The abuse of illegal drugs is one of the greatest challenges that the world is facing today. Occurring in all countries, from the richest to the poorest, it is a problem that involves all groups and, increasingly, all ages, fuelling global crime, corruption and terrorism, generating unimaginable wealth for the few and limitless harm for the many, costing millions of lives and threatening the very sustainability of communities the world over.1
This year marks the one hundredth anniversary of the ratification of the first international treaty on drug dependence: the Opium Convention at The Hague.1 However, the world is still haunted by the continued abuse of drugs. According to the United Nations Office of Drug Control, estimates of illicit drug use range from 149 to 271 million people worldwide and are associated with 200,000 premature deaths.2 Society has been trying to deal with this problem for over a hundred years but today the abuse of illegal drugs remains an enormous challenge and there is a frighteningly high social price to pay.3 The problem now seems to be taking on a new dimension with an increase in the non-medical use of prescription pharmaceuticals, particularly opioid pain medications. The prevalence of non-medical use of prescription medications may soon surpass illicit drug use.4 In the United States, only marijuana surpasses prescription pain medications as the first substance for initiation of illicit drug use.5
Although illicit drug use is a prevalent and disturbing global problem, the most widely used drugs are alcohol and tobacco. The harmful use of alcohol is responsible for 2.5 million deaths annually and is identified as the third largest risk factor for premature mortality, disability, and health problems.6 According to the World Health Organization (WHO) tobacco is used by 1 billion people, 80% living in low and middle-income countries. Tobacco consumption causes the death of nearly 6 million people each year, 600,000 of whom are killed by second-hand passive smoking.7
Family members, friends, co-workers, and community members from different regions and countries experiencing the visible and devastating social consequences of drug abuse and dependence may conclude that there is no solution to addiction and it remains a social or moral problem.8 Such assumptions dictate that solutions lie in restricting supply, interdiction, and incarceration of the user. As a social problem, there is no role for either medical treatment or public health approaches, such as harm-risk reduction (e.g. needle and syringe exchange programs). Changes in these perceptions may be hindered by the stigma attached to drug dependence.9
However, some people may try to seduce us into thinking that drug addiction is a moral weakness and not a disease, that effective medical treatment is a fiction, and that the answer to all this is criminalization. Modern medical research and neuroscience have demonstrated that this view is seriously flawed, if not simply wrong. In 2000, McLellan and colleagues argued that drug dependence is a chronic health problem, sharing characteristics with other chronic diseases such as hypertension, type 2 diabetes mellitus, and asthma.8 As with these other health conditions, the influence of heritability in drug dependence has been established, its etiology involves genetic and environmental factors, and the pathophysiology has been determined and involves changes in brain chemistry and function. The response to treatment of drug dependence, like for other chronic diseases, is influenced by varying adherence to treatment regimens. Effective treatments for asthma and diabetes exist; so too are there effective treatments for nicotine, alcohol, and opioid dependence. Dietary choices and exercise impact the outcome of diabetes; lifestyle choices impact the outcome of treatments for drug dependence. This does not invalidate the fundamental view that once dependence has developed, substances hijack the brain, diminishing volitional choice. An individual diagnosed with addiction needs treatment, and the family and community must also be healed of the effects of this illness.10
Public health is a discipline concerned with safeguarding and improving the physical, mental and social health, and wellbeing of the community as a whole. Drug dependence IS a community problem. Effective and culturally appropriate public health campaigns, using analytical and communicative strategies, are central to reducing the abuse of legal and illegal drugs and medications, preventing drug dependence, and increasing acceptance of medical treatment for those affected. This will play an important and key role in challenging prejudiced and stigmatized views of this important health issue. This, in turn, will hopefully increase access to treatment for individuals, families and communities.
After 100 years, drug abuse and addiction persist and are a much larger problem than the opium trade of 1912. A public health approach is central to addressing a chronic health problem that has been with us for over a thousand years.