10.2 Alcohol and drug abuse
Oxford Textbook of Public Health
Alcohol and drug abuse
Don C. Des Jarlais and Robert L. Hubbard
Definition of dependence on alcohol and other drugs
Youth and young adults
Intravenous drug users
HIV/AIDS among injecting drug users
Early risk reduction among injecting drug users
Using psychological theories of health-related behaviour
Social change theories of HIV risk reduction among injecting drug users
Providing the means for behaviour change
NIH Consensus Development Conference
Second-generation research questions
Abuse and dependence on alcohol and other drugs is a particularly complex public health problem. The complexity of alcohol and other drug abuse is a function of its diverse nature. Dependence disorders involve biomedical, pharmacological, psychological, and social factors. Substance abuse often involves multiple pharmacological agents used within a complex social environment in which some substances are legal and others illegal. Furthermore, the distinctions among use, abuse, and dependence are often blurred. The consequences of alcohol and other drug abuse are many and varied. Some are acute and put an individual at immediate risk, such as driving while intoxicated. Use of addictive substances such as alcohol by biologically vulnerable individuals may result in long-term consequences such as chronic alcoholism and cirrhosis of the liver. Sharing of injection equipment by intravenous drug users immediately increases their risk of exposure to the human immunodeficiency virus (HIV) and, once exposed, their life-styles compromise health and may lead to accelerated development of acquired immunodeficiency syndrome (AIDS). Thus simple definitions, explanations, or solutions for substance abuse are inadequate, inefficient, and potentially counterproductive. The examination of the appropriate match between individuals and the major interventions of diagnosis, prevention, and treatment has only recently begun. This chapter indicates some of the broad concepts necessary to understand substance abuse and dependence disorders, their consequences, and potential solutions.
The focus in the first section of the chapter is dependence on alcohol and other drugs. Whilst recognizing that problems of alcohol and drug abuse occur worldwide and across diverse cultures (Babor 1986), this discussion is limited by both space and data to the United States where the problem is most profound. The history and current conditions in the United States illustrate many of the issues that exist or can be expected to emerge in many countries in the future. The abuse of alcohol (Aaron and Musto 1981) and other drugs (Brecher et al. 1972) has persisted for centuries. Since 1900, attention to alcohol and other drug abuse has waxed and waned in the United States (Jaffe 1979). Some of the foremost reasons for renewed attention on alcohol and drug abuse in the 1980s and the 1900s are the increasing costs for treatment for dependence, the violent crime associated with cocaine distribution, and the role of intravenous drug use in the transmission of HIV. Intravenous drug use is now the second most common risk behaviour associated with AIDS. It is also the major contributing factor to pediatric and heterosexual AIDS cases in the United States (Turner et al. 1989).
This first section describes the definition, epidemiology, aetiology, and consequences of alcohol and drug abuse. The major efforts made in the United States to prevent and treat alcohol and other drug abuse are reviewed and their effectiveness documented. The chapter concludes with a discussion of the critical role of intravenous drug use in the AIDS epidemic. The last section incorporates a broader worldwide view. Within each section a broad array of perspectives on these problems is presented. These perspectives range from the biomedical search for genetic markers to legal attempts to control alcohol and other drug use. A full discussion of all perspectives is beyond the scope of one particular presentation. Because of the orientation of the authors, this presentation necessarily has a social/psychological orientation. This is not to suggest that the other approaches are not important to consider, only that the authors of this chapter are most qualified to deal with the research literature in their own discipline.
Definition of dependence on alcohol and other drugs
Various approaches have been used to characterize the use, abuse, and dependence on alcohol and other drugs. Numerous personal interviews and self-report inventories have been developed to obtain a comprehensive history of use as well as assessments of current use patterns, dependence, and drug- and alcohol-related problems (Skinner and Horn 1984; Babor et al. 1988). No single measure has yet been accepted as fully characterizing use, abuse, or dependence. From an epidemiological perspective, frequency of use and total number of times used in a lifetime are often the principal measures. Abuse refers to usage levels that have short-term acute personal or social consequences. Psychiatric diagnosis of dependence requires evidence of consequences over an extended period of time. The clinical definition of dependence, which is now undergoing careful review, has evolved over the past decade to include psychological as well as physiological components.
Assessment of alcohol dependence and problems has received more attention than diagnosis of drug abuse problems or dependence. Research on alcohol dependence has fostered interest in the measurement of drug dependence syndromes using similar diagnostic criteria (Edwards et al. 1981). Many of the assessments used to measure alcohol abuse have been modified for drug abuse research. A factor analysis study (Skinner and Horn 1984) identified a general cluster resembling the alcohol dependence syndrome postulated by Edwards et al. (1981). The salient markers of this factor include loss of behavioural control over drinking, withdrawal symptoms, and obsessive–compulsive drinking style. Validation research (Skinner and Horn 1984) indicates that the drug dependence symptoms correlate in predictable ways with clinic attendance, physical symptoms, and psychosocial problems.
Perhaps the most ambitious and theoretically sound approach to assessing dependence has been taken by Rounsaville et al. (1986) on the structured clinical interview for the third revised edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). The structured clinical interview is designed to determine diagnoses and symptoms of substance use disorder according to DSM-III-R (American Psychiatric Association 1987). The structured clinical interview provides a more comprehensive assessment of alcohol and drug dependence symptoms than the substance use disorders section of the Diagnostic Interview Schedule and provides diagnoses that can be applied to both DSM-III and DSM-III-R.
The criteria have been substantially revised (Rounsaville et al. 1986) and are designed to reflect aspects of the dependence syndrome (Edwards et al. 1981). Symptoms include:
more use than intended
inability to reduce use
amount of time seeking substance
physical effects of use
use replaces other activities
continued use despite problems
use to avoid withdrawal symptoms.
Dependence severity is assessed by considering the number of symptoms reported and the extent of impairment, the indication of level of dependence (mild, moderate, severe, partial remission, full remission) rather than simply the presence or absence of dependence or abuse. Abuse is defined as sporadic non-dependent patterns of use despite problems or physical hazards.
Initial attempts to define alcohol and drug dependence have been confounded by increased multiple use of various drugs during the 1970s and 1980s (Clayton 1985; Hubbard et al. 1986) and the rise of cocaine use during the 1980s. A very complex typology is needed to capture the full extent of alcohol and other drug use. In fact, many individuals who use alcohol heavily also report the use of marijuana and, increasingly, the use of cocaine. Almost all of those using marijuana will have used alcohol. At another extreme, most intravenous heroin users have used alcohol, cocaine, and marijuana (Hubbard et al. 1986). To address this problem, a general category of polydrug dependence, to include dependence on three or more specific psychoactive substances, or dependence on psychoactive substances in general, was introduced in DSM-III-R. These emerging approaches to definition within and across the complex array of usage patterns offer the promise of a more comprehensive understanding of abuse and dependence.
Since the 1960s in the United States national attention has been focused on the rapidly expanding problem of drug abuse. In particular, the concern was the involvement of adolescents with alcohol and other drugs. To trace these high levels of use, three series of national probability sample surveys have been conducted in the United States. Each year since 1974, a national sample of high school senior students has completed self-administered questionnaires on alcohol and drug use (Johnston et al. 1989). In the years 1972, 1974, 1975, 1979, 1982, 1985, and 1988, and annually since 1991, personal interviews on drug use have been conducted with a national sample of American household residents, stratified by ages 12 to 17, 18 to 25, and 26 years or older (National Institute on Drug Abuse 1989). Two national surveys on alcohol use have been conducted in 1967 and 1984 (Hilton and Clark 1987). These surveys have documented relative stability in alcohol use, but a rapid escalation from 1972 to 1979 in lifetime and current use of other drugs, particularly marijuana and cocaine. After 1979 the use of marijuana and, since 1985, cocaine dropped rapidly (Table 1). For youth the rates of marijuana use then began to increase in the mid-1990s.
