Services for the prevention and treatment of dependence on alcohol and other drugs

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PROBLEMS OF DEPENDENCE ON ALCOHOL AND OTHER DRUGS
SERVICES
EDUCATION AND TRAINING PROGRAMMES

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Pages: 47 to 55
Creation Date: 1967/01/01

Services for the prevention and treatment of dependence on alcohol and other drugs

Fourteenth Report [ 1] of the World Health Organization Expert Committee on Mental Health

The Committee met in Geneva from 4 to 10 October 1966 and its report was publisched in June 1967. [ 2] The following are extracts [ 3] from the Committee's report:

PROBLEMS OF DEPENDENCE ON ALCOHOL AND OTHER DRUGS

Over the last 15 years considerable international discussion has been devoted to problems of dependence on alcohol and problems of dependence on other drugs, with a gradually developing trend towards a combined approach.

Similarities and differences in causation and treatment

The Committee agreed that, despite existing differences between dependence on alcohol and dependence on other drugs, there are many significant similarities in the causation and treatment of these conditions. While the extent and nature of the problem, i.e., type of drug dependence and patterns of use and abuse, vary widely from country to country, the relatively frequent transfer from one drug of dependence to another, the not infrequent abuse of drugs in combination, the complex and changing patterns of abuse, and the rapid development of new drugs with potentialities for abuse, make it important that dependence on alcohol and other drugs be considered as facets of one problem, psychic dependence of various kinds being the common factor. [ 4]

To the degree that dependence-producing drugs interfere substantially with the normal functioning of the abuser and/or become a problem for other persons or society, they give rise to health problems that are susceptible of medical identification, classification and treatment. This does not imply that the problems under discussion come exclusively within the field of health. Social, cultural, legal, economic and other factors also play a role in causation, treatment, prevention and control. It is imperative that dependence on alcohol and other drugs be recognized as creating major health problems, which have to be considered not only in terms of the agents involved but also from the point of view of the host and the environment.

A combined approach to problems of alcoholism and drug dependence does not apply equally to all aspects of the problems. Differences in local conditions such as social structure, personal and cultural attitudes, and the incidence and prevalence of dependence on various agents have to be taken into account. In general, a combined approach will apply most usefully to research and will be less applicable to control measures, with treatment and education falling in between. In certain geographical areas, differences in dealing with problems of alcohol dependence as compared with those of dependence on other drugs may be quite significant, for example, in relation to the structuring of treatment services and of control mechanisms. In the past few years, the approach to alcoholism as an illness and to the alcoholic as a sick man has become rather widely accepted. On the other hand, those treating persons dependent on alcohol are often forced to take some interest in problems of dependence on other drugs, since a proportion of their patients abuse other drugs as well. This occurs mainly in spirit-drinking countries, where the prevalent type of alcoholic is the so-called "psychogenic alcoholic", [ 5] but the substantial presence

in mainly wine-drinking countries of "sociogenic alcoholics" [ 6] was noted. It seems that, for psychologically vulnerable persons and groups, alcohol and other drugs can often satisfy individual and collective needs. In such cases, environmental factors (for example, availability, local fashion, the law, religion, the attitude of the whole community) may determine what agent or agents the individual abuses.

Dependence on alcohol and dependence on barbiturates and certain other central nervous system depressants resemble each other so closely that they may be considered under the same heading. [ 7] The manifestations of intoxication and of the abstinence syndrome associated with these agents are quite similar. Indeed, these agents are often used in combination.

The medical and other professions now take an active interest in the problems involved and organizations such as Alcoholics Anonymous (A.A.) have done much to improve the attitude of the public as well as that of the person dependent on alcohol himself. In many countries, similar improvements are needed in the approach to dependence on other types of agents including opium. This is one of the most important likely consequences of a combined approach to dependence on alcohol and on other drugs.

