (including Cochrane Library, APA PsycNET, MEDLINE, Web of Science, Embase, Scopus, ProQuest) as well as Persian databases (such as Magiran, Irandoc, SID, and Barakat). No restrictions will be imposed, particularly with regard to publication dates, to ensure comprehensive coverage of relevant studies. A uniform search strategy will be applied across all databases, utilizing the intersection of three fields via the Boolean AND operator. To define search terms, the Medical Subject Headings (MeSH) dictionary will be referenced. Upon identification of relevant documents, their quality will be assessed using the GRADE approach, followed by evidence analysis. Insights gleaned from the literature review will also be incorporated. Subsequently, the recommended strategies developed will be offered to Nominal Group Technique (NGT) experts.

NGT will be applied will be employed to devise and implement effective strategies aimed at diminishing stigma and discrimination against individuals with SUDs at PATCs. NGT is a structured, group-based method utilized to achieve consensus. Participants are encouraged to independently generate viewpoints based on predetermined and organized questions facilitated by a moderator [ 99 ]. To initiate the NGT process, primary strategies will be extracted from the findings of the first and second phases of the study, in addition to insights gathered from a literature review and examination of relevant rules and regulations A meeting will then be held with the experts who must meet the inclusion criteria of being residents of Mazandaran, Iran, possessing a minimum of one year of relevant work experience, having comprehensive familiarity with Iranian culture and customs, and being employed in a clinic associated with the treatment of people who use drugs. During this meeting, specialists will be invited to share their opinions on the developed strategies in relation to the key study questions, with all ideas and suggestions being meticulously recorded. Subsequently, these suggestions will be organized and prioritized to formulate consensus-driven strategies for effectively reducing stigma and discrimination against Iranian individuals with SUDs.

Ethical approval

The Ethics Committee of the Mazandaran University of Medical Sciences in Mazandaran, Sari, Iran, has approved the protocol for the present study [code number: IR.MAZUMS.REC.1401.192]. Informed written consent will be obtained from all participants during the quantitative and qualitative stages. Participants will be assured of the confidentiality of their data and identities. Additionally, they will be informed that they have the right to withdraw from the project at any phase of the intervention, and that their decision to refuse participation at any time will not impact or alter the quality of services provided to them.

The study is still ongoing, and no results have yet been generated. We will wait until the completion of our first data collection before disseminating any findings.

This article outlines the protocol for a mixed-method study aimed at identifying and formulating appropriate strategies to mitigate addiction-related stigma and discrimination at PATCs. The study will offer comprehensive insights into the stigma encountered by a cohort of Iranian people who use drugs and the factors influencing their experiences. The findings of this study will be utilized to develop and implement culturally tailored strategies geared towards reducing stigma and discrimination associated with substance use among Iranian people who use drugs attending PATCs.

While stigma and discrimination linked with drug addiction is a global concern, their nature and expression are contingent upon the religious, social, and cultural frameworks prevalent in various societies. Operating as a multilevel phenomenon, stigma arises when harm resulting from unfavorable status, labeling, or discrimination transpires within a power structure that perpetuates and reinforces social inequalities among those labeled [ 100 ]. Stigma toward substance use can profoundly impact an individual’s social and personal connections, often resulting in feelings of worthlessness. Such stigma may provoke negative responses and behaviors from various organizations and individuals towards the affected person [ 101 , 102 ]. These behaviors can impede access to treatment for individuals with substance use disorders. Moreover, they contribute to social, financial, and health discrimination within these communities, fostering the perception that individuals with SUDs are undeserving of the opportunity to address their condition [ 103 ].

Stigma significantly impacts the spectrum of care for individuals with SUDs, influencing aspects such as treatment seeking, preference, maintenance, and adherence, consequently leading to poorer health outcomes within this population or ever, stigma may exacerbate disparities in accessing medical and health services, as individuals with SUDs may be hesitant to pursue and adhere to health-oriented measures [ 104 ].

Studies evaluating the stigma experiences of persons with SUDs are mainly qualitative in nature [ 21 , 52 , 62 , 98 , 105 , 106 ]. The present study will be one of the few studies addressing addiction-related stigma in Iran that applies a mixed-methods technique to identify suitable strategies to reduce addiction-related stigma and discrimination at PATCs from the perspective of Iranian people who use drugs. It is expected that the current work, by using quantitative and qualitative methods, will offer valid data regarding suitable cultural strategies to reduce stigma against persons with SUDs at health-care and treatment centers.

The findings of the current study hold potential significance for healthcare specialists and policymakers shedding light on the pivotal role of cultural strategies in mitigating stigma against individuals with SUDs within healthcare and treatment settings employing a culturally sensitive approach Furthermore, the study aims to elucidate the needs of individuals with SUDs and provide insights into the factors influencing addiction-related stigma that require attention. Effective strategies emerging from this research may encompass interventions geared towards enhancing the health outcomes of Iranian people who use drugs and their families, as well as those from other nationalities and countries sharing similar cultural contexts with Iran. Additionally, the study’s findings are anticipated to inform stigma-reduction education and healthcare support initiatives tailored to the Iranian population, underpinned by a culture-based approach.

