Substance abuse prevention: practical strategies for psychiatrists in the 21st century.

Strategies for health promotion and prevention require both population and individual level interventions. There is general face validity of the concept that an ounce of prevention is better than a cure. However, evidence to date on the effectiveness of these strategies is mixed. Emerging knowledge on the biology and genetics of substance use and substance use disorders may help in the development of innovative approaches to prevention in this century. There are several human experimental studies trying to establish the safety and efficacy of cocaine and nicotine vaccines. What role could these immunization strategies play in the prevention of addictive disorders? (1). Maria Elena Medina-Mora highlights the importance of understanding the interplay of biopsychosocial determinants of addictive disorders and clarifies the scope of prevention efforts beyond pure primary prevention. Patients with co-morbid addiction and mental health problems pose a special challenge to the clinician who wishes to implement effective prevention strategies (2). Using a broader understanding of prevention, clinicians, including psychiatrists, can play a key role in prevention within the context of co-morbid problems. They can routinely screen their patients for sub-clinical problems and provide early interventions, practice safe prescribing of medications to prevent iatrogenic drug dependence, immunize patients at high risk for hepatitis A and B, counsel patients on safe injection practices, tobacco cessation, use of condoms and the avoidance of high risk sexual activity. They can also offer testing for HIV infection, tuberculosis and other sexually transmitted diseases. The lessons learned from alcohol control strategies could be applied to other substances of abuse. Prohibition created more problems than it solved, but an integrated approach that includes a combination of re-evaluating social norms and context to prevent harmful consumption and abuse has led to reduced problems. Overall, the focus on problem drinkers is likely to reduce the burden of disease more than a focus on the severely dependent. In a study involving 42 family practices with a total of 15,686 patients, 105 problem drinkers were identified and randomly assigned to a total of three hours of counselling over a year or advice to stop drinking. Counselling led to 70% reduction in consumption with significant improvements in psychosocial functioning, liver damage and a reduction in health care utilization (3). Psychiatrists should also be strong advocates for the adoption of effective prevention policies. For example, in Canada, laws that deterred drinking and driving were associated with an 18% reduction in drunk driving fatalities (4). Moreover, light or moderate drinkers were more likely to abstain from drinking before driving after the introduction of laws that led to 90 day suspensions of driver licenses for breath alcohol concentrations greater than 80 mg% (5). There is evidence that comprehensive interventions targeted towards special populations such as pregnant drinkers can also have an impact. In Washington State, the presence of comprehensive diagnostic and prevention strategies reduced the incidence of fetal alcohol spectrum disorder (FASD), with enormous implications for children and society at large (6). The success of early interventions and secondary prevention is predicated on the ability and willingness of frontline providers to implement evidence- based interventions to reduce the burden of disease caused by substance use. Moreover, in this millennium, clinicians also need to be aware of the new strategies in substance abuse prevention and advocate for effective prevention policies.

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