The combined approach may also widen perspectives as to the efficacy of legal control provisions, which heavily influence the relation between health services and dependent persons as well as the social situation of the latter group. As regards control of alcohol, considerable knowledge has been accumulated through the attempts to enforce prohibition laws as well as various other legal provisions designed to influence the level of consumption, the extent of illegal consumption, and the distribution of consumption as to types of beverages. The findings may have some bearing on control of other drugs. On the other hand, experience of controlling some of the other drugs through international agreements may be relevant to the development of control measures for alcohol. There seems to be no way of eliminating completely the non-medical use of all dependence-producing drugs. From the health point of view, it may be of considerable relevance to consider the relation between systems of control and prevailing orientations to drugs within a society.

The development of programmes is therefore the responsibility of national and local authorities. This is a process in which WHO has already provided leadership, but the Committee believes that its efforts in this direction might be increased.

The Committee's report then goes on to discuss some of the characteristics of present-day drug dependence such as transfer between drugs and their use in combination, the complex and changing patterns of abuse among adolescents and the emerging problems of dependence on central nervous system depressants and stimulants and on hallucinogens.

Multi-disciplinary approach

Since the causes, prevention and control of dependence on alcohol and other drugs and the treatment of drugdependent persons involve multiple problems that exceed the scope of any one skilled profession or group, and since knowledge of these problems is so imperfect, it is imperative that a multi-disciplinary approach be made to their solution. The multi-disciplinary approach is fairly widely established within clinical facilities and should be further implemented. The inter-relatedness of the disciplines, as well as the potential contributions of specific disciplines, must also be recognized in research. [ 8]

Role of public health services

The Committee emphasized that, since dependence on alcohol and other drugs creates, or contributes to, major public health problems, it should be of concern to all public health organizations and administrations.

In any given country, the involvement of the public health services in these problems will depend on the prevalence of drug dependence and on the type of agents abused (including varieties of alcoholic beverages). The tasks involved will also be affected by the agedistribution and occupations of the abusers and by their patterns of consumption of alcohol and other drugs. Complicating factors arise in areas producing these agents. Traditional attitudes towards alcohol consumption and drug abuse will have to be taken into account.

In the selection of preventive measures consideration has to be given to economic and legislative control of the production and distribution of the "agents" of dependence and, in some cases, the financial interests involved. Apart from co-operation with judicial, legislative and other authorities in carrying out control measures, a public health service may be in a position to influence the final distribution of dependence-producing medicaments through the checking of prescriptions.

The Committee referred to a possible limitation on the production of drugs. The examination and evaluation by a special board of the need for and efficacy of drugs would permit reduction in the number of drugs made available, thus helping to avoid the difficulty of the physician faced with a multiplicity of new pharmaceuticals. Moreover, such a board could assist in judging when an obsolete drug should be replaced by a newer and more effective preparation. Such procedures are already in use in the USSR and the Scandinavian countries, for example. On an international scale, an important role is performed by WHO, which makes decisions and recommendations as to which drugs should be controlled under the relevant international conventions and how this should be done. This has led to the prescription of the use of certain drugs for therapeutic purposes

Medico-legal aspects

Juridical decisions concerning persons dependent on alcohol and other drugs are gradually influenced by the progress of scientific knowledge. There is inevitably a certain time-lag, dictated in part by reasons of prudence, between the progress of the medical and legal disciplines in this respect. In legislation drawn up concerning persons dependent on alcohol and other drugs, it should be recognized and stated that these are sick persons, and the legislation should provide for the working together of the control and judicial authorities and the therapeutic agencies.

Many countries, while recognizing that dependence on alcohol and dependence on drugs are illnesses, still have legal systems that prescribe punishment for persons exhibiting manifestations of such illnesses. Encouraging trends were noted in the increasingly widespread acceptance of drug dependence, particularly alcohol dependence, as an illness. Legal decisions have been reached, for instance, that a "chronic alcoholic" may not be convicted for being intoxicated in public. The inconsistency noted above should be resolved, in so far as possible, by changes in the systems of punishment. Such changes present very complex problems in the delineation of unlawful behaviour and the limits to the responsibility of the misbehaving person when he has voluntarily exposed himself to conditions that produced his illness.