Potential strengths of the study

This study has several advantages. The results will potentially fill some of the gaps in research on people with SUDs who encounter stigma and discrimination at PATCs thus holding significant clinical implications. By employing a mixed-methods approach, this study facilitates the integration of diverse approaches and methodologies. The collection of both qualitative and quantitative data will provide a comprehensive understanding of. People who use drugs’ experiences of stigma and discrimination at PATCs. Moreover, the qualitative component of the study involves various participants directly or indirectly associated with this phenomenon, including individuals with SUDs and staff/clinicians. Conducting interviews with substance users and clinicians will enable a deeper understanding of how the phenomenon is perceived by those directly affected by stigma/discrimination, as well as by individuals closely involved in the patients’ daily lives and clinicians, who play a crucial role in both the phenomenon and its treatment.

Potential limitations of the study

The researchers acknowledge several limitations in the current study although the developed strategies will be evaluated upon achievement to ascertain their suitability and effectiveness, detailed descriptions will be necessary to design appropriate interventions and allow for generalization in similar contexts. One limitation is related to the sampling, which will be conducted in only one province in Iran. To mitigate this weakness, we will try to use maximum variation in the study phases. Another limitation is the possibility that the participants will not cooperate and drop out before the end of the study. Additionally, the scarcity of research and literature reviews regarding the stigma experienced by this population at PATCs poses a challenge. Furthermore, there is limited available data on how stigma varies among different subgroups, such as based on gender, race, religion, or socioeconomic status. These limitations will be considered during the interpretation of the study results and may influence the generalizability of findings to broader contexts.

The stigma and discrimination faced by individuals’ with SUDs experience persist not only in the community but also within PATCs, and medical settings. This Stigmatization adversely affects the accessibility and acceptability of care, as the lack of anonymity limits the willingness of this population to seek SUD treatment. The present study aims to provide comprehensive insights into the development of appropriate strategies to reduce addiction-related stigma and discrimination at PATCs. By incorporating evidence-based practice principles, insights from people who use drugs’ experiences, and input from PATC staff, these strategies can offer valuable guidance for healthcare professionals, policymakers, and managers seeking to enhance the quality of care for individuals with a history of drug use worldwide. Furthermore, the strategies developed may serve as a blueprint for adapting interventions for patients with SUDs in various settings, including other healthcare treatment centers, clinics, and within the broader public community.

Data availability

Not applicable.

Abbreviations

substance use disorder

public addiction treatment centers

Perceived Stigma of Addiction Scale

Professional’s Discrimination, Acceptance, Attitude, and Training toward Substance Abusers

Social Distance Scale

focus group discussions

screening, brief intervention and referral to treatment

in-depth interviews

nominal group technique

standard deviation

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Khazaee-Pool, M., Naghibi, S.A., Pashaei, T. et al. Developing practical strategies to reduce addiction-related stigma and discrimination in public addiction treatment centers: a mixed-methods study protocol. Addict Sci Clin Pract 19 , 40 (2024). https://doi.org/10.1186/s13722-024-00472-8

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Drug addiction has long been and still is a topical issue around the world. There are different reasons why people get addicted and various levels to which people become dependent on drugs. Some people start taking them because of pure curiosity, others so as to improve their athletic performance or reduce stress and get rid of depression. It doesn't matter why people start, the main thing here is to get help at the right time and not to ruin their life and health. When people start taking drugs, with time the way their brain functions and looks is altered. First of all, drug taking causes elevation of dopamine level in brain, which results in the feeling of pleasure. Brain remembers this event and wants it repeated. So, the drug a person takes eventually reaches the significance that other physiological needs have. As a result, the person's abilities to think clearly, control behavior, exercise good judgment and feel well without drugs intake becomes affected. This, in its turn, causes problems in relations with family, friends, at work or in university. It is extremely important to recognize drug addiction at the right moment, preferably in the beginning, so as not to spoil social relationships and health. It is necessary to understand that the sooner the problem will be attended, the better it is for the treatment progress. There are certain symptoms of drug abuse: when drug is getting people into legal trouble, if because of it people start neglecting their responsibilities, when they use drugs under dangerous conditions, and when they cause problems in relationships.

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Philosophers and psychologists have been attracted to two differing accounts of addictive motivation. In this paper, we investigate these two accounts and challenge their mutual claim that addictions compromise a person’s self-control. First, we identify some incompatibilities between this claim of reduced self-control and the available evidence from various disciplines. A critical assessment of the evidence weakens the empirical argument for reduced autonomy. Second, we identify sources of unwarranted normative bias in the popular theories of addiction that introduce systematic errors in interpreting the evidence. By eliminating these errors, we are able to generate a minimal, but correct account, of addiction that presumes addicts to be autonomous in their addictive behavior, absent further evidence to the contrary. Finally, we explore some of the implications of this minimal, correct view.

