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World Psychiatry. Feb 2005; 4(1): 33.
PMCID: PMC1414717

How effective is substance abuse prevention?

Two major phenomena can be observed in the field of prevention of substance use and abuse: on the one hand, a growing recognition of the need to systematically evaluate the effects of preventive interventions, and a growing body of knowledge on "what works"; on the other, a rather grim and disappointing picture of increasing substance use worldwide, with very significant negative social and health consequences. What is going wrong?

Research has provided insight into a vast range of risk factors for starting use, continuing use, developing harmful use and dependence. Increasingly, the search for protective factors has come to the forefront, and interventions have started to focus on reinforcing such protective factors. Concerted action at community level, prevention at the work place, working with multiproblem families are just a few of the key issues, complementing the formerly prevailing awareness campaigns and school programs that served more the need "to do something about prevention" than to do something based on evidence for effectiveness. Early recognition and intervention strategies, geared towards a reduction of hazardous and harmful consumption rather than towards abstinence, have generated manuals for practice and an increasing number of evaluation studies. In a broader sense, reducing risks and reducing negative consequences from substance use have become as important as preventing use or forestalling the start of use.

Evaluating preventive action has become part of an evidence-based policy; evaluation guidelines are produced; reviews have analyzed the accumulating knowledge. However, in spite of the growing body of evidence about how to avoid or reduce the negative consequences of substance use, the use and the related problems are on the increase in many countries. Hazardous and harmful alcohol use is especially on the rise, in developing countries as well as in Eastern Europe (1). Major increases in injecting drug use, with all associated health and social risks, are being recorded: opiate injecting is especially increasing in Eastern Europe and South and South- East Asia, which is leading to more blood-born HIV infection and hepatitis; amphetamine injecting is increasing in many regions worldwide (2).

The implementation of available preventive strategies in this area is largely deficient. Some factors can be mentioned which contribute to this "transfer gap". Most research evidence stems from Western style market economies, and their acceptability and applicability in the developing world has to be tested. Strategies must be culture specific and targeted. Regarding legal substances, the most cost-effective prevention strategies (taxation, conditioned availability, reduced promotion) are not high on political agendas and are not popular. The exception is tobacco smoking, some sort of a "success story" in substance abuse prevention, but only in countries with adequate levels of risk awareness, while cigarette marketing has shifted successfully to developing countries (3). It looks as if substance abuse prevention only has a chance as far as health promotion and consumer protection become relevant issues for health policy and the population at large.

Finally, there cannot be effective prevention without an understanding of why substances of abuse are so attractive and how most people manage to use them without losing control and without negative consequences. The recent results of brain research have demonstrated how stress increases the risk to develop substance dependence (4), and the "self-help" theoretical model (taking drugs for stress relief and enhanced emotional experience) is gaining from the insight that addictive behaviors are just one special form of a learning process. Prevention can profit from research on how people and especially young people learn to protect themselves against the risks of substance use (5). But, in the end, substance abuse prevention has limited chances in the presence of a growing economic inequity between and inside countries, and a widespread insecurity about the future (6).

References

1. World Health Organization. Global status report on alcohol. Geneva: World Health Organization; 1999.
2. United Nations Drug Control Programme. Global illicit drug trends. Vienna: United Nations Drug Control Programme; 2000.
3. World Health Organization. The world health report 2002. Geneva: World Health Organization; 2002.
4. Volkow N. Fowler JS. Wang GJ. The addicted human brain: insights from imaging studies. J Clin Invest. 2003;111:1444–1451. [PMC free article] [PubMed]
5. Calafat A, editor. Risk and control in the recreational culture. Palma de Mallorca: Irefrea; 2001.
6. World Health Organization. The world health report 2001. Geneva: World Health Organization; 2001.

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