Close co-operation between treatment and rehabilitation services on the one hand, and the police and courts on the other, is therefore imperative. In some countries of Eastern Europe, the health services provide special centres to which police may take persons found intoxicated in the streets. In one Canadian provincial programme, an arrangement has been made with the police whereby, as facilities allow, persons found intoxicated in public, and who have not committed any other offence or misdemeanour, may be taken by the police direct to the treatment services. In one area, young persons using marihuana, after being charged in the courts, are, by special arrangement, placed on probation and, as a condition of probation, ordered to attend at the treatment facilities. In some areas, intoxicated persons brought before the courts and pleading as "chronic alcoholics" are referred to, treatment facilities. Where a person dependent on alcohol or other drugs is sentenced to prison for crime, therapeutic action should proceed during his detention. Despite the heavy burden involved, such collaboration between the police, courts and medical services in the therapeutic process is to be encouraged, even though it highlights the need for additional health services.

There has been considerable discussion about the merits of voluntary treatment as compared with compulsory treatment. Although the former is generally to be preferred, recognition should be given to the fact that, in most societies utilizing voluntary treatment, considerable pressure influences the willingness to "volunteer ". Despite some widely stated views to the contrary, compulsory treatment of persons dependent on alcohol and other drugs is often successful. When civil commitment of drug-dependent persons to medical authorities is used (and this procedure is to be recommended in appropriate cases), a clear legal delineation is needed of the circumstances entailing such commitment. For compulsory treatment to be of value the following conditions must be met: the basic legislation should be preventive and therapeutic in its aim; public opinion must be in accord with this aim; and ample services must be available. Furthermore, those persons invested with legal responsibility for case-finding should not, ordinarily, also be required to operate the therapeutic programme. However, physicians who detect such patients in the course of their practice would be expected, whenever possible, to treat them. The need for compulsory treatment appears to bear an inverse relation to the degree of public understanding, lack of stigma, and the availability of adequate treatment services for voluntary patients.

Close liaison between police and treatment services in the event of accidents involving drivers or pedestrians under the influence of alcohol or other drugs can be an important aid to case-finding and often permits detection of patients in an early stage of drug dependence.

Medico-legal measures are essential in the prevention and control of dependence on alcohol and other drugs, but it should be kept in mind that reasonably successful control of one agent often, in fact usually, leads to the emergence of another agent as a substitute.

The control of alcohol as a dependence-producing agent presents particularly complex problems since,unlike other dependence-producing substances, it is used legally as a beverage in most countries.

It is important that legislation should envisage close co-operation between public health authorities and the authorities concerned with the production, importation, retailing and taxation of alcoholic beverages so that these activities harmonize, as far as possible, with the best interests of public health.

Health personnel should be active participants in all bodies established to develop co-ordinated governmental policies with regard to dependence on alcohol and other drugs, including the elaboration of legislation on these subjects.

Inter-organizational approach

A multiplicity of agencies is involved in dealing with problems concerning dependence on alcohol and other drugs. In some cases, this has led to duplication of activities, and at times work has been carried out at cross-purposes. However, there is an increasing tendency for bodies concerned with these problems of dependence to co-ordinate their work in areas of common interest.

SERVICES

Assessment of needs

A thorough epidemiological investigation is not an essential prerequisite for the setting up of services for the treatment and care of persons dependent on alcohol or other drugs. However, if authorities are to provide support for development of services commensurate with needs, some indication of the types and extent of the problems involved is required.

In view of the relative crudeness of the available data, it is not possible to provide accurate figures for the prevalence of dependence on alcohol and other drugs. Clearly, the most prevalent type of drug dependence will vary from one country to another. Thus, in Singapore, opium smoking and morphine taking are common and there is little abuse of alcohol, whereas in Chile and in France, alcohol dependence is common and there is relatively little abuse of narcotics. However, it seems reasonable to assume that at least several million persons are dependent on alcohol and other drugs throughout the world and, indirectly, this problem also affects the families of which they are members, as well as the societies of which they are a part.

In some countries (e.g., Canada and the USA) there are provisional data to suggest that the prevalence of dependence on alcohol may be 100 times that of dependence on narcotics, The prevalence of dependence on other drugs falls somewhere in between, possibly towards the lower end of the scale.

