Australian Drug and Alcohol Review 1987: 6; 289-292

Alcohol and Drug Use Perspective Marcus Grant

Division of Mental Health,

A World

World Health Organization, Geneva

Abstract: The current world situation with regard to alcohol and other drug abuse is summarised, and the implications of the trends in use are considered from a public health perspective.

Keywords: Substance abuse; substance dependence; cocaine; heroin dependence; amphetamines; cannabis; alcoholism; smoking.

Introduction The purpose of this paper is to summarize the

current world situation with respect to alcohol and drug abuse. It will describe very briefly each major substance of abuse and give an indication of what the current global trends are. It will then discuss what the implications of those trends seem to be from a public health perspective. It is important to emphasise that the figures quoted, which are all from official sources, are almost certainly substantial under-estimates of the seriousness of the situation. It would be mislead- ing to assume that these figures represent anything more than a broad indication of the extent of the problem with respect to these substances. The figures quoted are based on data that were collected by the World Health Organization during a survey which ended in the early 1980s; where possible, data gathered since then will be used to indicate any changes in the situation. The various health and social problems that are as- sociated with these substances will not be discus- sed in this paper.

Drug abuse

First of all, with regard to raw opium, a high rate of abuse was found in the Middle East, in South East Asia and the Western Pacific with a total of 1.6 million opium abusers. The highest rates were found in opium producing countries and neighbouring countries and especially in rural coffee growing regions. The risk of dependence was greatest in adults and elderly males. This

pattern does not seem to have changed substan- tially since these data were gathered. Heroin, by contrast, has a global total of abusers which is estimated to be about 750,000. Extensive abuse has been reported in North America and in the highly industrialised European countries in the last decades. In recent years, other countries have also become involved, particularly South East Asia, the Middle East and parts of Europe not previously affected. The target populations seem to be mainly adolescents and young adults, with a peak in the age range 18-25.

High rates of cocoa and cocaine misuse are found primarily in the Americas. Especially in Peru and Bolivia, Argentina, Columbia, Chile, Ecuador and parts of Brazil, coca leaf chewing and coca paste smoking predominate. Sniffing of cocaine powder has increased especially in North America and in various European countries and there is already some evidence that "crack" has appeared in Australia as well. Inhaling of freebase is mainly reported in the U.S.A. The number of coca leaf abusers is estimated at about 1.6 million, while cocaine abusers are estimated to number 4.8 million. In recent years, cocaine abuse has shown the highest rate of increase of all the drugs. The target groups for coca leaf chewing are all age groups in the indigenous population, but for coca paste smoking, it is mainly confined to adoles- cents and young adults. As for cocaine, it used to be the middle and upper class urban males, but with the appearance of "crack", that has diver- sified much more because of the significantly lower price on the streets.

290

Amphetamine abuse has been reported from 68 countries in all, suggesting a worldwide distribu- tion. Over 80% of the world's amphetamine abusers are, however, to be found in the United States. A global total of 2.3 million abusers has been quoted, but the statistical basis for this seems less reliable than for some other drugs. No extensive changes have been reported in recent years.

Cannabis use is reported from 120 countries, with a total number of 29 million individuals involved. Twenty-five countries from the African, the American, the European regions of WHO fall into the high use category. The nature of the data used in these statistics suggests that there is a major under-estimation of cannabis use in most countries. Users are found in all age groups and all social strata. Special target groups include adult smokers in rural areas of Africa, Asia and the Middle East, as well as other urban or semi-urban populations in practically all regions of the world.

Hallucinogens are reported to be abused by two million persons living in 15 countries but mainly, again, in the United States. Abuse has decreased internationally in recent years. The main risk groups remain urban youth and indigenous populations of North and South America.

Khat misuse in the form of khat chewing is reported from Kenya, Djubuti, United Arab Emirates and Yemen, although very recently, khat use has also been reported from other East African countries. Essentially, it is the male population in all age groups and social classes that is affected. No figures on incidence and prevalence are available. The abuse of this stimulant, although seemingly increasing, will probably be restricted to the area now affected unless new ways of conservation and transportation are devised.

An unknown number of individuals obtain barbiturates, sedatives and tranquillisers from doctors on legitimate medical grounds and are therefore not reported. This should be kept in mind when interpreting the significance of the globally reported figure of 3.4 million abusers. At least some level of abuse was identified in 88 countries in all. Populations most at risk may be medical and psychiatric patients but abuse of these drugs is also reported amongst illegal drug users. In recent years, an increase of abuse and a corresponding increase in concern has been ob- servable and the dependence liability of many of these drugs is being more realistically examined.