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Substance use and addiction research in India

Pratima murthy.

Department of Psychiatry, De-Addiction Centre, National Institute of Mental Health and Neuro Sciences, Bangalore - 560 029, India

N. Manjunatha

B. n. subodh, prabhat kumar chand, vivek benegal.

Substance use patterns are notorious for their ability to change over time. Both licit and illicit substance use cause serious public health problems and evidence for the same is now available in our country. National level prevalence has been calculated for many substances of abuse, but regional variations are quite evident. Rapid assessment surveys have facilitated the understanding of changing patterns of use. Substance use among women and children are increasing causes of concern. Preliminary neurobiological research has focused on identifying individuals at high risk for alcohol dependence. Clinical research in the area has focused primarily on alcohol and substance related comorbidity. There is disappointingly little research on pharmacological and psychosocial interventions. Course and outcome studies emphasize the need for better follow-up in this group. While lack of a comprehensive policy has been repeatedly highlighted and various suggestions made to address the range of problems caused by substance use, much remains to be done on the ground to prevent and address these problems. It is anticipated that substance related research publications in the Indian Journal of Psychiatry will increase following the journal having acquired an ‘indexed’ status.

INTRODUCTION

Substance use has been a topic of interest to many professionals in the area of health, particularly mental health. An area with enormous implications for public health, it has generated a substantial amount of research. In this paper we examine research in India in substance use and related disorders. Substance use includes the use of licit substances such as alcohol, tobacco, diversion of prescription drugs, as well as illicit substances.

METHODOLOGY

For this review, we have carried out a systematic web-based review of the Indian Journal of Psychiatry (IJP). The IJP search included search of both the current and archives section and an issue-to-issue search of articles with any title pertaining to substance use. This has included original articles, reviews, case series and reports with significant implications. Letters to editor and abstracts of annual conference presentations have not been included.

Publications in other journals were accessed through a Medlar search (1992-2009) and a Pubmed search (1950-2009). Other publications related to substance use available on the websites of international and national agencies have also been reviewed. In this review, we focus mainly on publications in the IJP and have selectively reviewed the literature from other sources.

For the sake of convenience, we discuss the publications under the following areas: Epidemiology, clinical issues (diagnosis, psychopathology, comorbidity), biological studies (genetics, imaging, electrophysiology, and vulnerability), interventions and outcomes as well as community interventions and policies. There is a vast amount of literature on tobacco use and consequences in international and national journals, but this is outside the scope of this review. Tobacco is mentioned in this review of substance use to highlight that it should be remembered as the primary licit substance of abuse in our country.

The number of articles (area wise) available from IJP, other Indian journals and international journals are indicated in Figures ​ Figures1 1 and ​ and2. 2 . A majority of the publications in international journals relate to tobacco, substance use co-morbidity and miscellaneous areas like animal studies.

Publications in the area of substance use and related disorders

Break up of areas of publication

EPIDEMIOLOGY

Much of the earlier epidemiological research has been regional and it has been very difficult to draw inferences of national prevalence from these studies.

Regional studies

Studies between 1968 until 2000 have been primarily on alcohol use [ Table 1 ]. They have varied in terms of populations surveyed (ranged from 115 to 16,725), sampling procedures (convenient, purposive and representative), focus of enquiry (alcohol use, habitual excessive use, alcohol abuse, alcoholism, chronic alcoholism, alcohol and drug abuse and alcohol dependence), location (urban, rural or both, Slums), in the screening instruments used (survey questionnaires and schedules, semi-structured interviews, quantity frequency index, Michigan Alcohol Screening Test (MAST) etc). Alcohol ‘use/abuse’ prevalence in different regions has thus varied from 167/1000 to 370/1000; ‘alcohol addiction’ or ‘alcoholism’ or ‘chronic alcoholism’ from 2.36/1000 to 34.5/1000; alcohol and drug use/abuse from 21.4 to 28.8/1000. A meta-analysis by Reddy and Chandrashekhar[ 26 ] (1998) revealed an overall substance use prevalence of 6.9/1000 for India with urban and rural rates of 5.8 and 7.3/1000 population. The rates among men and women were 11.9 and 1.7% respectively.

Regional epidemiological studies in substance use: A summary

U - Urban; R - Rural; Sl - Slum; SR - Semi-rural; NM - Not mentioned

Regional studies between 2001 and 2007 continue to reflect this variability. Currently, the interest is to look at hazardous alcohol use. A study in southern rural India[ 27 ] showed that 14.2% of the population surveyed had hazardous alcohol use on the AUDIT. A similar study in the tertiary hospital[ 28 ] showed that 17.6% admitted patients had hazardous alcohol use.