The abuse of, as well as dependence on, one or more of these drugs represents a massive problem in many countries with very different cultures, political systems, races and religions. Although the pattern of expression varies from country to country and society to society, the effects of illness resulting from alcohol and drug dependence and the associated crime, accidents, family disruption, suicide, premature death; loss of productivity, as well as associated hospital, prison and welfare costs, are everywhere apparent, though not fully delineated. Often, the use and abuse of these substances, particularly alcohol, is so widespread and pervasive that problems of dependence are not perceived as such.

In developing areas, although there is a dearth of information about many of the above problems, there are important indications of significant dependence on alcohol. Sporadic tribal or village ceremonial drinking has, in many instances, been replaced by more regular drinking in bars. Importation and production of beverage alcohol has increased up to tenfold in some countries of Africa and Asia. These problems seem related to increasing urbanization, widespread industrialization, difficult living and working conditions, and weakening of tribal and family ties.

There is widespread abuse of narcotic and other drugs in certain developing areas. In India, opium and cannabis are rather extensively used, although their consumption is now declining. In Hong Kong, Thailand and Iran, heroin is now tending to supersede opium and morphine as the chief drug of dependence. In Singapore, however, the drugs of dependence are still opium and morphine. Dependence on opium and hashish is widespread in Egypt. Khat is used in the countries on the east and west coasts of the Red Sea. Cannabis is used in most countries of the African continent, coca-leaf and cocaine are used extensively in Peru and Bolivia and cannabis in Brazil.

In the USA, many drugs, including alcohol, are taken to excess, and the smuggling of narcotics, particularly of heroin, creates a very serious problem. In Europe, the number of heroin users is relatively small, but in some areas abuse of this drug is an increasing problem. The abuse of central nervous system depressants and stimulants, as well as analgesics, is also reported to be increasing in these and other areas.

As services begin to develop in any given area, data will be required on: the amount and place of consumption of alcohol and other dependence-producing drugs; the number and characteristics (pathological and social) of dependent persons, by drug of dependence; and the attitudes and mores of the community

to be served. Some suggested means by which these data can be obtained are the following:

  1. The amount and place of drug consumption:

  2. survey of production, imports and exports;

  3. survey of medical prescriptions;

  4. studies of physicians' prescribing patterns and attitudes;

  5. field studies of populations of users and abusers;

  6. comparison of these data for countries of comparable standards of living.

  7. The number and characteristics (pathological and social) of dependent persons, by agent of dependence:

  8. confidential reporting to medical authorities of such persons coming to the attention of physicians (this is strongly recommended);

  9. police reports of offences associated with drug dependence;

  10. Jellinek's method of estimating the extent of alcohol dependence;

  11. items (ii), (iii) and (iv) under a above.

  12. The attitudes and mores of the persons to be served and the cultures of which they are part:

  13. clinical impressions;

  14. field studies involving the use of skills of psychologists, sociologists and cultural anthropologists.

In discussing measures of prevention, treatment and rehabilitation, the Committee stresses health education, the medical control of drugs, legislation and research.

Influencing social attitudes

Social and cultural attitudes towards the consumption of alcohol and other drugs appear to have a bearing on the development of dependence, as exemplified by differences in prevalence among different cultural groups: for example, the low rate of dependence on alcohol among Jews and its high rate in France and Chile. Attitudes towards heavy consumption may also affect symptomatology: condemnation by society may arouse guilt feelings in the user, drive him to even greater dependence on drugs, and prevent him from seeking treatment. This is not to say that abuse of alcohol and other drugs should therefore be condoned.

It was noted on page 49 that the medical profession and the general public in many countries are now coming to accept alcohol dependence as an illness, but that in too few countries has similar progress been made with regard to persons dependent on other drugs. The Committee reiterates here that greater acceptance of the concept that dependence, whether on alcohol or on other drugs, is an illness could help the persons affected to a more hopeful attitude towards themselves and their disability.

Psychological, socio-economic and cultural factors appear to play important roles in the development of dependence on alcohol and other drugs, Measures such as application of mental health principles in childhood, improvement of social conditions and the alteration of certain cultural attitudes and patterns should decrease the likelihood of people becoming dependent on alcohol or other drugs.