Table 1 Trends in prevalence of self-reported use of marijuana, cocaine, and alcohol in the National Household Survey on Drug Abuse in the United States, 1974–1998
The spectrum of problems associated with drug use persists and now includes the crucial role of intravenous heroin and cocaine use in the transmission of HIV infection. The large-scale household or school-based surveys do not provide useful information on the relatively rare and hidden populations of intravenous drug users. Estimates of the size and usage patterns of this population are derived largely from studies of convenience samples, statistical models, and informed guesses.
Youth and young adults
While alcohol and other drug abuse occurs at all income levels and in virtually all age groups, the high levels of abuse among youths and young adults causes the most concern. In the United States, approximately 70 per cent of all youth have at least experimented with illegal drugs by the time they leave high school (Johnston et al. 1999) and one in three senior students report current heavy drinking (five or more drinks in a row in the past 2 weeks). A survey of 7500 youth aged 11 to 14 years has shown that initiation of alcohol and drug abuse rises exponentially through the years of early adolescence (Hubbard et al. 1988). By the age of 14, two in five adolescents have at one time consumed two or more drinks or reported trying drugs for non-medical reasons.
The trends in the use of drugs by youth showed a levelling off from the mid-1970s to the early 1980s, a rapid decline in the late 1980s, and an increase in the mid-1990s (Table 1). Percentages of youth who had ever tried marijuana (26.7 per cent in 1979) had fallen to 20.1 per cent in 1985 and to 9.9 per cent in 1993, before beginning an annual increase to 17 per cent in 1998. Cocaine use rose rapidly from 1.5 per cent in 1972 to 5.5 per cent in 1979 and 6.1 per cent in 1982, but fell to 2.4 per cent in 1991 and to 1.1 per cent by 1993, and then climbed to 2.2 per cent by 1998. Although the percentages of youths aged 12 to 17 years who use drugs are currently lower than the 1979 figures, rates have been increasing since the mid-1990s. Lifetime use reported in 1998 is 21 per cent for any illicit drugs, 37 per cent for alcohol, and 36 per cent for cigarettes (Substance Abuse and Mental Health Services Administration 1999).
The levels and trends for youth in the household surveys have paralleled those for high school senior students (Johnston et al. 1999), which show a downward trend in the use of marijuana and other illicit drugs from 1979 to 1993, with rates increasing through 1998. Cocaine use was an exception to this rapid downward trend, having stabilized through 1986 at the levels attained in the late 1970s. Rates decreased from 1986 through 1993 before beginning to climb again through 1998. By 1986 about one in every six high school senior students reported trying cocaine, and one in 20 reported use in the 30 days prior to the survey. By 1998 about one in every 10 high school senior students reported trying cocaine and only one in 40 reported use in the last 30 days. Between 1983 and 1986, the proportion of seniors reporting daily cocaine use in the month before the survey and the proportion who had been unable to stop using in the prior year had both doubled. Between 1986 and 1998, the proportion of seniors reporting daily cocaine use in the month before the survey had fallen to the 1983 level. The proportion who had smoked crack cocaine, a more dangerous and effective route of administration, had also doubled from 1983 to 1986, but rapidly declined from 5.7 per cent (1986 level) to 1.5 per cent by 1991. In 1986 only half of the senior students thought there was much risk associated with occasional cocaine use. The 1988 survey, however, shows a marked decline in cocaine use coupled with a heightened perception of risk. Lifetime use is reported by one in eight, and one in 30 report use in the past 30 days. About seven in ten high school senior students viewed occasional cocaine use as harmful. By 1993, rates of lifetime use of cocaine had decreased to 6 per cent and less than 2 per cent of high school senior students used cocaine in the 30 days prior to the survey (Johnston et al. 1994). The 1993 data also reported an increased number of drugs used and less negative attitudes toward drugs.
Although use among young adults has also declined during the 1980s, many continue to use various types of drugs. The National Household Survey on Drug Abuse conducted in 1979 showed that 44.2 per cent of persons aged 18 to 25 years had used marijuana in the year before the survey (Table 1). There was a general downward trend until the mid-1990s (21.8 per cent in 1995) with an increase to 24.1 per cent in 1998. Cocaine use decreased from a high of 17 per cent in 1979 to 4.3 per cent in 1995, before rising slightly to 4.7 per cent in 1998. Self-reports of any illicit drug in the year before the survey fell from a high of 45.5 per cent in 1979 to around 25 per cent through 1998. Lifetime cocaine use prevalence among those aged 19 to 28 was 32 per cent in 1986, but had dropped steadily to 12.3 per cent by 1998 (Johnston et al. 1999).
In contrast with the rapid increases and decreases in drug use, alcohol use has remained relatively constant. Levels of alcohol consumption by youth and adults (Substance Abuse and Mental Health Services Administration 1999) or high school senior students (Johnston et al. 1989, 1994, 1999) has remained consistent from 1974 to 1998. The comparative volume of consumption or level of abstention for adults did not differ between 1964 and 1984 (Hilton and Clark 1987). About three in ten adults over 23 years old report current abstention, and about one in 20 drink 45 or more drinks a month and drink five or more drinks at a time on at least some occasions. Among high school senior students, a little over half drank in the past month, and three in ten report drinking five or more drinks in a row. Some small decreases in alcohol consumption were reported which paralleled the declines in other drug use. In the household surveys, a little over one-third of youth 12 to 17 years old report ever using alcohol. Among young adults 18 to 25 years old, eight in ten reported alcohol use at some time in their lives.
Levels of drug use for adults (aged 26 to 34 years old) have not fluctuated as dramatically as those for youth and young adults. About nine in ten of older adults report some experience with alcohol. Lifetime rates of marijuana use (45 per cent in 1979, 54.9 per cent in 1993, and 47.9 per cent in 1998) and cocaine use (13.4 per cent in 1979, 25.4 per cent in 1993, and 17.1 per cent in 1998) have shown the same trends as youth and young adults. Use of all drugs in the past year has remained relatively low (around 10 per cent for marijuana and under 5 per cent for cocaine) throughout the 1970s and 1980s and the 1990s (Table 1).
Dependence on alcohol and other drugs has been assessed in few national studies. Surveys of alcohol use in 1967 and 1984 (Hilton and Clark 1987) generally found little change in indicators of alcohol dependence or consequences. About two in ten men and one in ten women reported at least one dependence indicator in the 12 months prior to the survey, and about one in ten men and women reported at least one consequence. In 1984, somewhat higher prevalence of two kinds of dependence (skipped meals and loss of memory) was reported. The only indicators of consequences that increased between 1967 and 1984 were related to employment. A national probability sample survey in 1988 showed similar rates of dependence although some differences were found when the DSM-III-R criteria were used (Grant et al. 1991). An estimated 15.3 million American citizens over 18 years old met a dependence criterion in the past year.
More detailed and reliable data on dependence are available from a consortium of community epidemiological studies conducted from 1980 to 1982. In three American cities, lifetime rates between 11.5 and 15.7 per cent for alcohol abuse/dependence disorders and between 5.5 and 5.8 per cent for drug abuse/dependence were found for the adult residents interviewed in households (Robins et al. 1984). Current 6-month prevalence rates for men ranged between 8.2 and 10.4 per cent for alcohol dependence, and 2.5 and 3.0 per cent for drug dependence (Myers et al. 1984). Rates for females were between 4.5 and 5.7 per cent for alcohol abuse/dependence, and 1.8 and 2.2 per cent for drug abuse/dependence. Both of these data sets indicate that a substantial proportion of individuals in the United States have self-recognized problems with alcohol and drugs, and many meet the DSM-III-R criteria for dependence.
Intravenous drug users
Estimating the number of intravenous drug users is an imprecise art. The problem of estimation is further hampered by differing definitions of past and current behaviour that qualifies an individual as an intravenous drug user. Spencer (1989) reviewed the variety of indirect estimates (derived from statistical models of indicators such as emergency room and medical examiner reports), direct estimates (based on surveys of convenience samples, back extrapolation, and capture–recapture estimates), and informed guesses. Considering all sources, Turner et al. (1989) conclude that a reasonable guess of the number of intravenous drug users in the United States is between 500 000 and 2 million.