The only incidence study on alcohol use from Delhi[ 17 ] found that annual incidence of nondependent alcohol use and dependent alcohol use among men was 3 and 2 per 1000 persons in a total cohort of 2,937 households.

National Studies

The National Household Survey of Drug Use in the country[ 29 ] is the first systematic effort to document the nation-wide prevalence of drug use [ Table 2 ]. Alcohol (21.4%) was the primary substance used (apart from tobacco) followed by cannabis (3.0%) and opioids (0.7%). Seventeen to 26% of alcohol users qualified for ICD 10 diagnosis of dependence, translating to an average prevalence of about 4%. There was a marked variation in alcohol use prevalence in different states of India (current use ranged from a low of 7% in the western state of Gujarat (officially under Prohibition) to 75% in the North-eastern state of Arunachal Pradesh. Tobacco use prevalence was high at 55.8% among males, with maximum use in the age group 41-50 years.

Nationwide studies on substance use prevalence

H-H - House to house survey; M - Male; F - Female; A - Alcohol, C - Cannabis; O - Opioids; T - Tobacco

The National Family Health Survey (NFHS)[ 30 ] provides some insights into tobacco and alcohol use. The changing trends between NFHS 2 and NFHS 3 reflect an increase in alcohol use among males since the NFHS 2, and an increase in tobacco use among women.

The Drug Abuse Monitoring System,[ 29 ] which evaluated the primary substance of abuse in inpatient treatment centres found that the major substances were alcohol (43.9%), opioids (26%) and cannabis (11.6%).

Patterns of substance use

Rapid situation assessments (RSA) are useful to study patterns of substance use. An RSA by the UNODC in 2002[ 31 ] of 4648 drug users showed that cannabis (40%), alcohol (33%) and opioids (15%) were the major substances used. A Rapid Situation and Response Assessment (RSRA) among 5800 male drug users[ 32 ] revealed that 76% of the opioid users currently injected buprenorphine, 76% injected heroin, 70% chasing and 64% using propoxyphene. Most drug users concomitantly used alcohol (80%). According to the World Drug Report,[ 33 ] of 81,802 treatment seekers in India in 2004-2005, 61.3% reported use of opioids, 15.5% cannabis, 4.1% sedatives, 1.5% cocaine, 0.2% amphetamines and 0.9% solvents.

Special populations

In the last decade, there has been a shift in viewing substance use and abuse as an exclusive adult male phenomenon to focusing on the problem in other populations. In the GENACIS study[ 34 ] covering a population of 2981 respondents [1517 males; 1464 females], across five districts of Karnataka, 5.9% of all female respondents (N =87) reported drinking alcohol at least once in the last 12 months, compared to 32.7% among male respondents (N = 496). Special concerns with women’s drinking include the fetal alcohol spectrum effects described with alcohol use during pregnancy.[ 35 ]

Abuse of other substances among women has largely been studied through Rapid Assessment Surveys. A survey of 1865 women drug users by 110 NGOs across the country[ 36 ] revealed that 25% currently were heroin users, 18% used dextropropoxyphene, 11% opioid containing cough syrups and 7% buprenorphine. Eighty seven per cent concomitantly used alcohol and 83% used tobacco. Twenty five per cent of respondents had lifetime history of injecting drug use and 24% had been injecting in the previous month. There are serious sexually transmitted disease risks, including HIV that women partners and drug users face.[ 36 , 37 ]

Substance use in medical fraternity

As early as 1977, a drug abuse survey in Lucknow among medical students revealed that 25.1% abused a drug at least once in a month. Commonly abused drugs included minor tranquilizers, alcohol, amphetamines, bhang and non barbiturate sedatives. In a study of internees on the basis of a youth survey developed by the WHO in 1982,[ 38 ] 22.7% of males ‘indulged in alcohol abuse’ at least once in a month, 9.3% abused cannabis, followed by tranquilizers. Common reasons cited were social reasons, enjoyment, curiosity and relief from psychological stress. Most reported that it was easy to obtain drugs like marijuana and amphetamines. Substance use among medical professionals has become the subject of recent editorials.[ 39 , 40 ]

Substance use among children

The Global Youth Tobacco Survey[ 41 ] in 2006 showed that 3.8% of students smoke and 11.9% currently used smokeless tobacco. Tobacco as a gateway to other drugs of abuse has been the topic of a symposium.[ 42 ]

A study of 300 street child laborers in slums of Surat in 1993[ 43 ] showed that 135 (45%) used substances. The substances used were smoking tobacco, followed by chewable tobacco, snuff, cannabis and opioids. Injecting drug use[ 44 ] is also becoming apparent among street children as are inhalants.[ 45 ]

A study in the Andamans[ 46 ] shows that onset of regular use of alcohol in late childhood and early adolescence is associated with the highest rates of consumption in adult life, compared to later onset of drinking.