Abuse of volatile solvents, such as inhalants, glues and, in some cases, gasoline, was reported by relatively few countries, the global total being

thought to be something in the region of 70,000 abusers. Those affected are mostly teenagers and even younger children in Central, South and North America, especially from lower social strata. In most recent years, increased concern has been expressed about this problem, which in all probability has been underestimated substantially, partly due to the special difficulties in surveying this age group in those countries. Some evidence has emerged of the spread of solvent abuse amongst youthful populations in cities in some African countries.

Alcohol and tobacco abuse Alcohol consumption has been steadily increas-

ing worldwide. The consumption and production data for alcohol are easier to obtain than any of the other substances discussed so far, although it must be borne in mind that in the case of alcohol, there is extensive domestic production in many parts of the world, especially in Africa and Latin America. Between the period 1960-62 and the period 1980- 82, per capita consumption increased by at least 50% in very many countries in the developed world. But reports from Africa, South and Central America, Asia, the Pacific islands and the Carribean also suggest substantially increasing consumption. Indeed, during the 1980s, alcohol consumption has levelled off and even declined modestly in many European countries and North America. The steepest rates of increase have been in the developing world, though of course in many developing countries these rates begin from a somewhat lower base.

Tobacco use is reported to have levelled off or decreased in North America and in several European countries, with an increasing number of ex-cigarette smokers. This trend has only been observed in male populations, whereas in females a reverse trend has begun to emerge. In many developing countries, however, as smoking is becoming increasingly prevalent, the correspond- ing health damage is starting to become visible with increasing lung cancer mortality rates. A shift from developed to developing countries in the marketing policy of the tobacco industry has been observable. The increasing awareness in developed countries of the health risks associated with high rates of cigarette smoking has not as yet become an important factor influencing rates of tobacco use in the developing world.

Overall trends When considering trends in substance abuse a

remark has to be made concerning the elderly adult group. Quite often when one reads reports

291

of concern being expressed about drug abuse, the focus is upon adolescent populations. But with increased life expectancy, the number of elderly adults is growing considerably. There is, unfor- tunately, sparse information on substance use and abuse risks in this age group. Some 20 years ago, these risks seemed to be less in comparison with the risks of younger age groups. In recent years, h o w e v e r , t h e r e are i n d i c a t i o n s in the epidemiological literature of an increased risk, especially concerning alcohol, sedative and hyp- notic use among the elderly.

As regards the overall picture concerning recent trends in drug abuse, at least two different scenarios need to be distinguished. The first scenario is characterised by traditional patterns of drug use with a history of many centuries behind them and a high degree of integration with the cultural and everyday life of adult, mostly rural populations. This has applied to the use of raw opium, cannabis, coca leaves and alcohol in certain countries. In other countries, however, the scenario has become complicated by the availability of other drugs and by an overproduc- tion and/or suppression of traditional drugs. Together with changes in the socio-cultural con- text, these factors have resulted in a destabiliza- tion of traditional drug use and in establishing new and more hazardous patterns of multiple drug use.

The other scenario is wht might be character- ised as the modern drug wave, starting in the early 1960s in the highly industrialized countries, and affecting primarily the urban and semi-urban youth, but spreading later to more and more countries in all regions of the world and to other population groups. This trend has led to an enormous expansion in the abuse of cannabis, stimulants, hallucinogens, heroin, and most par- ticularly of course, cocaine. Epidemiological data, as well as data on drug seizures, provide evidence of this process of a rapid, very wide spread of abuse. Within the second scenario, a speedy increase of multiple drug use, with a variety of rapid changes in consumption patterns, is now observable.

Concerning risk factors and populations at risk, there are also trends and changes, especially in the groups affected by the new drug wave. These groups have altered considerably during the last two decades. At first, middle and upper class youths, and especially students, were the main target group and increased drug use coincided with increased youth protest. This phenomenon is visible nowadays only in those countries that have

very recently been touched by the drug wave. Those that were hit earlier show a definite shift in the risk profile towards groups from deprived areas with deficient social backgrounds and psy- chopathological characteristics. Earlier sex dif- ferences, with a disproportionately high ratio of young males, have almost vanished, resulting in more or less equal consumption and abuse rates in males and females. The age of first drug use has become lower and the rates of inhalant abuse and alcohol drinking among very young school chil- dren have increased in many parts of the world.