Alcohol abuse costs were almost $90 billion in 1980 (Harwood et al. 1984). Drug abuse added another $47 billion. The major contributors to these costs are lost productivity and treatment costs. Lost productivity attributed to alcohol abuse was estimated to be $51 billion and that attributed to drug abuse was estimated to be $26 billion. Treatment services related to alcohol abuse cost almost $10 billion and drug abuse just over $1 billion. This represents direct health services provided to victims, including long- and short-term hospitalization, services from physicians, and other sources. The overall costs also include the economic costs of fetal alcohol syndrome, crime, and violent crime due to drug abuse, premature mortality resulting from drug overdoses, liver disease, suicide, homicide, motor vehicle crashes, and other causes. These costs were estimated to be $15 billion, of which $6 billion dollars was attributable to motor vehicle deaths. Cirrhosis of the liver represented $3.4 billion and homicide $2.4 billion. Drug abuse costs $2 billion for accidental overdoses. Alcohol abuse is also accountable for $2.3 billion in criminal justice-system costs, $1.8 billion in incarceration losses, and $172 million in property losses. Drug addiction cost society approximately $9 billion because of the addicts’ pursuit of non-productive and criminal careers, another $6 billion for criminal justice expenses, and $1.5 billion for incarceration. These costs alone place alcohol and drug abuse as one of the main contributors to the social cost of health-related problems in the United States.
With the emergence of the AIDS epidemic in the 1980s, every drug abuser who contracts AIDS adds another $80 000 in medical care costs to the equation (Scitovsky and Rice 1987). As described below, intravenous drug users play an important role in the AIDS epidemic as they are second only to male homosexuals in the ranking of high-risk groups for AIDS in the United States (Turner et al. 1989). Intravenous drug use is also a major factor in cases involving children, heterosexuals, black people, and Hispanics (Day et al. 1988; Des Jarlais and Friedman 1988). Regardless of sexual orientation, past or present intravenous drug users represent over one-quarter of reported AIDS cases in the United States and the proportion continues to increase. Tests for HIV have shown that 10 to 58 per cent of sampled intravenous drug users are seropositive (Robert-Guroff et al. 1986; Chaisson et al. 1987; Des Jarlais et al. 1989). This increased risk of infection suggests that future estimates of the social costs of drug abuse will escalate dramatically over the next decade due to the AIDS epidemic.
The goal of efforts to deal with alcohol and drug abuse involves identifying those at risk and intervening to prevent or treat the problem. Information on risk factors to help target prevention, treatment, and rehabilitation efforts is largely limited to youth and young adults. Research is moving closer to uncovering basic biological and psychosocial mechanisms in alcohol and other drug use, but it does not appear likely that any simple explanation will be found. Being the child of a substance abuser has been found to be a consistent predictor of abuse. Both genetic and family environmental factors have been cited as influential agents (Kandel et al. 1978; Schuckit 1980; Cloninger et al. 1981; Goodwin 1985; Petrakis 1985).
Delinquent behaviour, including alcohol and drug abuse, often occur together (Jessor et al. 1980; Robins 1980). Many of the studies conclude that involvement in delinquent behaviour precedes drug use (Bachman et al. 1978; Elliott et al. 1985; Kandel et al. 1986) and that both behaviours have the same aetiological sources (Elliott et al. 1985; Hawkins et al. 1985). Early delinquent behaviour, usually before the age of 10, has also been linked to earlier initiation (Kandel et al. 1986) and frequent drug use (Johnston et al. 1978; Kandel et al. 1978; Kellam and Brown 1982; Rachal et al. 1982; Robins and Przybeck 1985; Kaplan et al. 1986). Other social factors such as low socio-economic status of parents, social isolation, and poor living conditions have also been found to be related to chronic delinquency and drug use (Farrington 1985; Hawkins et al. 1987). Studies have also identified association of alcohol and drug abuse with depression, low self-esteem, and psychological distress (Kandel et al. 1978; Kaplan et al. 1982; Aneshensel and Huba 1983).
One of the areas that has received relatively little attention in aetiological research is the examination of factors leading to cessation. Kandel and Raveis (1989) found that health and social factors discouraging use among young adults were predictive of cessation and a more extensive degree of previous involvement in drug use was predictive of continuation. Interpretation of these correlates of the likelihood of stopping use will require more comprehensive understanding of use, abuse, and dependence (Meyer 1989), including the relative roles of pharmacological, social, and physiological factors combined with the level and nature of involvement.
Another area where data are lacking is the dynamics of the initiation into intravenous drug use. Des Jarlais et al. (1986) suggest that initiation is often an unanticipated behaviour. Turner et al. (1989) conclude that some of the same factors contributing to initiation of other types of illicit use (such as peer groups) also predict initiation of intravenous use and continuation of usage. The uncertainty surrounding initiation, particularly in the face of the AIDS epidemic, dictates the need for more extensive and intensive research on initiation, development, maintenance, and cessation of intravenous drug use.
Identifying youth at risk for alcohol/drug initiation and continued use is a potentially efficient and effective means for targeting prevention efforts. In the United States, however, youth in general are at risk for drug initiation (Hubbard et al. 1988). Surveys of high school students have shown that non-medical drug use begins in the early teens, peaks in early adulthood, and declines sharply thereafter (Kandel 1980). Initiation to marijuana is almost completed by the age of 20 and to psychedelic drugs by the age of 21 (Kandel and Logan 1984). More than half of inhalant, phencyclidine, and barbiturate users initiate use before tenth grade (15–16 years old). Prior to the crack epidemic, most cocaine users initiated use in the last 2 years of high school (Johnston et al. 1984).
Drug use prevention programmes should ideally first reach youth prior to adolescence and then reinforce the message throughout adolescence. Research findings suggest that prevention efforts oriented towards delaying the age of onset of initiation may prevent the initiation of other, perhaps more dangerous drugs (Kandel 1982), a greater frequency of use (Rachal et al. 1982), and the involvement in other delinquent acts (Brunswick and Boyle 1979).
Prevention strategies seek to prevent substance abuse by informing, educating, and training individuals so that they have the necessary information, skills, and confidence to choose not to abuse alcohol or other drugs. Environmental approaches seek to restrict the opportunity for exposure to alcohol and other drugs. Prevention programmes and organizations offering prevention services often adopt one or more strategies (Tobler 1986).
Information activities are designed to provide accurate and timely information about alcohol and other drugs and their effects on the individual, family, and community.
Education activities use a structured process to assist individuals in learning and improving basic life skills (decision-making, problem-solving, community, and peer/social resistance skills).
Alternative programmes provide challenging positive growth experiences in which individuals can develop the self-discipline, confidence, personal awareness, self-reliance, and independence they need to become socially mature individuals by offering positive alternatives to alcohol and other drug-using behaviours.
Intervention services identify individuals with early substance abuse problems, help them assess their problems and take action to resolve them, and provide emotional support and practical guidance during the early stages of recovery.
Environmental controls include efforts to make alcohol and other drugs less accessible by raising drinking ages, increasing enforcement, or otherwise reducing access to alcohol and other drugs.
Most drug education programmes are based on a knowledge/attitude, a value/decision-making, or a social competency theoretical approach (Moskowitz 1983). The knowledge/attitude approach has been used most widely, although empirical support for the assumed causal links between knowledge of the consequences of drug use, attitudes concerning use, and use behaviour is limited (Hanson 1980; Kinder et al. 1980; Goodstadt 1981). The effectiveness of the value/decision-making approach (Huba et al. 1980; Goodstadt 1981), which assumes that logical weighing of the costs and benefits of drug use takes place, is also not well supported. Studies measuring the effects of the teaching of social skills on drug use prevention among adolescents show promising results. Pentz (1983) concluded that teaching skills such as assertiveness, initiating/maintaining conversation, non-verbal expression, expressing feelings/empathy, decision-making, expressing an opinion or request, self-control, praise, and responding to criticism, reduce drug use and related behaviours among adolescents. Similarly Botvin (1983), after instituting a prevention programme teaching life skills to adolescents, found a 50 per cent reduction in new cigarette smoking 1 year after the programme.