Studies in other populations

A majority of 250 rickshaw pullers interviewed in New Delhi[ 47 ] in 1986 reported using tobacco (79.2%), alcohol (54.4%), cannabis (8.0%) and opioids (0.8%). The substances reportedly helped them to be awake at night while working. In a study of prevalence of psychiatric illness in an industrial population[ 48 ] in 2007, harmful use/dependence on substances (42.83%) was the most common psychiatric condition. A study among industrial workers from Goa on hazardous alcohol use using the AUDIT and GHQ 12 estimated a prevalence of 211/1000 with hazardous drinking.[ 19 ]

Hospital-based studies

These studies have basically described profiles of substance use among patients and include patterns of alcohol use,[ 49 – 53 ] opioid use,[ 54 – 56 ] pediatric substance use,[ 57 ] female substance use,[ 58 ] children of alcoholics[ 59 ] and geriatric substance use.[ 60 ]

Alcohol misuse has been implicated in 20% of brain injuries[ 61 ] and 60% of all injuries in the emergency room setting.[ 62 ] In a retrospective study of emergency treatment seeking in Sikkim between 2000 and 2005,[ 63 ] substance use emergencies constituted 1.16% of total psychiatric emergencies. Alcohol withdrawal was the commonest cause for reporting to the emergency (57.4%).

Effects of substance use disorders

Mortality and morbidity due to alcohol and tobacco have been extensively reviewed elsewhere[ 35 , 64 – 66 ] and are beyond the scope of this review. The effects of cannabis have also been reviewed.[ 67 ] Mortality with injecting drug use is a serious concern with increase in crude mortality rates to 4.25 among injecting drug users compared to the general population.[ 68 ] Increased susceptibility to HIV/AIDS and other sexually transmitted diseases has been reported with alcohol[ 69 ] as well as injecting drug use.[ 70 ]

Clinical issues

Harmful alcohol use patterns among admitted patients in general hospital has highlighted the importance of routine screening and intervention in health care settings.[ 71 ]

Peer influence is a significant factor for heroin initiation.[ 72 ] Precipitants of relapse (dysfunction, stress and life events) differ among alcohol and opioid dependents.[ 73 ] Chronologies in the development of dependence have been evaluated in alcohol dependence.[ 74 , 75 ]

Craving a common determinant of relapse has been shown to reduce with increase in length of period of abstinence.[ 76 ]

Alcohol dependence constitutes a significant group among the psychiatric population in the Armed Forces.[ 77 ] A study of personality factors[ 78 ] among 100 alcohol dependent persons showed significantly high neuroticism, extroversion, anxiety, depression, psychopathic deviation, stressful life events and significantly low self-esteem as compared with normal control subjects. Alcohol dependence causes impairment in set shifting, visual scanning and response inhibition abilities and relative abstinence has been found to improve this deficit.[ 79 , 80 ] Alcohol use has had a significant association with head injury and cognitive deficits.[ 81 , 82 ] Persistent drinking is associated with persisting memory deficits in head injured alcohol dependent patients.[ 82 ] Mild intellectual impairment has been demonstrated in patients with bhang and ganja dependence.[ 83 – 86 ]

Kumar and Dhawan[ 87 ] found that health related reasons like death/physical complications due to drug use in peers and patients themselves, knowledge of HIV and difficulties in accessing veins were the main reason for reverse transition (shift from parenteral to inhalation route).

Evaluation and assessment

Diagnostic issues have focused on cross-system agreement[ 88 ] between ICD-10 and DSM IV, variability in diagnostic criteria across MAST, RDC, DSM and ICD[ 89 ] and suitability of MAST as a tool for detecting alcoholism.[ 90 ] The CIWA-A was found useful in monitoring alcohol withdrawal syndrome.[ 91 ]

The utility of liver functions for diagnosis of alcoholism and monitoring recovery has been demonstrated in clinical settings.[ 92 – 94 ] A range of hepatic dysfunction has been demonstrated through liver biopsies.[ 95 ]

A few studies have focused on scale development for motivation[ 96 , 97 ] and addiction related dysfunction[ 98 ] (Brief Addiction Rating Scale). An evaluation of two psychomotor tests comparing smokers and non-smokers found no differences across the two groups.[ 99 ]

Typology research has included validation of Babor’s[ 100 ] cluster A and B typologies, age of onset typology,[ 101 ] and a review on typology of alcoholism.[ 102 ]

Craving plays an important role in persistence of substance use and relapse. Frequency of craving has been shown to decrease with increase in length of abstinence among heroin dependent patients. Socio-cultural factors did not influence the subjective experience of craving.[ 76 ]

In a study of heroin dependent patients, their self-report moderately agreed with urinalysis using thin layer chromatography (TLC), gas liquid chromatography (GLC) and high performance liquid chromatography (HPLC).[ 103 ] The authors, however, recommend that all drug dependence treatment centers have facilities for drug testing in order to validate self-report.

