REITOX Academy Intensive Course

Public Health & Substance Misuse:
An European Perspective

Professor Salman Rawaf MD PhD FRCP FFPHM
Salman.Rawaf@swlondon.nhs.uk

Current European Policies

• Social Control
• Reduce Crime
• Demand Reduction

Why does it matter?

• Dependence itself
• cause/aggravate co-morbidities
  - liver
  - mental health
  - neurological
  - ...
• Linked hazards - HIV; hep B; hep C
  - overdose

Drugs impact on health

• Accident and emergency
  - 50% of users attend in 2 years (NTORS)
  - 25% of all attendances
  - St T's - 20% of all psychiatric presentations due to D & A
  - 16% RTA's

Others ...

• O & G
• Paeds
• Primary care
• Mental health
• GUM
• General medicine
• others
• 3-4/1000 births
• increasing
• 1% of list
• 30% co-morbid
• high
• Hep C, HIV

The extent of the problem

• Waves of fashion;
• but also sea level rising.
• but also note
• 120 K die per annum due to smoking
• 30-40 K alcohol related deaths per year

Lifetime experience of drugs - Europe (EMCDDA) 2000

Lifetime and 12-month use of cannabis - U.K. 1994, 1996 & 1998

Last 12-month prevalence of ecstasy and cocaine use in England and Wales (1999)

Cocaine and crack

• Cocaine availability has decreased to be replaced by crack
• Crack is extracted from cocaine
• High risk sexual behaviour
• Violence

New Notifications for Heroin Addiction U.K. (1980-1996)

Blood-borne diseases: HIV rates among drug injectors in EU countries - EMCDDA (2000)s

Able to benefit? - realistic criteria “Success” Rates for Addictions (Reduction of at least 50% in use after 6 months)

Prevention better than Treatment

Smoking and Alcohol Relationship

Psychological Health and Educational Aspirations

	No regular use (n=1135)	1 Substance (n=522)	2 Substances (n=223)	3 substances (n=131)
Anxiety	3.7	4.0	4.5	5.4
Depression	4.0	4.5	5.4	6.0
Educational aspirations	4.2	4.2	4.1	3.8

Substance = alcohol, tobacco or cannabis
* Statistically significant, p<0.001

Anti-social and Criminal Behaviour

Substance Use and Conduct Problems

Policy Shift

Government Expenditure: Estimated L1.4 billion per annum

Substance Misuse: Population Segmentation

1. Total population 2. Targeted population at risk 3. Users 4. Problem users 5. Dependant users

If you do nothing, do

• Prevention works
• Population approaches are effective
• Enabling everyone
• Each contact is an opportunity
• Treatment works, but costly