Prevention efforts have been implemented and developed primarily in three social realms: the school, the family, and the community. Educational programmes presented in schools are the most frequently employed approach to drug abuse prevention. However, evaluative studies (Schaps et al. 1984) and reviews (Goodstadt 1980; Schaps et al. 1981) provide little support for the effectiveness of school-based programmes. Goodstadt (1980), in a review of several drug education programmes, observed that most had mixed results, i.e. they produced negative results on some attitudinal and behavioural dimensions and positive results on others. He concluded that, although education programmes do not appear to be as harmful or counterproductive as some detractors claim, their results are not as strongly positive as one would like. While these educational programmes have reported some positive results, both the programmes and the evaluations of them have been criticized because of an inadequate theoretical base. They assume, albeit implicitly, that attitudes are strongly related to behaviours and that a single exposure will have enduring effects throughout the adolescent years. Attitudes are usually not good predictors of behaviour (Fishbein and Ajzen 1975), and most programmes do not consider the complex development stages of adolescence (Greenspan 1985).
Many theories have addressed the importance of involving parents in any type of intervention. Bry (1983) notes the significance of modelling and the necessity for communication skills to teach young people how to say ‘no’ in dealing with the pressures of substance abuse behaviours and other negative behaviours. McAlister (1983) points specifically to the significance of prevention programmes which address low self-esteem, poor skills for coping with stress, and alienation from school and family. He addresses the significance of self-image being more related to family relationships than to school relationships. These theories give credence to involving parents with their children in a family approach to prevention.
Descriptions of community action programmes in alcohol (Hewitt and Blane 1984) and drug abuse (Flay and Sobel 1983) have generally focused on media campaigns. However, Project STAR (Students Taught Awareness and Resistance), a community-based drug and alcohol abuse prevention programme in Kansas City, Missouri, is a comprehensive approach which works through a liaison between the programme implementers and researchers (Pentz et al. 1986). Programme components are implemented and progress is observed and tested for any effect on drug use. The component is then refined according to the evaluation results before the initiation of the next programme component. Data from the delayed implementation of this multicommunity trial (Pentz et al. 1989) indicates the potential effectiveness of comprehensive intervention. The interventions included a combination of mass media, school-based programmes, parental involvement, and community support. Prevalence of alcohol, tobacco, and marijuana was lower in the sites where the intervention had been implemented compared with control sites where the intervention had been delayed, 17 versus 24 per cent for cigarettes, 11 versus 16 per cent for alcohol, and 7 versus 10 per cent for marijuana. The rate of increase in usage was also lower in the sites where the intervention had been implemented.
Treatment in one form or another for both alcohol and drug abuse has been available since the turn of the century. However, it was only in the late 1960s and early 1970s that both alcohol and drug abuse treatment became major parts of the public health system in the United States. The administration of the public treatment system in America shifted from the federal government to states under the Omnibus Reconciliation Act of 1981. Treatment systems rapidly evolved to meet the demands of cost containment in the 1990s. In the next millennium, the evolution of treatment programmes and the system that supports them is likely to continue.
The alcohol treatment system emerged from an effort in the late 1960s to establish community-based alcohol treatment centres throughout many parts of the United States. Combined with this public approach was the availability of proprietary inpatient programmes based on the Minnesota Model treatment protocol (Laundergan 1982; Cook 1988). These short-term inpatient regimens help guide alcohol abusers through the first phases of the 12 steps of the Alcoholics Anonymous recovery programme.
The rapid escalation of heroin addiction in communities in the late 1960s, coupled with the high rates of addiction among returning Vietnam veterans, led to the establishment of a national system of drug abuse treatment programmes to deal with the increasing rates of addiction and associated crime (Jaffe 1979). Since these early years there have been far-reaching changes in the drug abuse treatment system. The three major modalities or types of treatment developed and currently being administered under public funding in the United States are the outpatient methadone clinics, therapeutic communities, and outpatient drug-free programmes. Outpatient methadone programmes treat opioid abusers, most of whom use heroin intravenously. After stabilization with medically prescribed doses of methadone, clients receive a variety of counselling and other services to help them resume productive lives. Therapeutic communities use group counselling with all types of drug abusers over long stays in a 24-hour community environment. Outpatient drug-free programmes tend to be oriented towards non-opioid users and emphasize counselling, often in community mental health centre settings. Among the three modalities, there are great variations in programme size, structure, therapeutic approach, services, and funding. Treatment for drug abuse, particularly cocaine, began to be provided in chemical dependency programmes originally designed for alcoholism in the late 1980s.
The treatment system in the United States now includes a broad array of public and private programme types. The proportion of privately funded alcohol and drug abuse treatment programmes increased during the 1980s. By the 1990s drug abuse treatment was delivered in a wider variety of settings, including chemical dependency programmes (formerly exclusive alcohol treatment programmes), community mental health centres, and treatment programmes designed primarily for alcohol. The distinction between publicly funded and private treatment has become blurred. The treatment of many clients in the traditional public treatment modalities has seldom been supported by public funds.
The effectiveness of both alcohol and drug abuse treatment has been continually questioned. One of the major reasons for this is the difficulty of conducting broad-based epidemiological outcome studies or controlled clinical trials of sufficient scope to answer some of the major questions about treatment. In America, only one national study of alcohol treatment and two of drug abuse treatment have been successfully mounted in the past 30 years. Clinical trials based on unblinded random assignment have often failed because of limited compliance (Fuller et al. 1986) and retention (Bale et al. 1980) for sufficiently long periods to demonstrate the efficacy of any particular treatment approach.
Epidemiological outcome studies do indicate positive effects. The major clinical epidemiological study of alcohol treatment was conducted in the early 1970s with a sample of 593 clients followed 18 and 48 months after treatment (Armor et al. 1978; Polich et al. 1981). After 4 years, 21 per cent were abstinent for at least 1 year before the follow-up. A positive correlation was reported between those clients receiving five or more outpatient visits and those with more than 7 days’ worth of inpatient visits. Using a cost-offset framework in an analysis of health insurance data, Holder and Blose (1986) attributed substantial savings to alcohol treatment in health care costs. Other follow-up studies of proprietary programmes reviewed by the Institute of Medicine (1989) find abstinence rates of between 40 and 60 per cent in the first year after treatment. Similar results were found in studies of state programmes (Hubbard et al. 1988) and proprietary programmes (Hoffman and Harrison 1987). Because of the often low rates of response to follow-up, the method of obtaining reports, and imprecise measurement of treatment process, including continuing care and other methodological considerations, these rates of abstinence probably exaggerate the positive effects of treatment.
In contrast with these findings and those for drug abuse treatment reported below, the Institute of Medicine panel found little evidence supporting longer-term treatment for alcohol abuse (Saxe et al. 1983; Annis 1986; Miller and Hester 1986), and a series of random assignment studies have found neither length of treatment nor intensity (inpatient versus outpatient) influenced outcome. In such unblinded research, however, the levels of severity of client problems are likely to interact with selection bias from compliance and attrition to confound the interpretation of results. Further, most alcohol treatment protocols tested, typically less than 3 months, may not be of sufficient duration or intensity to produce demonstrable effects. Controlled studies of alcohol treatment may need to focus more on comparison of different continuums of care to examine how inpatient and outpatient programmes can contribute to long-term compliance with aftercare and relapse prevention.
Such an approach has been implemented in a national multisite trial of three outpatient protocols for alcohol abuse based on 12-step, cognitive–behavioural, or motivational enhancement approaches (Project MATCH Research Group 1993). These studies demonstrated that in all three approaches clients did achieve reductions in alcohol.