Comorbidity/dual diagnosis

Cannabis related psychopathology has been a favorite topic of enquiry in both retrospective[ 104 , 105 ] and prospective studies[ 106 ] and vulnerability to affective psychosis has been highlighted. The controversial status of a specific cannabis withdrawal syndrome and cannabis psychosis has been reviewed.[ 67 ]

High life time prevalence of co-morbidity (60%) has been demonstrated among both opioid and alcohol dependent patients.[ 107 ] In alcohol dependence, high rates of depression and cluster B personality disorders[ 54 , 108 ] and phobia[ 109 ] have been demonstrated, but the need to revaluate for depressive symptoms after detoxification has been highlighted.[ 110 ] It is necessary to evaluate for ADHD, particularly in early onset alcohol dependent patients.[ 111 ] Seizures are overrepresented in subjects with alcohol and merit detailed evaluation.[ 112 ] Delirium and convulsions can also complicate opioid withdrawal states.[ 113 , 114 ] Skin disease,[ 115 ] and sexual dysfunction[ 116 ] have also been the foci of enquiry. Phenomenological similarities between alcoholic hallucinosis and paranoid schizophrenia have been discussed.[ 117 ] Opioid users with psychopathology[ 118 ] have diverse types of psychopathology as do users of other drugs.[ 119 ]

In a study of 22 dual diagnosed schizophrenia patients, substance use disorder preceded the onset of schizophrenic illness in the majority.[ 120 ] While one study found high rates of comorbid substance use (54%) in patients with schizophrenia with comorbid substance users showing more positive symptoms[ 121 ] which remitted more rapidly in the former group,[ 122 ] other studies suggest that substance use comorbidity in schizophrenia is low, and is an important contributor to better outcome in schizophrenia in developing countries like India.[ 123 , 124 ]

The diagnosis and management of dual diagnosis has been reviewed in detail.[ 125 ]

Social factors

Co-dependency has been described in spouses of alcoholics and found to correlate with the Addiction Severity scores of their husbands.[ 126 ] Coping behavior described among wives of alcoholics include avoidance, indulgence and fearful withdrawal.[ 127 ] These authors did not find any differences in personality between wives of alcoholics compared to controls.[ 128 ] Delusional jealousy and fighting behavior of substance abusers/dependents are important determinants of suicidal attempts among their spouses.[ 129 ] Parents of narcotic dependent patients, particularly mothers also show significant distress.[ 130 ]

BIOLOGY OF ADDICTION

An understanding of the cellular and molecular mechanisms of drug dependence has led to a reformulation of the etiology of this complex disorder.[ 131 ] An understanding of specific neurotransmitter systems has led to the development of specific pharmacotherapies for these disorders.

Cellular and molecular mechanisms

Altered alcohol metabolism due to polymorphisms in the alcohol metabolizing enzymes may influence clinical and behavioral toxicity due to alcohol. Erythrocyte aldehyde dehydrogenase was demonstrated to be suitable as a peripheral trait marker for alcohol dependence.[ 132 ] Single nucleotide polymorphism of the ALDH 2 gene has been studied in six Indian populations and provides the baseline for future studies in alcoholism.[ 133 ] An evaluation of ADH 1B and ALDH 2 gene polymorphism in alcohol dependence showed a high frequency of the ALDH2*2/*2 genotype among alcohol-dependent subjects.[ 134 ] DRD2 polymorphisms have been studied in patients with alcohol dependence, but a study in an Indian population failed to show a positive association. Genetic polymorphisms of the opioid receptor µ1 has been associated with alcohol and heroin addiction in a population from Eastern India.[ 135 ]

Neuro-imaging and electrophysiological studies

Certain individuals may develop early and severe problems due to alcohol misuse and be poorly responsive to treatment. Such vulnerability has been related to individual differences in brain functioning [ Figure 3 ]. Individuals with a high family history of alcoholism (specifically of the early-onset type, developing before 25 years of age) display a cluster of disinhibited behavioral traits, usually evident in childhood and persisting into adulthood.[ 136 ]

Brain volume differences between children and adolescents at high risk and low risk for alcohol dependence

Early onset drinking may be influenced by delayed brain maturation. Alcohol-naïve male offspring of alcohol-dependent fathers have smaller (or slowly maturing) brain volumes compared to controls in brain areas responsible for attention, motivation, judgment and learning.[ 137 , 138 ] The lag is hypothesized to work through a critical function of brain maturation-perhaps delayed myelination (insulation of brain pathways).

