Differentiating drugs by harm potential: the rational versus the feasible

What is a public health approach to substance use? A qualitative systematic review and thematic synthesis

BACKGROUND

Psychoactive substance use and the regulations that govern it both have the potential to lead to harm. A 'public health approach' (PHA) is frequently invoked as a means of addressing these harms, but the term is used in inconsistent and contradictory ways. This study systematically reviewed the English-language academic literature to understand how a public health approach to substance use is defined and described.

METHODS

This review employed thematic synthesis, a methodology designed to rigorously synthesize qualitative evidence. Eligible articles were published in peer-reviewed journals, in the English language, with full text available, and focused primarily on substance use. There were no limits on year of publication. Original research, opinion/commentary, and reviews were included. The searches were conducted in October 2021 in CINAHL, Embase, Medline, PAIS Index, PsycINFO, Scopus, Sociological Abstracts, and Web of Science.

RESULTS

272 articles from 25 countries, published between 1950 and 2021, were synthesized. Definitions of a PHA have changed over time and differ by substance. The most commonly cited characteristics of a PHA were: for alcohol, regulation, e.g. of price and availability (54% of articles); for cannabis: regulation (68%); for illicit drugs: that a PHA is distinct from a criminal justice approach (63%); for opioids: substance use disorder treatment (55%); and for tobacco: regulation (62%).

CONCLUSION

There is no consensus on the definition of a public health approach to substance use, but there is substantial agreement when it comes to PHAs to specific substances. There are also similarities in how they are described for legal substances versus illicit ones. This review found areas of disagreement regarding the extent to which PHAs should focus on individual-level factors. Policymakers, academics, and others developing or implementing PHAs to substance use should be explicit about their aims and objectives - as well as the premises and assumptions underlying them.

Harm Reduction for the Prevention of Youth Gambling Problems

Despite the growing popularity of the harm reduction approach in the field of adolescent alcohol and substance abuse, a harm reduction approach to prevention and treatment of youth problem gambling remains largely unexplored. This article poses the question of whether the harm reduction paradigm is a promising approach to the prevention of adolescent problem gambling and other risky behaviors. The authors use a universal, selective, and indicative prevention framework to present current prevention initiatives that have emerged from the harm reduction health paradigm for adolescent substance and alcohol abuse. The risk-protective factor model is used as a conceptual basis for designing youth problem gambling harm reduction prevention programs. This framework illustrates the developmental appropriateness of the harm reduction approach for youth. Implications drawn from this conceptual examination of harm reduction as a prevention approach to adolescent problem gambling provide valuable information for treatment providers as well.

How do researchers categorize drugs, and how do drug users categorize them?

This paper considers drug classifications and terms widely used in US survey research, and compares these to classifications and terms used by drug users. We begin with a critical review of drug classification systems, including those oriented to public policy and health services as well as survey research. We then consider the results of a pile sort exercise we conducted with 76 respondents within a mixed method study of Southeast Asian American adolescent and young adult drug users in urban Northern California, USA. We included the pile sort to clarify how respondents handled specific terms which we understood to be related to Ecstasy and methamphetamines. Results of the pile sort were analyzed using graphic layout algorithms as well as content analysis of pile labels. Similar to the national surveys, our respondents consistently differentiated Ecstasy terms from methamphetamine terms. We found high agreement between some specific local terms (thizz, crystal) and popular drug terms, while other terms thought to be mainstream (crank, speed) were reported as unknown by many respondents. In labeling piles, respondents created taxonomies based on consumption method (in particular, pill) as well as the social contexts of use. We conclude by proposing that divergences between drug terms utilized in survey research and those used by drug users may reflect two opposing tendencies: the tendency of survey researchers to utilize standardized language that constructs persons and experiences as relatively homogeneous, varying only within measurable degrees, and the tendency of drug users to utilize specialized language (argot) that reflects their understandings of their experiences as hybrid and diverse. The findings problematize the validity of drug terms and categories used in survey research.

Drug classification: science, politics, both or neither?

Governments currently classify illicit drugs for various purposes: to guide courts in the sentencing of convicted violators of drug control laws, to prioritize targets of prevention measures and to educate the public about relative risks of the various drugs. It has been proposed that classification should be conducted by scientists and drug experts rather than by politicians, so that it will reflect only accurate factual knowledge of drug effects and risks rather than political biases. Although this is an appealing goal, it is inherently impossible because rank-ordering of the drugs inevitably requires value judgements concerning the different types of harm. Such judgements, even by scientists, depend upon subjective personal criteria and not only upon scientific facts. Moreover, classification that is meant to guide the legal system in controlling dangerous drug use can function only if it is in harmony with the values and sentiments of the public. In some respects, politicians may be better attuned to public attitudes and wishes, and to what policies the public will support, than are scientific experts. The problems inherent in such drug classification are illustrated by the examples of cannabis and of salvinorin A. They raise the question as to whether the classification process really serves any socially beneficial purpose.

Recent advances in the treatment of opiate addiction

Although addiction to heroin and other opiates is a major public health issue in the United States and many other countries, advances in pharmacologic and nonpharmacologic treatment have been made. Some of these advances represent a major shift from traditional treatment philosophies, whereas others are characterized by more subtle, though important, improvements. This review discusses recent advances in opiate-addiction treatment in the context of three main domains: the use of buprenorphine and buprenorphine/naloxone in an office-based paradigm, psychosocial treatment and the addressing of medical and psychiatric comorbidity, and harm reduction strategies.

Assessing drinking outcomes in alcohol treatment efficacy studies: selecting a yardstick of success

BACKGROUND

Although the number of alcohol treatment efficacy trials has mushroomed, there is no consensus on how best to measure outcomes. To advance the goal of establishing cross-trial consistency in measuring outcomes in clinical efficacy studies, the National Institute on Alcohol Abuse and Alcoholism convened a panel of experts and charged them with exploring, debating, and, ultimately, selecting a "sentinel" or "optimal" outcome measure to be used in future alcohol treatment studies. The goal of this article, one in a series of several presented at the National Institute on Alcohol Abuse and Alcoholism conference, is to discuss (1) the rationale underlying selection of an optimal outcome measure, (2) the necessary characteristics of an optimal outcome measure, (3) the utility of selecting an optimal measure, and (4) which drinking assessment methods could be used to collect data to portray the optimal outcome measure.

METHODS

At a minimum, the criteria for an "optimal" measure include that it be psychometrically sound. In addition, it should have considerable currency in the field, thereby increasing its prospects for adoption. The measure should also be consistent with the concepts of greatest interest and relevance to the field (e.g., directly reflect the fundamental goal of alcohol treatment). In light of these highly desired features, percent of days heavy drinking was chosen at the conference as a practical and relevant measure of alcohol treatment outcome.

CONCLUSIONS

Percent of days heavy drinking should be the optimal measure of alcohol treatment outcome. Currently, daily drinking estimation methods are the most useful for gathering data that can reflect the optimal measure. In addition, data gathered by daily drinking estimation methods can be used to study a variety of other outcome variables of interest to clinical researchers.