A series of studies conducted primarily over the past two decades has demonstrated the effectiveness of the publicly funded methadone-maintenance and therapeutic community approaches (Tims 1981; Tims and Ludford 1984). Use of most drugs declines during and after treatment (Sells and Simpson 1976; Smart 1976; Sells 1979; Holland 1982; DeLeon 1984). Criminal activity is reduced among programme clients, particularly during treatment (Gorsuch et al. 1976; Nash 1976; McGlothlin et al. 1977; Dole and Joseph 1978).
In the late 1970s a clinical epidemiological study of drug abuse treatments assessed outcomes for 10 000 methadone, residential, and outpatient drug-free clients up to 5 years after treatment (Hubbard et al. 1989). Substantial decreases in regular heroin, cocaine, and psychotherapeutic drug abuse, and diminished overall severity of drug abuse, were apparent during and after treatment for clients treated over a period of at least 3 months. The prevalence of regular heroin use for methadone clients in the first year after treatment (17 per cent) was one-quarter of the pretreatment rate. For residential clients, the post-treatment prevalence of regular heroin (12 per cent) was one-third of the rate prior to treatment, and non-medical psychotherapeutic drug use (9 per cent) was one-fifth of the rate prior to treatment; regular use of cocaine declined by half to 16 per cent in the post-treatment period. In the case of outpatient drug-free clients, prevalence of non-medical psychotherapeutic drug use was half the pretreatment rate. In any given year of follow-up, less than 20 per cent of former clients in any modalities were regular users of drugs other than marijuana or alcohol. Reductions in criminal activity were maintained up to 5 years after leaving treatment.
All types of treatment achieved statistically and clinically significant reductions for the drug usage they were designed to treat if a client stayed in a programme long enough. In multivariate analysis controlling for a variety of factors, including demographics, drug use patterns, prior treatment, and reason for seeking treatment, the risk of relapse was reduced by three to four times for those clients who stayed in treatment for 6 months or more compared with those who left earlier.
The authors conclude that, although treatment does have a demonstrable effect, substantial improvement is needed. Programs only attract a relatively low proportion of individuals who might benefit from treatment. Retention rates have been low, particularly for the long-term treatment or continuum of care necessary. The increasingly complex problems of multiple drug usage and impairment require more trained and committed staff. Further, recovering addicts and abusers must also have access to an array of relapse prevention rehabilitation, habilitation, and support services in the community.
This research was replicated in the Drug Abuse Treatment Outcome Studies (DATOS) for a sample of 10 000 adults entering treatment between 1991 and 1993.
The DATOS research in community-based treatment has replicated a number of major findings that have been consistently found in other studies. Another set of findings requires further examination as studies have included a broader variety of programmes in complex, changing health care, social service, and criminal justice environments.
A broad array of programmes has been designed to meet the needs of substance abusers including therapeutic community or long-term residential, outpatient drug-free, methadone, and short-term inpatient. However, the range of options appears to be diminishing, including the elimination of short-term inpatient rehabilitation and longer-term stays in therapeutic communities (Etheridge et al. 1997). Clients select and are selected for different modalities of treatment based on the type of drug use, the severity of related problems, and the resources to pay for treatment. Few clients are referred to methadone treatment by the criminal justice system. Increasing proportions of clients in other modalities have been referred by the criminal justice system. The source of referral can result in longer stays (Joe et al. 1999).
The diverse modality and programme approaches to treatment can be described by the nature of core therapy for substance abuse and the comprehensive services for related problems. Over the decades of the 1970s and 1980s, core services have improved, particularly the integration of 12-step components, while comprehensive services have declined and are less likely to meet the needs of clients (Etheridge et al. 1997).
Treatment has been effective for the type of drug use for which it has been targeted: opioids in the 1960s and 1970s, multiple drug use in the 1980s, and cocaine in the 1990s. Stays of 90 days significantly reduce the probabilities of relapse to drug use within the first year following treatment. Involvement in self-help at least twice a week is related to further decreases in the probability of relapse to cocaine for those who stayed in treatment more than 90 days (Etheridge et al. 1999).
The effects of treatment (particularly time in treatment) on related problems are not as consistent and appear to be diminishing with the erosion of comprehensive services. A 1-year stay in a therapeutic community has been consistently related to increases in the probability of post-treatment employment and decreases in the probability of illegal activity. However, the effects of treatment duration on illegal activity for methadone and outpatient drug-free clients in the follow-up year found in the 1970s and 1980s have not been consistently replicated in more recent studies (Hubbard et al. 1997).
Economic analyses of benefits and costs consistently show that treatments in therapeutic communities, methadone and outpatient drug-free treatment generate benefits in crime reduction during and after treatment that more than pay for the costs of treatments (Flynn et al. 1999). Clients in therapeutic communities, who have the highest crime rates, generate the greatest reduction in crime costs after treatment.
HIV/AIDS among injecting drug users
HIV infection among injecting drug users (IDUs) has become a worldwide public health problem of sufficient importance to warrant a special section in a text on public health. Injection of illicit psychoactive drugs has been reported from 129 different countries, and HIV infection among IDUs has been reported in 103 different countries (Ball et al. 1998). The injection of illicit psychoactive drugs does not in itself transmit HIV. Rather, it is the microtransfusions of HIV-infected blood which occur when two or more persons use the same injection equipment that transmit the virus. It is thus possible to reduce HIV transmission among IDUs not only by reducing illicit drug injection itself, but also by reducing the instances in which two or more IDUs use the same injection equipment.
The first HIV epidemic among IDUs almost occurred in New York during the middle 1970s (Des Jarlais et al. 1994). During the 1980s, HIV then spread among IDUs in the rest of the United States and in Western Europe and Australia (Ball et al. 1998). During the late 1980s, HIV spread to IDUs in Asia, most notably in Thailand (Des Jarlais et al. 1992a), and also in Latin America. The spread of HIV among IDUs continued during the 1990s, particularly in Asia, and from the middle 1990s onward in Russia and Eastern Europe (Ball et al. 1998). Given the development of this pandemic of HIV transmission among IDUs, public health officials need to plan on the continued diffusion of HIV among IDUs throughout the world.
In many areas, HIV has spread extremely rapidly among IDUs, with the HIV seroprevalence rate (the percentage of IDUs infected with HIV) increasing from less than 10 per cent to 40 per cent or more within a period of 1 to 2 years (Des Jarlais et al. 1992b). Two factors have been associated with extremely rapid transmission of HIV among IDUs: lack of awareness of HIV/AIDS as a local threat, and mechanisms for rapid efficient mixing within the local IDU population. Without an awareness of AIDS as a local threat, IDUs are likely to use each other’s equipment very frequently. Indeed, prior to an awareness of HIV/AIDS, providing previously used equipment to another IDU is likely to be seen as an act of solidarity among IDUs, or as a service for which one may legitimately charge a small fee.
Not all types of sharing of injection equipment will lead to rapid transmission of HIV within populations of IDUs. Sharing within small friendship networks can certainly transmit HIV, but will not lead to rapid transmission within the population. Rapid transmission requires sharing within settings that permit IDUs to share with large numbers of other IDUs within short time periods. ‘Shooting galleries’ (places where IDUs can rent injection equipment, which is then returned to the gallery owner for rental to other IDUs) and ‘dealer’s works’ (injection equipment kept by a drug seller, which can be lent to successive drug purchasers) are examples of situations that provide rapid efficient mixing within an IDU population. The ‘mixing’ (or ‘sharing’ of injection equipment) is rapid in that many IDUs may use the gallery or the dealer’s injection equipment within short periods of time, and ‘efficient’ in that the ‘sharing’ of the equipment may occur on an almost random basis. The efficient mixing serves to spread HIV across potential social boundaries, such as friendship groups, which otherwise might have served to limit transmission.
Shooting galleries and dealer’s works situations tend to arise where there are legal restrictions on sale and possession of drug injection equipment. These restrictions can both make it difficult to purchase sterile injection equipment, and make it difficult for IDUs to carry their own equipment with them for fear of being arrested (Des Jarlais and Friedman 1992).