Functionally, this is thought to create a state of central nervous system hyperexcitability or disinhibition.[ 139 ] Individuals at risk have also been shown to have specific electro-physiological characteristics such as reduced amplitude of the P300 component of the event related potential.[ 140 , 141 ] Auditory P300 abnormalities have also been demonstrated among opiate dependent men and their male siblings.[ 142 ]

Such brain disinhibition is manifest by a spectrum of behavioral abnormalities such as inattention (low boredom thresholds), hyperactivity, impulsivity, oppositional behaviors and conduct problems, which are apparent from childhood and persist into adulthood. These brain processes not only promote impulsive risk-taking behaviors like early experimentation with alcohol and other substances but also appear to increase the reinforcement from alcohol while reducing the subjective appreciation of the level of intoxication, thus making it more likely that these individuals are likely not only to start experimenting with alcohol use at an early age but are more likely to have repeated episodes of bingeing.[ 143 ]

INTERVENTIONS, COURSE AND OUTCOME

Although there are a few review articles on pharmacological treatment of alcoholism,[ 144 , 145 ] there is a dearth of randomized studies on relapse prevention treatment in our setting.

Treatment of complications of substance use has been confined to case reports. A case report of thiamine resistant Wernicke Korsakoff Syndrome[ 146 ] successfully treated with a combination of magnesium sulphate and thiamine. Another case of subclinical psychological deterioration[ 147 ] (alcoholic dementia) improved with thiamine and vitamin B supplementation.

Pharmacological intervention

A randomized double blind study compared the effectiveness of detoxification with either lorazepam or chlordiazepoxide among hundred alcohol dependent inpatients with simple withdrawal. Lorazepam was found to be as effective as the more traditional drug chlordiazepoxide in attenuating alcohol withdrawal symptoms as assessed using the revised Clinical Institute Withdrawal Assessment for Alcohol scale.[ 148 ] This has implications for treatment in peripheral settings where liver function tests may not be available. However, benzodiazepines must be used carefully and monitored as dependence is very common.[ 149 ]

In a study closer to the real-world situation from Mumbai, 100 patients with alcohol dependence with stable families were randomized to receive disulfiram or topiramate. At the end of nine months, though patients on topiramate had less craving, a greater proportion of patients on disulfiram were abstinent (90% vs. 56%). Patients in the disulfiram group also had a longer time to their first drink and relapse.[ 150 ] Similar studies by the same authors and with similar methodology had earlier found that disulfiram was superior to acamprosate and Naltrexone. Though the study lacked blinding, it had an impressively low (8%) dropout rate.[ 151 , 152 ] A chart based review has shown there was no significant difference with regard to abstinence among the patients prescribed acamprosate, naltrexone or no drugs. Although patients on acamprosate had significantly better functioning, lack of randomization and variations in base line selection parameters may have influenced these findings.[ 153 ] Short term use of disulfiram among alcohol dependence patients with smoking was not associated with decrease pulmonary function test (FEV 1 ) and airway reactivity.[ 154 ]

Usefulness of clonidine for opioid detoxification has been described by various authors. These studies date back to 1980 when there was no alternative treatment for opioid dependence and clonidine emerged as the treatment of choice for detoxification in view of its anti adrenergic activity.[ 155 – 157 ] Sublingual buprenorphine for detoxification among these patients was reported as early as 1992. At that time the dose used was much lower, i.e. 0.6 -1.2 mg/ day which is in contrast to the current recommended dose of 6-16 mg/day. Comparison of buprenorphine (0.6-1.2 mg/ day) and clonidine (0.3-0.9 mg/day) for detoxification found no difference among treatment non completers. Maximum drop out occurred on the fifth day when withdrawal symptoms were very high.[ 158 ] A 24- week outcome study of buprenorphine maintenance in opiate users showed high retention rates of 81.5%, reduction in Addiction Severity Index scores and injecting drug use. Use of slow release oral morphine for opioid maintenance has also been reported.[ 159 ] Effectiveness of baclofen in reducing withdrawal symptoms among three patients with solvent dependence is reported.[ 160 ]

Psychosocial

Psychoeducational groups have been found to facilitate recovery in alcohol and drug dependence.[ 161 ] Family intervention therapy in addition to pharmacotherapy was shown to reduce the severity of alcohol intake and improve the motivation to stop alcohol in a case-control design study.[ 162 ] Several community based models of care have been developed with encouraging results.[ 163 ]

Course and outcome

An evaluation after five years, of 800 patients with alcohol dependence treated at a de-addiction center, found that 63% had not utilized treatment services beyond one month emphasizing the need to retain patients in follow-up.[ 164 ]

In a follow-up study on patients with alcohol dependence, higher income and longer duration of in-patient treatment were found to positively correlate with improved outcome at three month follow up. Outcome data was available for 52% patients; 81% of those maintained abstinence.[ 165 ] Maximum attrition was between three to six months. In a similar study among in-patients, 46% were abstinent. The drop out rate was 10% at the end of one year.[ 101 ] Studies done in the community setting have shown the effectiveness of continued care in predicting better outcome in alcohol dependence. In one study the patient group from a low socio-economic status who received weekly follow up or home visit at a clinic located within the slum showed improvement at the end of month 3, 6 and 9, and one year, in comparison with a control group that received no active follow-up intervention.[ 166 ] In a one-year prospective study of outcome following de-addiction treatment, poor outcome was associated with higher psychosocial problems, family history of alcoholism and more follow-up with mental health services.[ 167 ]

COMMUNITY INTERVENTIONS AND POLICIES

The camp approach for treatment of alcohol dependence was popularized by the TTK hospital camp approach at Manjakkudi in Tamil Nadu.[ 168 ] Treatment of alcohol and drug abuse in a camp setting as a model of drug de-addiction in the community through a 10 day camp treatment was found to have good retention rates and favorable outcome at six months.

