Policy Implications of Multiple Drug Use

2015

Public policies that deal with the use and abuse of alcohol and drugs are very fragmented, reflecting in many ways the history of various substances as well as the role played by the substances in this society. Alcohol is a good example. Because the impact of alcohol on traffic fatalities is so painfully obvious, public interest in the control of alcohol has increased in the recent past. There have been a number of initiatives at Federal, state, and local levels concerning enforcement of minimum age drinking and dram shop liability laws and a push in some areas for raising the driving age. However, very little public policy attention has been directed toward the other control strategies that might have a larger impact on alcohol consumption and its relationship to traffic accidents and fatalities (i.e., changes in laws that would eliminate tax deductions for advertising, restriction of advertising of various types of alcoholic beverages, or substantial increases in the tax placed on alcoholic beverages and thus on the price). After all, when the economics of alcohol is examined it is easy to see how thoroughly interwoven alcohol is in society. The value of alcohol in the advertising, trucking, and agricultural sectors of society is massive. If public policies concerning one substance such as alcohol are this fragmented, it should not be surprising that no public policies exist concerning multiple drug use, even though alcohol plays an integral role in most patterns of multiple drug use and abuse. Tobacco provides another good example. While few deny the impact of cigarette smoking on the morbidity and mortality statistics in this society, public policies on tobacco have perhaps as much to do with agriculture and family farms as they do with public health. In an open society, one of the negative aspects of dealing with any social problem is that it must compete with other social problems for a priority score on an already full agenda. Suffice it to say that public policies on drug use and abuse, including alcohol and tobacco, will probably never be monolithic or coherent and integrated. Because multiple drug use is so varied and difficult to conceptualize, existing public policies concerned with specific substances or with alcohol and drug abuse in general will have to serve as the mechanisms through which the problem of multiple drug use is attacked.

Policy Implication 1: Recognition of Developmental Aspects of Multiple Drug Use for Prevention Purposes

“Prevention is a powerful and attractive word in the Federal dictionary these days. This is particularly so in the public health arena. The genesis of such an intense interest in prevention can probably be traced back to antiquity. A more proximate stimulus is the 1979 publication entitled Promoting Health, Preventing Disease: Objectives for the Nation. In this influential volume, specific objectives were targeted for cigarette, alcohol, and drug abuse as well as topics such as physical fitness and exercise. The recommended prevention strategies ranged from traditional educational and informational campaigns to regulatory and economic incentives/disincentives.

Given what is known about the developmental nature of use of specific drugs and, as noted earlier in this chapter, of multiple drug use and abuse, the health promotion and disease prevention approach to reducing use of cigarettes, alcohol, and other drugs may be the most efficacious prevention policy. The most effective way to reduce use of illicit drugs other than marijuana is to reduce use of marijuana. The most effective way to reduce use of marijuana is to reduce the percentage of the population that uses cigarettes and alcohol. Drug use or multiple drug use is developmental. Effective early intervention will reduce the need for secondary and tertiary prevention efforts. Significant progress has been made in the past few years concerning the prevention of cigarette, alcohol, and marijuana use. However, policies based on the health promotion and disease prevention model are, develop-mentally speaking, still in infancy. There is room for optimism though as a result of the success of the various community-based heart disease prevention programs.

However, there has been a tendency in the prevention field to cast a “broad net,” to use generic prevention messages for children primarily at risk because of their young age and the fact that they are children. Most of these studies are located within the schools and are adjuncts to the health curriculum. These efforts must clearly be continued. Equally clear is the need to direct more prevention resources toward early detection of risk for multiple drug use and early intensive intervention for this relatively small percentage of the youth population. It could be argued, appropriately, that any attempt at early detection/identification/intervention incurs a high risk of false positives. It could also be argued that the knowledge base concerning the predictors of multiple drug use and the phenomenon itself is very sparse. However, these are facts of life in practically every social problem arena. It would be better to detect/identify/intervene with less than the best possible instruments than to wait until such are available. A failure to act has significant negative consequences that are more severe than known risk of false positives.

Policy Implication 2: Recognition of Multiple Drug Use for Treatment Purposes

The basic human need for identifying and solving social problems is nowhere clearer than in the alcohol and drug abuse fields. Ambiguity is the enemy. Complexity is the enemy. In order for public policies to be accepted, articulated, and implemented, they must be simplified and homogenized so that competing interest groups can’t sabotage the entire process. This is certainly true in the treatment arena. Every data set available suggests that exclusivity is not a prevalent characteristic among substance users and abusers. There are few alcoholics, heroin addicts, heavy marijuana users, speed freaks cocaine users, or users of any other drug class whose use is limited to just one drug. We all know that the persons entering treatment programs across this country are, for the most part, multiple drug users. It simply doesn’t make a great deal of sense to put persons through a 21-day detoxification program for one drug when they have been abusing a number of drugs, using them simultaneously to enhance effects, to counteract effects, or as substitutes for preferred drugs temporarily not available. The tendency in this society to pigeonhole everything into one slot and then to assign numerical values to the slots is counterproductive in the alcohol and drug treatment areas. The symptoms simply don’t fit neatly into one slot. As the prevalence of multiple drug use is increasing, at the same time concerns about containing health care costs and redefining DRGs are pushing the treatment fields toward greater differentiation and more explicit classification. A major public policy issue related to multiple drug use is how to reconcile this push toward greater differentiation and specificty with the reality that treatment clients simply don’t come in those sizes and shapes. This is one issue where scientists and clinicians must effectively translate the complexity of the real world into clear and persuasive language that will preserve the quality of health care for alcohol and drug abusers without diluting the commitment of government to deal with this societal problem.

In conclusion, there is no doubt that multiple drug use is a large, complex, and growing problem in all segments of American society. No sector of society is immune from the deleterious effects of simultaneous use of multiple drugs. If multiple drug use is to be dealt with effectively, more creative and realistic approaches to prevention and treatment must be devised. The costs to society of alcohol and drug abuse are large and getting larger. The best place to start anything is at the beginning. The potential for multiple drug use begins with use of any drug. The best way never to begin “other drugs” is never to begin using the so-called “gateway” drugs. Multiple drug use can be stopped at the beginning.

 

 

Selections from the book: “Recent Developments in Alcoholism. Volume 4: Combined Alcohol and Drug Abuse. Typologies of Alcoholics. The Withdrawal Syndrome. Renal and Electrolyte Consequences.” Edited by Marc Galanter. An Official Publication of the American Medical Society on Alcoholism, the Research Society on Alcoholism, and the National Council on Alcoholism. 1986.