At present there is no vaccine to prevent HIV infection and no cure for HIV infection. Thus public health efforts to reduce morbidity and mortality related to HIV among IDUs must focus on modifying the risk behaviour of IDUs. We will review current knowledge of HIV prevention programmes for IDUs. In doing so, it will be useful to provide some historical context on the evolution of these efforts.
Early risk reduction among injecting drug users
The first evidence that IDUs would change their risk behaviour in response to information about AIDS came from several studies in New York (Des Jarlais et al. 1985; Friedman et al. 1987; (Selwyn et al. 1987). This risk reduction occurred due to the implementation of formal HIV prevention programmes for IDUs in the city. In all of these studies, the majority of drug users reported that they knew about AIDS, that they knew that it was transmitted through the ‘sharing’ of needles and syringes, and that they had already made at least some changes in their injection behaviour (e.g. reduced sharing of injection equipment).
IDUs in New York had learned about AIDS through the mass media and through their own oral communication networks. Because of the relatively large number of cases of AIDS among IDUs in New York even in the early 1980s, there had been a considerable amount of mass media coverage. The relatively large number of cases of AIDS among IDUs in New York also meant that a substantial number of IDUs either knew someone firsthand who had developed AIDS, or knew someone who knew someone who had developed AIDS. An additional potentially important factor in this early behaviour change/risk reduction was the expansion of the illicit market in sterile injection equipment (Des Jarlais and Hopkins 1985).
While the early studies indicated that IDUs would learn about AIDS from the mass media and through oral communication networks, it became clear by the mid-1980s that there would be many additional advantages to having health workers provide face-to-face AIDS education for IDUs. Face-to-face education would permit more detailed information to be transmitted, using culturally appropriate terminology (that might not have been possible in mass media), answering any questions that the drug users might have, and adopting an emotional tone responsive to the IDUs participating in the immediate communication.
It is possible to provide AIDS education for drug users in drug abuse treatment programmes, and many treatment programmes did develop AIDS education efforts (Des Jarlais et al. 1992c). With the great majority of drug users, however, various types of ‘community outreach’ programmes were developed to provide AIDS education to active drug users. The earliest programmes were in New Jersey (Jackson and Rotkiewicz 1987) and San Francisco (Watters et al. 1994). Outreach programmes have since become the primary method for preventing HIV transmission among IDUs in most countries throughout the world. The outreach programmes have become increasingly sophisticated in terms of the theories utilized to lead to risk reduction, the use of former or current drug users as the health outreach workers, and the provision of the means for behaviour change (condoms to reduce unsafe sexual behaviour, bleach for disinfection of used injection equipment, and sterile needles and syringes for drug injection).
Using psychological theories of health-related behaviour
While the earliest studies did show an effect of providing ‘education’ about AIDS in changing HIV risk behaviour among IDUs, it was also clear that ‘information-only’ prevention programmes were not likely to be very strong in producing long-term behaviour change. Knowledge of possible adverse consequences is rarely sufficient to change behaviour in the health field.
Various theories of health-related behaviour, including the Health Belief model (Becker and Joseph 1988), social learning theory (Bandura 1977), and the theory of reasoned action (Fishbein and Ajzen 1975), have been utilized in programmes. While there are differences among these theories, there are also more important similarities. All include elements of expectancy-value decision-making analyses. Thus these theories tend to emphasize perceived probabilities (of contracting or avoiding AIDS, of being able to successfully perform new behaviours) and subjective valuations of different outcomes (the seriousness of developing AIDS, social costs of performing new behaviours if one’s injecting or sexual partners were resistant). With some variation in explicitness, these theories also consider social factors (role models, perceived social norms) and various ‘barriers’ to changing HIV risk behaviours.
Utilizing these psychological theories of health behaviour required more than the one-way communication possible in mass-media approaches, and more than the usually brief conversations that occur between outreach programme workers and IDUs encountered in the streets. The National AIDS Demonstration Research/AIDS Targeted Outreach Model (NADR/ATOM) programme was begun in the United States in 1987, and eventually included 41 projects in nearly 50 different cities (Brown and Beschner 1993). In all of the cities, the NADR/ATOM project involved street outreach to IDUs not in treatment programmes. The eligibility criteria for subjects to be enrolled in the research component of the NADR/ATOM projects required that the person must have injected illicit drugs in the previous 6 months, and must not have been in drug abuse treatment in the preceding 1 month. Approximately 40 per cent of the more than 30 000 subjects enrolled in the NADR/ATOM projects reported that they had never been in drug abuse treatment.
Many of the NADR/ATOM projects used experimental designs to test psychological theories of health behaviour change. All subjects were provided with a ‘standard’ intervention to reduce HIV risk behaviour, which included information about HIV and AIDS, a baseline risk assessment, and the option of HIV counselling and testing. Some of these subjects were then randomly assigned to an ‘enhanced’ condition that typically involved several additional hours of counselling/education/skill-training, which incorporated components of the psychological theories of health behaviour. Subjects were followed at 6-month intervals to assess changes in HIV risk behaviours and the incidence of new HIV infections.
The NADR/ATOM projects provided a wealth of data about HIV risk behaviours among IDUs not in drug treatment programmes. With respect to changes in HIV risk behaviours, there were two strong and very consistent findings. First, almost all of the NADR/ATOM projects showed substantial reductions in injection risk behaviour from the baseline assessment to the follow-up interviews. For example, those reporting sharing needles declined from 54 per cent to 23 per cent (Stephens et al. 1993).
The second consistent finding was that almost none of the different projects showed significant differences in risk reduction between the ‘standard’ intervention and the ‘enhanced’ interview. The general lack of differences between the ‘standard’ and the ‘enhanced’ interventions should not be interpreted as meaning that the psychological theories of health behaviour are not relevant to HIV risk reduction among IDUs. Rather, these results suggest two other possible explanations. First, after the provision of basic information about AIDS (as in the standard intervention), 2 to 6 hours of additional education and counselling does little to further ‘strengthen’ anti-AIDS attitudes, perceptions, and intentions.
A second explanation is that risk reduction among IDUs—again, after basic HIV/AIDS education—is primarily a function of social processes rather than the characteristics of individual IDUs.
Social change theories of HIV risk reduction among injecting drug users
There is increasing evidence that social change processes, particularly peer influences, are important in HIV risk reduction among IDUs (Des Jarlais et al. 1994; Neaigus et al. 1994; Latkin et al. 1996). Almost all injection risk behaviours (‘sharing’ of injection equipment) and all sexual risk behaviours occur within social settings. Initiating and maintaining safer injection and safer sexual behaviours may require changes in the social relationships among IDUs and their sexual partners.
In an analysis of factors associated with risk reduction among IDUs in four of the cities (Bangkok, Glasgow, Rio de Janeiro, and New York) participating in the World Health Organization’s Multi-Centre Study of AIDS and Drug Injection, ‘talking with drug using friends’ was significantly associated with risk reduction in all four cities (Des Jarlais et al. 1993a). Despite the substantial variation in the drugs injected in these cities (heroin in Bangkok, heroin and buprenorphine in Glasgow, cocaine in Rio de Janeiro, and heroin and cocaine in New York) and the obvious cultural differences among IDUs in these cities, peer influence appeared to be an important component of risk reduction in all four cities.
Several of the NADR/ATOM models explicitly focused on peer influence and social change processes. The Chicago Project (Wiebel et al. 1996) had its origins in the long tradition of ethnography, community research, and outreach to drug users by researchers at the University of Chicago. In this particular project, ex-addicts, under the supervision of trained ethnographers, conducted outreach to IDUs not in treatment. Specific efforts were made to enrol influential persons (indigenous leaders) within drug-use networks into the project, and have them act to influence other IDUs to practice safer injection. This project thus utilized the naturally occurring social structure among IDUs to change HIV risk behaviours. A cohort research design was used, with subjects followed for 5 years. The subjects reported dramatic reductions in injection risk behaviour. At the start of the project, 95 per cent of subjects reported engaging in injection risk behaviour, and this declined to only 15 per cent of the subjects reporting injection risk behaviour in the fifth year of the study. (HIV incidence among subjects in this study is discussed below.)