Early diagnosis and treatment

Important elements of secondary prevention are early diagnosis and treatment, which can be furthered by widespread and adequate public and professional education and training (see page 53). Persons dependent on alcohol or other drugs can be recognized by health workers such as physicians, public health nurses and social workers, provided they have adequate knowledge of drug dependence. Case-finding and guidance of patients to treatment channels may also be accomplished by law-enforcement authorities, following arrest for certain unlawful activities, such as stealing to obtain money to buy drugs or driving while intoxicated. The police and magistrates should be taught to identify those persons who should be examined medically to determine their need for treatment. In North America, about half the persons dependent on alcohol are believed to be still fully employed. Industry, therefore, is potentially well situated for detection of incipient alcohol dependence and the prevention of later and more serious consequences.

There are general similarities between the progressive social, physical and psychological decline of persons dependent on alcohol and of those dependent on other drugs. Social and cultural factors, as well as the nature of the agent and the extent of its abuse, affect this decline. Where adequate treatment is available, early diagnosis and treatment can help to prevent further progress of the illness, such as the development of physical complications in the case of alcohol and certain other central nervous system depressants.

In most countries, it is particularly important to carry out case-finding activities in the following three groups:

  1. Persons employed in occupations where they have supervision of their activities. Dependent persons in such a situation may be fairly readily identified and encouraged to seek treatment. Generally, the treatment of persons in this group has relatively good prospects as compared with treatment of those who are not employed.

  2. Unemployed or self-employed persons are less accessible to case-finding. On the average, the prospects for successful treatment of persons in this group who are dependent on alcohol or other drugs lie somewhere between those for the first group and those for the third.

  3. The much smaller group of socially, and often psychologically and physically, deteriorated persons typified by the "derelicts" found in nearly all societies contains many persons dependent on alcohol and other drugs. The chances of improvement in members of this group are the poorest. While they are not particularly difficult to identify, their motivation for treatment is usually quite low and often difficult to modify.

It may be noted that one of the early steps that a government could take in providing leadership in this field is to establish a definite policy and programme for all governmental employees.

Treatment and rehabilitation

The treatment of persons dependent on alcohol, with the best methods available, has produced encouraging results. Marked improvement or social recovery has been reported in up to 50-70 per cent of cases, depending mainly on the underlying personality of the person treated. The proportion of therapeutic failures is generally higher among abusers of other drugs, but social and cultural factors and the extent of dependence on a particular drug within the population also affect the treatment results.

There are many principles that are equally valid in the treatment of persons dependent on alcohol and those dependent on other drugs. An important fact, often overlooked, is that detoxification of the dependent person is only one aspect of the total treatment process. Indeed, this measure is less time-consuming and difficult than the other essential therapeutic steps. Intensive treatment of psychological dependence and of drug-induced and other physical disorders, social and vocational rehabilitation, and long-continued follow-up through supportive and consultative services are all needed in the majority of cases if the dependent person is to have an optimum chance of living his life free of drugs as a productive citizen. Nor must non-relapse into dependence on alcohol or other drugs be considered as the sole criterion of effectiveness of the therapeutic regime. Improved interpersonal relations, working patterns and satisfactions in living must also be used as criteria in judging therapeutic results.

Another common principle is the need for teamwork. The therapy of dependence on alcohol and other drugs requires very close collaboration between many professional disciplines and voluntary and official agencies, as discussed on page 48. The medical practitioner, social worker, clinical psychologist, nurse, clergyman, probation officer, local authorities, the patient's family, and organizations such as Alcoholics Anonymous or Narcotics Anonymous all have their parts to play and consequently all need to be well informed on the subjects of alcoholism and drug dependence.

However, the treatment of persons dependent on alcohol and other drugs is, or should be, to a large extent a medical problem. The physician-general practitioner, psychiatrist or other medical specialist-must assume ultimate responsibility for the medical treatment of the patient. Nevertheless, the other groups mentioned above have important contributions to make. Indeed, during certain phases of treatment, members of the therapeutic team other than physicians may appropriately carry the major therapeutic role. Non-medical personnel may well bear the ultimate responsibility for the rehabilitation phase (which overlaps with treatment).