Community perceptions of substance related problems are useful to understand for policy development. In a 1981 study in urban and rural Punjab of 1031 respondents, 45% felt people could not drink without producing bad effects on their health, 26.2% felt they could have one or two drinks per month without affecting their health. About one third felt it was alright to have one or two drinks on an occasion. 16.9% felt it was normal to drink ‘none at all’. Alcoholics were identified by behavior such as being dead drunk, drinking too much, having arguments and fights and creating public nuisance. Current users gave the most permissive responses and non-users the most restrictive responses regarding the norms for drinking.[ 169 ] The influence of cultural norms[ 170 ] has led the tendency to view drugs as ‘good’ and ‘bad’.

Simulations done in India have demonstrated that implementing a nationwide legal drinking age of 21 years in India, can achieve about 50-60 % of the alcohol consumption reducing effects compared to prohibition.[ 171 ] However, recently there are attempts to increase the permissible legal alcohol limit. This kind of contrarian approach does not make for coherent policy.

It has been argued that the 1970s saw an overzealous implementation of a simplistic model of supply and demand.[ 171 ] A presidential address[ 172 ] in 1991 emphasized the need for a multipronged approach to addressing alcohol-related problems. Existing programs have been identified as being patchy, poorly co-ordinated and poorly funded. Primary, secondary and tertiary approaches were discussed. The address highlighted the need for supply and demand side measures to address this significant public health problem. It highlighted the political and financial power of the alcohol industry and the social ambivalence to drinking. More recently, the need to have interventions for harmful and hazardous use, the need to develop evidence based combinations of pharmacotherapy and psychosocial interventions and stepped care solutions have been highlighted.[ 173 ] Standard treatment guidelines for alcohol and other drug use disorders have suggested specific measures at the primary, secondary and tertiary health care level, including at the solo physician level.[ 174 ] An earlier report in 1988 on training general practitioners on management of alcohol related problems[ 175 ] suggests that their involvement in alcohol and health education was modest, involvement in control and regulatory activities minimal, and they perceived no role in the development of a health and alcohol policy.

There have been reviews of the National Master Plan 1994, which envisaged different responsibilities for the Ministries of Health and the Ministry of Welfare (presently Social Justice and Empowerment) and the Drug Dependence Program 1996.[ 176 , 177 ] A proposal for adoption of a specialty section on addiction medicine[ 178 ] includes the development of a dedicated webpage, co-ordinated CMEs, commissioning of position papers, promoting demand reduction strategies and developing a national registry.

SUMMARY AND CONCLUSIONS

While epidemiological research has now provided us with figures for national-level prevalence, it would be prudent to recognize that there are regional differences in substance use prevalence and patterns. It is also prudent to recognize the dynamic nature of substance use. There is thus a need for periodic national surveys to determine changing prevalence and incidence of substance use. Substance use is associated with significant mortality and morbidity. Substance use among women and children is increasingly becoming the focus of attention and merits further research. Pharmaceutical drug abuse and inhalant use are serious concerns. For illicit drug use, rapid assessment surveys have provided insights into patterns and required responses. Drug related emergencies have not been adequately studied in the Indian context.

Biological research has focused on two broad areas, neurobiology of vulnerability and a few studies on molecular genetics. There is a great need for translation research based on the wider body of basic and animal research in the area.

Clinical research has primarily focused on alcohol. An area which has received relatively more attention in substance related comorbidity. There is very little research on development and adaptation of standardized tools for assessment and monitoring, and a few family studies. Ironically, though several evidence based treatments have now become available in the country, there are very few studies examining the utilization and effectiveness of these treatments, given that most treatment is presently unsubsidized and dependent on out of pocket expenditure. Both pharmacological and psychosocial interventions have disappointingly attracted little research. Course and outcome studies emphasize the need for better follow-up in this group.

While a considerable number of publications have lamented the lack of a coherent policy, the need for human resource enhancement and professional training and recommended a stepped-care multipronged approach, much remains to be done on the ground.

Finally, publication interest in the Indian Journal of Psychiatry in the area of substance use will undoubtedly increase, with the journal having become indexed.

Source of Support: Nil

Conflict of Interest: None declared