One of the New York NADR projects involved ‘self-organization’ among IDUs (Friedman et al. 1992, 1993). The Dutch ‘Junkie Bonds’—one of which had initiated the first syringe exchange programme in Holland—served as a model for how IDUs can act together to further their own health interests. In the New York project, outreach workers recruited IDUs and assisted them in developing self-help groups to address HIV transmission and other issues of importance to them. In particular, the subgroup of commercial sex workers among IDUs had a number of common interests. Regular group meetings were held to discuss how the participants could change peer norms about injection and sexual risk behaviours. Attending the meetings was strongly associated with both the subjects’ own risk reduction and efforts to change the behaviour of other IDUs (Friedman et al. 1993).
Broadhead and colleagues (Broadhead et al. 1998) have developed a ‘peer driven’ outreach programme for IDUs. Individual IDUs are recruited into the study and provided with AIDS education. These initial subjects are then asked to recruit other IDUs into the study, and paid modest stipends for their recruiting efforts. The initial subjects are asked not only to recruit new subjects, but also to provide AIDS education to the new subjects. An AIDS information test is given to each of the peer-recruited subjects, and if the newly recruited subject passes the test, the original subject who did the recruiting and educating receives an increased stipend.
Latkin and colleagues have developed an AIDS risk reduction programme that utilizes naturally occurring peer networks of IDUs (Latkin et al. 1996). Existing peer networks are brought in for multiple sessions that not only provide information about HIV and AIDS, but also attempt to develop new social norms within the peer groups. These new norms emphasize practising safer injection and safer sex. These efforts have led to substantial reductions in risk behaviours.
Social change theories do not necessarily replace ‘AIDS education’ and psychological theories of health-related behaviour. Knowledge of HIV infection and AIDS and how to practise safer sex and safer injection are still important, as are perceptions of risk and a sense of efficacy in practising safer behaviours. Given the continuing developments in HIV/AIDS research (such as new therapies), AIDS education must also be done on a continuing basis.
Social change theories offer important additional power for reducing HIV risk behaviours, however. Influencing others to adopt new behaviours can also serve to strengthen the intentions of prevention programme participants to change their own risk behaviours. If social norms about injection and sexual behaviour can be changed, then it will be possible to change the behaviour of IDUs who do not directly participate in the prevention programme. Finally, the peer approval that comes with following the new norms can itself serve to reinforce safer injection and safer sex practices among IDUs.
Individual knowledge and motivation to reduce HIV risk and social support for reducing HIV risk may be critical to successful HIV prevention among IDUs. Having the means to reduce risk is also critical.
Providing the means for behaviour change
Reducing HIV risk behaviour often requires providing or facilitating access to means for behaviour change. Reducing sexual risk behaviours often requires access to condoms, reducing drug injection often requires access to drug abuse treatment, and reducing injection risk behaviour often requires access to sterile injection equipment, or to means for disinfecting HIV-contaminated injection equipment. In many developed countries, increasing legal access to sterile injection equipment was an important aspect of initial efforts to reduce HIV transmission among IDUs. For example, in 1985, the city of Amsterdam rapidly expanded existing syringe exchange services (previously implemented to reduce hepatitis B transmission) (Buning et al. 1988). In 1987 the United Kingdom implemented a nation-wide system of syringe exchange programmes (Stimson et al. 1988). In 1987, France repealed its laws requiring prescriptions for the sale of sterile injection equipment and set up a programme for encouraging pharmacists to sell injection equipment to IDUs (Espinoza et al. 1988; Ingold and Ingold 1989). Australia repealed its prescription requirement laws in 1984 and then established a system of syringe exchange programmes.
In many European countries, such as Italy, Germany, and Spain, there were no legal restrictions on the sale and possession of injection equipment prior to awareness of HIV infection among IDUs, and education programmes were implemented to educate and encourage IDUs to inject with sterile equipment. Many of these countries have since established syringe exchange programmes as a means for providing face-to-face outreach efforts to IDUs and to provide for safe disposal of the exchanged (potentially HIV-contaminated) injection equipment (Lurie et al. 1993). Providing legal access to sterile injection equipment, through expanded pharmacy sales, syringe exchange, or both, is now a standard aspect of HIV prevention in almost all industrialized countries.
In the United States, there was also some early consideration of providing legal access to sterile injection equipment as a method for reducing HIV transmission among IDUs (Des Jarlais and Hopkins 1985). Early exchanges were implemented by activists in the northeast and by community-based organizations in the northwest (see Lurie et al. (1993 and Normand et al. (1995) for histories of early syringe exchange efforts in the United States). There were many impediments to providing legal access to sterile injection equipment for IDUs in the United States (Des Jarlais and Friedman 1992; Lurie et al. 1993; Normand et al. 1995; Gostin 1998). The states with large numbers of IDUs (e.g. New York, California, and Illinois) had laws requiring prescriptions for the sale of injection equipment, and almost all states had laws criminalizing the possession of equipment for injecting illicit drugs.
Efforts to increase access by IDUs to sterile injection equipment, either through changing laws and/or by implementing ‘underground’ syringe exchanges in defiance of existing statutes, often generated intense controversy over whether this would increase illicit drug use and/or represent official ‘condoning’ of it (Lurie et al.1993; Normand et al. 1995). In some areas, racial/ethnic group antagonisms compounded the controversies (Anderson 1991). There is, however, no evidence that programmes to provide sterile injection equipment to IDUs has led to an increase in illicit drug use (Normand et al. 1995).
In 1989, federal legislation was enacted that prohibited the use of any federal funds to support syringe exchanges or other distribution of sterile injection equipment to persons who inject illicit drugs. This prohibition remains in effect.
Given the legal, political, and funding difficulties in providing legal access to sterile injection equipment, there was an obvious need to find some other means to assist IDUs in practising safer injection. Based on ethnographic interviews with IDUs, the Mid-City Consortium in San Francisco (Newmeyer et al. 1989) identified criteria for possible disinfection of HIV-contaminated drug injection: the disinfectant should be strong and readily available, the disinfection procedure should be very quick, should not harm the injection equipment, and should not harm the injector if small amounts of disinfectant were injected. Of the various possible disinfectants, household bleach appeared to be the closest to meeting these criteria. Outreach workers began distributing small bottles of bleach with instructions on how to use the bleach as a disinfectant (two rinses of the needle and syringe with bleach, followed by two rinses with clean water). The use of bleach was readily accepted by IDUs in San Francisco.
After the initial success in encouraging IDUs in San Francisco to use bleach as a disinfectant, many other outreach programmes adopted bleach distribution. The great majority of the NADR/ATOM programmes included bleach distribution.
Bleach distribution has also been adopted in developing countries such as India (Hanzo et al. 1997) where there is strong political opposition to having health workers provide IDUs with sterile injecting equipment.
While there is no doubt that bleach is a strong viricide, and that bleach has been readily accepted by IDUs as a method of disinfecting injection equipment, there is mixed evidence as to whether bleach distribution is effective as a method of reducing HIV transmission. There have been three studies of the effects of practising bleach disinfection that used HIV incidence as an outcome measure. In Baltimore (Vlahov et al. 1994) and New York (Titus et al. 1994), the self-reported use of bleach to disinfect injection equipment did not provide any protection against incident HIV infection, while a protective effect was found in Miami (McCoy et al. 1994). The reasons why bleach has not been more effective have not been fully determined. It is possible that the small spaces within a needle and syringe protect HIV from exposure to the bleach (perhaps through the formation of clots) or that there is not sufficient contact time between bleach and virus when bleach is used in field settings. At present, bleach is distributed in many projects throughout the world, but the use of bleach is considered only as a fallback method of HIV prevention. Using new needles and syringes is strongly preferred.