Many forms of treatment of alcohol dependence have achieved success in the hands of therapists representing various disciplines and philosophies. However, the therapist's basic attitude to the problem and to the dependent patient is probably more important than particular treatment techniques, especially following detoxification. It is essential, in treating persons with all forms of dependence on alcohol and other drugs, that the therapist should accept the patient, emotionally as well as intellectually, as a sick person and avoid a moralistic and condemnatory attitude. While he must help the patient to face reality and accept responsibility for his own actions, the therapist must avoid attitudes of rejection, which only serve to reinforce the dependent person's own feelings of guilt, isolation and hopelessness and drive him even further towards his pathological adaptation to life and his tendency to abuse of alcohol or other drugs.

On the basis of present knowledge, treatment should usually start with withdrawal of the drug. This should be abrupt and complete in the case of drugs such as the central nervous system stimulants, cannabis, hallucinogens and alcohol, but gradual (measured in days or weeks rather than months) in the case of drugs such as the opiates and the barbiturates. After withdrawal of the drug and a diagnostic evaluation of the factors that are of importance in a given case, the patient should be treated with a combination of the available psychological, physical (including pharmaceutical) and social methods best suited to his individual needs. This process may well have to be continued for months or even years. It overlaps with the rehabilitation phase, which in turn overlaps with follow-up services, during which the patient is assisted in the process of learning to live contentedly and usefully without relying on alcohol or other drugs. Long-range plans for treatment, rehabilitation and long-continued support are absolutely essential.

Individual and group psychotherapy have both been employed in the treatment of persons dependent on alcohol and other drugs. Group therapy has found increasing application in such treatment for a number of reasons, such as the need that these patients have for re-socialization, their feeling of isolation, their need to identify and to achieve a feeling of belonging among people with the same affliction and with similar underlying problems, and the opportunity that group therapy provides for support by group members in times of crisis.

Following the example of Alcoholics Anonymous (A.A.), similar bodies have been formed with the aim of helping persons dependent on other drugs, such as "Narcotics Anonymous ", " Syanon ", and many others. Many persons dependent on alcohol and some persons dependent on other drugs have been helped by these organizations without any medical assistance, others with medical collaboration. Where hospital or outpatient treatment is available, the main value of these organizations is in the case-finding and rehabilitation phases.

The attitude of the family is of great importance in the after-care period. Relatives' groups, guided by the physician, social worker, clinical psychologist, nurse, clergyman or other trained worker, can be of great benefit.

Not all drug-dependent persons - and certainly not all those dependent on alcohol - require hospital care. The rest may be treated either at home by the family doctor, or at outpatient clinics. However, a drug-free environment is often essential in the early phase of treatment. Alcohol-dependent persons requiring hospitalization have been found to benefit greatly from a therapeutic community unit run on permissive lines and operated to a large extent by the patients themselves, who thus learn responsible living. This approach may also prove useful to other drug-dependent persons, although sometimes a less permissive arrangement may be required.

Dependence on alcohol and other drugs is essentially a relapsing illness but, as stated earlier, relapse is not to be considered as indicating therapeutic failure. When relapse does occur, it should be seen as a challenge to try again. The majority of persons who have recovered from dependence on alcohol or other drugs have succeeded only after a number of relapses. The therapist frequently has to be satisfied with achieving a limited goal.

The Committee then discusses existing types of services for personas dependent on alcohol and other drugs, and notes that they vary widely in the degree to which they have been planned and implemented. As far as narcotic drugs are concerned, the major national approach to their abuse has been one of criminal penalties "which have steadily been increased without differentiating between traffickers and addicts or between heroin and cannabis ". The report discusses combined services for persons dependent on alcohol and other drugs, services exclusively concerned with alcohol dependence or with dependence on other drugs. In the establishment of such services the report points to a pilot centre as one of the best methods with which to begin finding out about local problems of dependence. Ideally, treatment of high quality should be made available through an adequate variety of facilities to all who suffer through alcohol or drug dependence.

EDUCATION AND TRAINING PROGRAMMES

A comprehensive approach to the problems of dependence on alcohol and other drugs should include a strong, well-organized programme of education aimed at prevention.

