Time to focus on preventables

In a recent Canadian Public Health Association discussion paper, “A New Approach to Managing Illegal Psychoactive Substances in Canada,” the point was made emphatically that our current approach to managing risk is not working.

Here are some of its highlights:

- A psychoactive substance is a chemical that changes brain function and results in alterations in perception, mood, consciousness or behaviour. Societies mitigate the health, social, and economic consequences of the use and misuse of psychoactive substances such as alcohol, tobacco, cannabis, opioids, amphetamines, cocaine, tranquillizers and sleeping pills in a variety of ways with varying degrees of success. Their effects on population health, however, are often overshadowed by our fascination with the direct effects of substance misuse on individuals [e.g. recent rise in the opioid death rate due to adulteration of the drug supply with fentanyl and its analogues]. Currently, western societies manage illegal psychoactive substances largely through prohibition and criminalization and legal drugs, like tobacco and alcohol, through regulation, restricted availability and price control. The laws and systems initially introduced to control these substances reflected the times and prevalent issues of the day, but no longer reflect current scientific knowledge concerning substance-related harms to individuals, families, or communities.

- There is growing evidence, awareness, and acceptance that prohibition and criminalization are not reducing drug use and associated harms. The war on drugs has been lost. Furthermore, it is clear that drug prohibition engenders an environment that fuels the growth of illegal markets, organized crime, violent injuries, and the deaths of users, dealers, and police. It also has unintended public health consequences such as accelerating the spread of HIV and hepatitis C, and increasing overdose deaths from black market sales of extremely potent and contaminated products. An alternative to prohibition and criminalization does exist in a public health approach that is based on the principles of social justice, attention to human rights and equity, evidence-informed policy and practice, and addressing and improving the underlying determinants of health. Such an approach espouses health promotion and the prevention of death, disease, injury, and disability as its central tenet. It bases its initiatives on evidence of what has worked or shows promise of working. - Worldwide psychoactive substance use is estimated at 2 billion alcohol users, 1.3 billion smokers and 185 million illicit drug users, including 147 million cannabis users. Amongst the many preventable factors responsible for the global burden of disease, tobacco, alcohol and illicit drugs comprised 12.9 per cent of all deaths worldwide in 2010. Looking at the percentage of preventable years of life lost, it has been estimated that they account for 9.1 per cent.

- Tobacco is responsible for 8.7 per cent of all deaths worldwide and 3.7 per cent of total preventable years of life lost [Disability Adjusted Life Years]. Alcohol causes 3.8 per cent of all deaths and 4.5 per cent of preventable years of life lost. You might be surprised to learn that all the illicit psychoactive drugs combined [cannabis, opioids, cocaine, amphetamines, prescription medications misused, others] only result in 0.4 per cent of worldwide deaths and 0.9 per cent of preventable years of life lost. The health burden from psychoactive substance use is higher in the developed world. Deaths from psychoactive drug use are predominantly male, ranging from 80 per cent for tobacco and illicit drug use to 90 per cent for alcohol. As more men quit smoking tobacco, the female death rate from smoking is expected to surpass that of males in the near future. One of the differences amongst these substances is that they tend to affect different age groups. Illicit drug use causes harm earliest in life, alcohol in middle age, while 70 per cent of tobacco deaths occur after the age of 60.

It is time for us to focus our public health attention on the more common preventable causes of disease such as alcohol, tobacco and obesity. As Pogo once so wisely said “We have met the enemy and he is us.”