There have been a series of summary evaluations of syringe exchange programmes, including ones conducted by the United States National Commission on AIDS (1991), the United States General Accounting Office (1993), the University of California (Lurie et al. 1993), and the National Academy of Science (Normand et al. 1995). All of these evaluations have concluded that syringe exchange programmes do lead to reductions in injection risk behaviour and do not lead to increases in illicit drug use. There are now a moderately large number of studies that have used HIV incidence as an outcome measure for assessing syringe exchange programmes. Almost all studies, including studies from Tacoma, Washington (Hagan et al. 1995), Lund, Sweden (Ljungberg et al. 1991), Glasgow, Scotland (Frischer et al. 1993), the United Kingdom (Stimson et al. 1991; Stimson 1995), Portland, Oregon (Oliver et al. 1994), and New York (Des Jarlais et al. 1996), have shown low HIV incidence rates associated with syringe exchanges. In all these studies except for New Haven, the estimated HIV incidence among syringe exchange participants was less than 2/100 person-years at risk. The New York study may show the strongest protective effect of participating in a syringe exchange against new infections with HIV. The relative risk of becoming infected with HIV among consistent users of the syringe exchange programmes was 0.30 compared with IDUs who did not use the exchange.
The low incidence rates in areas with syringe exchange programmes may occur through both direct and indirect effects of syringe exchanges. Participants in the exchanges receive both supplies of sterile injection equipment and counselling and information about HIV. Since syringe exchanges tend to attract IDUs who would otherwise be at very high risk for HIV infection, reducing risk behaviour among the IDUs who come to syringe exchanges can have a partial ‘herd immunity’ effect that protects the local IDU population as a whole. Sterile injection equipment, information about HIV, and new social norms against sharing injection equipment may also diffuse outward from IDUs who directly participate in syringe exchange programmes to other IDUs in the community. Thus large-scale syringe exchange programmes should probably be considered as community-level interventions, whose protective effect extends beyond the IDUs who participate directly in the programmes.
The great majority of the studies of syringe exchange programmes have shown low HIV incidence associated with the programmes. There are also several studies of syringe exchange programmes that clearly did not provide sufficient protection against HIV infection for either their participants or for other IDUs in the community. In both Montreal (Bruneau et al. 1994) and Vancouver (Strathdee et al. 1997), HIV incidence exceeded 10/100 person-years at risk among syringe exchange participants. The reasons for these high incidence rates have not been determined, but likely factors include that the exchanges attracted very high-risk drug injectors and that the supplies of sterile injection equipment were not sufficient to protect against HIV transmission within contexts of very frequent cocaine injection.
NIH Consensus Development Conference
The National Institutes of Health held a Consensus Development Conference on methods to reduce HIV transmission (United States National Institutes of Health 1997). The conference included both sex- and drug injecting-related HIV transmission. With respect to methods of preventing injection-related transmission, the conference found three methods to be effective: community outreach, access to sterile injection equipment, including syringe exchange and pharmacy sales, and drug abuse treatment. This Consensus Development Conference can be viewed as an excellent summary of the first decade of research preventing HIV infection.
Second-generation research questions
The initial research questions in HIV prevention for IDUs have been answered: it is clear that drug users will change their risk behaviour to reduce their chances of developing AIDS, and it is clear that specific HIV prevention programmes can be effective in reducing HIV transmission. The data to date also show that programmes to increase ‘safer injection’ among drug users do not lead to any increases in illicit drug use (Normand et al. 1995).
A ‘second generation’ of research issues has now come to the fore (Des Jarlais 1997). First, how do we explain the wide variation in the apparent effectiveness of different HIV prevention programmes? As noted in the discussion of syringe exchange programmes, participants in the great majority of programmes have had low HIV incidence rates. There are also several notable exceptions, such as the Montreal and Vancouver programmes. There is also meaningful variation in HIV incidence rates among participants in different community outreach programmes (Friedman et al. 1995). At present, the most likely explanations are in terms of background HIV seroprevalence and a dose–response effect. From standard infectious disease control theory, as the number of potential disease transmitters increases within a local population, the incidence of new cases will increase. (With ‘all other things being equal’, and with many ‘other things’). The implication of this principle is that more prevention efforts will be needed for higher HIV seroprevalence populations. Dose–response relationships for HIV prevention work can be expected in at least two areas. The more health care workers that encourage social reinforcement for risk reduction, the more likely that risk reduction will be maintained over time. The greater the numbers of sterile needles and syringes that are distributed within an IDU population, the less the need for sharing of needles and syringes within that population.
How should HIV prevention services be integrated with other health and social services for drug users? HIV prevention services were a major innovation in the drug abuse field in that many of the services were delivered in the community. Outreach and syringe exchange programmes have often uncovered large unmet needs among drug users, including needs for drug abuse treatment and primary medical care. Many of the outreach and syringe exchange programmes have set up mechanisms for referring drug users to other health and social services. Some programmes, particularly syringe exchange programmes operating from indoor sites, provide a rather wide variety of services, from screening for tuberculosis to women’s support groups. The impression in the field is that providing onsite services greatly increases the likelihood that the drug users will actually receive the needed services. Providing onsite services for many different sites, however, can become quite expensive.
The hepatitis B and hepatitis C viruses are also spread through the sharing of drug injection equipment, and both are considerably easier to transmit than HIV. Whether syringe exchange programmes that are effective in controlling HIV will also be effective in controlling the hepatitis B and hepatitis C viruses remains to be determined. There is some evidence that syringe exchange programmes can reduce hepatitis B and hepatitis C virus transmission (Hagan et al. 1995), but there is also evidence for unacceptably high rates of hepatitis B and hepatitis C virus transmission among syringe exchange participants (Hagan et al. 1999). Given the variation in the effectiveness of syringe exchange programmes in controlling HIV, it is likely that there is even greater variation in the effectiveness of behavioural prevention programmes for controlling the hepatitis B and hepatitis C viruses among drug users. There is, of course, a highly effective vaccine for preventing hepatitis B virus infection. Very few countries, however, have been able to mount effective programmes to vaccinate IDUs or persons at high risk of becoming IDUs.
Finally, and perhaps most importantly, there is the question of how to increase implementation of HIV prevention programmes for drug users in many countries throughout the world. In some areas, simple lack of financial resources and local expertise are the determining factors. In other countries, there is ‘denial’ that either HIV/AIDS or illicit drug injection will ever be problems in their societies. Finally, the first policy response to illicit drug injection is often limited to law enforcement, without consideration of public health aspects of illicit drug use. Even in countries such as the United States, where a public health perspective is sometimes applied to psychoactive drug use, law enforcement predominates.
Implementing effective HIV prevention programmes for IDUs on a public health scale will probably require adopting a policy perspective on drug use that emphasizes public health concerns, without permitting full commercial exploitation of the profits to be made in selling psychoactive drugs. (The distribution of nicotine in cigarettes may be taken as the prototype for commercial exploitation of the profits to be made in marketing an addictive drug.) The ‘Harm Reduction’ movement (Berridge 1992; Des Jarlais et al. 1993b; Heather et al. 1993) is presently attempting to develop and elaborate a policy perspective that would emphasize public health concerns for policy decisions on psychoactive drug use.
Alcohol and drug use, abuse, and dependence are complex and require careful conceptual and empirical consideration. Their consequences are profound, including the substantial social costs in terms of lost productivity and the transmission of HIV, the causative agent for AIDS. The persistent and dynamic nature of alcohol and drug abuse in the United States illustrates the difficulties in identifying and implementing successful approaches to reduce abuse, dependence, and related consequences. As indicated by the discussion of the role of drug use in the worldwide AIDS epidemic, these difficulties are not limited by country or culture. Basic cross-cultural research on underlying causes and consequences of abuse and dependence is needed so that prevention and treatment efforts can be better informed. The selection and evaluation of the prevention and treatment approaches for a specific country or culture must consider how the social, economic, and political contexts may influence the utilization and effectiveness of the approach.
In the face of a worldwide AIDS epidemic, fuelled in large part by the sexual and injecting behaviours of drug abusers, increased support for collaborative cross-cultural research and development of effective intervention is needed. Such efforts should accelerate our ability to combat the AIDS epidemic while generating more effective approaches to reduce the persisting problem of alcohol and drug dependence.
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