Objectives and methods

Primary prevention is aimed at reaching all persons in the community, especially the potentially vulnerable persons and groups, and providing them with information and education designed to protect them against possible later disease. Such education attempts to help the public to understand both the motivations underlying abuse of drugs and alcohol and the socially accepted use of alcohol and certain other drugs. The public also needs information on the physiological and other effects of consumption of alcohol and other drugs, and on the recognition of abuse of such agents. An important objective of health education is to foster public recognition of dependence on alcohol and other drugs as illnesses requiring treatment. Information on the objectives of the preventive and treatment services and on the methods of gaining access to them should encourage public collaboration and assist in early case-finding and treatment. In some areas, it may be found necessary to create a climate of social disapproval of the excessive use of alcohol and other drugs and to advocate total abstinence from certain agents. Similarly, educational programmes may be required to counteract popular misconceptions about the value of alcohol and other drugs, for both dietetic and medical purposes.

As in all other educational programmes, it is important that half-truths and exaggerations be avoided. Since knowledge of a given subject can never be complete, factual information should be presented only as the best currently available, and with a willingness to modify the educational as well as other facets of the over-all programme as new knowledge is attained.

In developing a programme of education on problems of dependence on drugs, including alcohol, it is important to investigate the patterns of use and abuse, as well as the values and attitudes attached to abstinence, use and abuse in significant segments of the population. Such an investigation will include a study of the way persons of various ages and classes customarily learn the use of alcohol and drugs in the population under consideration. A realistic formulation of the goals of the educational programme should be related to the values and experiences of significant groups in the population. The most effective channels through which information reaches various segments of the population should be determined and utilized.

It is evident that any educational programme must give primary attention to local circumstances, with particular reference to the drugs (including alcohol) used predominantly in the country and the degree to which such drug-usage creates a problem, together with a consideration of the local customs, attitudes, predominant mores and institutional patterns.

The Committee was mindful of the long-continued discussions about the "merits" and "hazards" of providing information on drug dependence to relatively uninformed groups. Intelligent action is unlikely to be fostered by ignorance or misinformation; nevertheless, the Committee sees little need to mount intensive preventive educational programmes for the public and its numerous special groups in the absence of actual or potential problems. However, because of the rapidly changing patterns of dependence on alcohol and other drugs, health and welfare officials, and members of the medical profession in particular, must be well informed about the manifestations of all types of drug dependence, the prevention of such dependence, and the treatment and rehabilitation of drug-dependent persons.

Target groups

To be effective, educational programmes need to be directed to specific population groups. Educational material can then be developed in accordance with the interests, occupations, principal concerns and other special factors related to each group. In this way, the educational programme can be made realistic, and limited but attainable goals can be set.

Health education of school-children may be made the responsibility of schools, parents or other groups who can be appropriately instructed in how to pass on information to children. A programme for older schoolchildren and students might include information on customs connected with use and abuse of alcohol and other drugs among various communities and groups, variations in community attitudes towards consumption of such agents, and the hazards attached to certain patterns of consumption and to certain drugs in particular. Inevitably, a child acquires much of its health education through imitation of its parents, who may require to be specially alerted to the need to provide an appropriate example.

In the case of an educational programme directed towards employers (an industrial programme), emphasis should be placed on the need for the development of a definite policy that will recognize dependence on alcohol or other drugs as a health problem and also on the establishment of specific procedures that will enable the affected employee to be identified and to obtain treatment for his illness.

The impact on industrial and community health of problems of dependence on alcohol and other drugs warrants considerable emphasis on education about these problems in the course of undergraduate professional training of many types. The majority of those taking such courses do not plan to work exclusively with such problems but will, in fact, have to deal with many persons dependent on alcohol and drugs in the course of a career devoted to other kinds of human problems. The specific groups to be reached during their professional training would include psychiatrists and other physicians, psychologists, sociologists, social workers, nurses (especially public health nurses), religious leaders, lawyers, attorneys and the police.

The report considers the training, both didactic and clinical which should be given to persons who are likely to have to deal with cases of alcohol or drug dependence. The official curriculum should provide for systematic teaching in this area and it should not be left to the chance interest of a teacher to include it in the course of study. Since dependence is an aspect of behaviour it should be viewed within the broad framework of human behaviour and human pathology.