In a summary of current trends in psychoactive substance abuse, mention must be made of a levelling off process in the consumption of illegal drugs in those countries where this consumption started some 10 to 20 years ago, accompanied by a similar levelling off and even decrease in cigarette smoking in males. For females, the increase in smoking started later than for males, and the levelling off process may be correspondingly later. In countries where illegal drug use started only a few years ago, consumption rates are still incres- ing, and in some cases increasing dramatically. The illegal drug with the highest annual rate of increase in use is cocaine in its various forms. The most marked increase rates, however, are seen for alcohol and prescription drugs that are diverted to a "grey market ~. It is therefore possible to gain an impression of an overall shift from illegal towards legal substances. This hypothesised shift is far from being adequately substantiated or under- stood. Also, the apparent shift of highest risk from affluent societies to societies with deficient risk awareness needs more clarification.

Finally, a shift to even younger age groups, especially in the lower social strata has been reported, especially in the abuse of inhalants, and this needs additional study.

Implications for public health Some implications of these trends for public

health are quite obvious. Clearly we can expect a global increase in alcohol related morbidity, a global increase in multiple drug use morbidity, an increase in tobacco related morbidity, especially in identified regions and population groups, and an increase in cocaine related morbidity in iden- tified regions and population groups. In addition, of course, it is now essential to take into account the rate of AIDS morbidity amongst intravenous drug abusers which is already making an ad- ditional impact on public health. There can be no doubt that this represents a most serious burden to society and that additional costs are to be

292

expected wherever health delivery systems are used. Accurate calculations of these future costs are not currently available.

The focus of these proceedings is on issues to do with early identification, and one of the major implications of the data reported in this paper is that, as new population groups emerge, so the need for earlier identification both at an individual level and at a population level is going to become much more pressing. Although most of the papers in these proceedings are concerned with iden- tification at an individual level, it is clear that almost all the available data on drug abuse are grossly deficient. There is a need for much better national monitoring systems with respect to the use of all these substances. Beyond national monitoring systems, there is also the need for much better co-ordination of data among coun- tries. Increasingly, drugs are being consumed in countries other than those in which they are p.roduced. The division into countries of produc- uon, countries of consumption and countries in transit is becoming increasingly blurred. Many countries find themselves to be in all three states, depending on which drug it is that is being- discussed. Thus, there is a need for better national monitoring, better international co-ordination of data, but most importantly of all, better feedback into appropriate policies and programmes.

The International Conference on Drug Abuse and Illicit Trafficking took place in Vienna in 1987 at the specific request of the Secretary General of the United Nations. In their submissions and contributions to that conference, the represen- tatives of the 138 countries involved described not just what they are hoping to do but some of the successes which they have already achieved. It is, however, necessary to sound a word of caution. Of course, one witnessed, with considerable enthusiasm, country after country describing their increasing concern about drug abuse, not only Australia, the United States, and European coun- tries, but developing countries as well. It is therefore all the more important to take a hard took at these expressions of concern and say: ~Well, is this because drug use itself is increasing

dramatically, or is it only concern that is increas- ing dramatically? If concern is increasing dramatically, is that something which matches the data we have, or is it something which is occurring for other reasons?" The W H O does not have an answer to those questions, but they are important questions, difficult questions to answer, and they lie at the root of many issues which are addressed in other papers in these proceedings.

There can be no doubt that drug abuse does impose enormous costs on any society. There can be no doubt that all those who abuse drugs are in need of help. There can be no doubt that prevention programmes should be mounted to try to prevent increased abuse of drugs. At the same time, it is important to be sure that the concern which has been expressed is not out of keeping with the real scale of the problem and does not divert attention from other equally serious health and social issues. It is essential that we do not consider drug abuse in isolation, but locate it within the broad context of all social and health problems. It is only by doing so that we can work together towards the goal to which all Member' States of the W H O have given their assent, namely the achievement of health for all by the year 2000.

Bibliography 1. Hughes PH et al. Core data for epidemiological

studies of non-medical drug use. Geneva: WHO, 1980. (WHO Offset Publication, no. 56)

2. Johnson LD. Review of general population surveys of drug abuse. Geneva: WHO, 1980. (WHO Offset Publication, no. 52)

3. Rootman I, Hughes PH. Drug-abuse reporting systems. Geneva: WHO, 1980. (WHO Offset Publication, no. 55)

4. Assessment of public health and social problems associated with the use of psychotropic drugs. Geneva: WHO, 1981. (Technical Report series, no. 656)

5. Rexed B, Edmonson K, Khan I, Samsom HJ. Guidelines for the control of narcotic and psy- chotropic substances in the context of the inter- national treaties. Geneva: WHO, 1984.

6. Problems related to alcohol consumption. Geneva: WHO, 1980. (Technical Report Series, no. 650)