1

Wld. Hlth. Org., Techn. Rep. Ser., 1967, 363.

2

The meeting was opened by Dr. P. Dorolle, Deputy Director-General of WHO. Dr. K. Evang (Norway) was elected Chairman, and Dr. M. Kato (Japan) Vice-Chairman; Dr. C. Cameron (United States) was appointed Rapporteur.

3

Summaries of parts of the report have been made by the Editor and these appear in italics; there are also certain minor editorial modifications.

4

In some countries, particularly those in which the regular drinking of wine is a very prominent social pattern, some persons are reported to abuse alcohol to the point of developing physical dependence and complications without developing obvious significant psychic dependence

05

5 The etiology is to be found largely in pre-existing psychopathology.

6

The etiology is to be found largely in social and cultural patterns.

7

Eddy, N. B., Halbach, H., Isbell, H. & Seevers, M. A. (1965) Bull. Wld. Hlth. Org., 32, 721

8

A later section sets out the experts' proposals as to the nature of such research and how it should be carried out.

RECOMMENDATIONS

001

Dependence on alcohol and dependence on other drugs create or contribute to major public health problems and should therefore be of concern to all public health organizations and administrations.

002

While recognizing that there are important differences between types of drug dependence, the Committee recommends that problems of dependence on alcohol and dependence on other drugs should be considered together, because of similarities of causation, interchangeability of agent in respect of maintenance of dependence and hence similarities in measures required for prevention and treatment (see page 45).

003

To give the concept of "drug dependence" its full value and practical significance, its implications for clinical work, research, and administrative and legal measures should be explored jointly by the professions and authorities concerned, both nationally and internationally.

004

Dependence on alcohol and other drugs must be considered, not only in terms of the agents involved, but from the point of view of the host and environment as well.

005

The etiology, prevention and control of dependence on alcohol and other drugs and the treatment of dependent persons involve multiple problems that extend beyond the competence of any single profession or group; it is therefore imperative that a multi-disciplinary approach be used.

006

Services for prevention and treatment of dependence on alcohol and other drugs, must take into account the circumstances, customs, attitudes and institutional patterns with particular reference to the types of drugs used predominantly and the degree to which use and abuse of these drugs create problems.

007

The extent to which approaches to different types of dependence should be combined and the rate at which this should be done will depend on local factors and should thus be decided by national and local authorities.

008

The services for the prevention and treatment of dependence on alcohol and other drugs should, as far as possible, be integrated with other health and welfare services.

009

Small pilot centres should be set up in developing areas to become foci of interest, study and experience in establishing the need for and means of dealing with problems of dependence on alcohol and other drugs, consonant with local conditions.

010

Comprehensive services to deal with problems of dependence on alcohol and other drugs should include well-organized programmes of public education aimed at securing an understanding of these problems and a rational approach to them.

011

Undergraduate, graduate and post-graduate training curricula for the disciplines involved in the treatment and rehabilitation of persons dependent on alcohol and other drugs should provide for systematic teaching on the relevant aspects of dependence on and abuse of drugs.

012

Public health authorities and medical professional bodies should undertake to establish guide-lines for ethical medical practice in relation to the use of dependence-producing drugs.

013

Legislation concerning persons dependent on alcohol and/or other drugs should recognize that these are sick persons. Medical and public health experts should be involved in the framing of such legislation.

014

Adequate treatment and rehabilitation should, if necessary, be ensured by civil commitment of drugdependent persons to medical authority, which would provide direction and supervision of their care, from initial diagnosis to rehabilitation.

015

Research is vital for obtaining the much-needed knowledge of the causes, prevention, and control of abuse of, or dependence on, alcohol and other drugs, and the treatment and rehabilitation of drug-dependent persons. In many studies a combined approach to dependence on alcohol and on other drugs would be extremely helpful.

016

WHO should provide further leadership in the development of co-ordinated, multi-disciplinary, international research programmes and the stimulation of international co-operation and exchange of information on the problems under consideration.

017

Hospitals, units or other facilities for advanced training and research on problems of dependence on alcohol and other drugs should be established, preferably in association with universities.