tag:theconversation.com,2011:/ca-fr/topics/substance-abuse-2713/articlesSubstance abuse – La Conversation2023-11-17T16:36:02Ztag:theconversation.com,2011:article/2180482023-11-17T16:36:02Z2023-11-17T16:36:02ZSouth Africa’s police are losing the war on crime – here’s how they need to rethink their approach<p>South Africa’s <a href="https://www.youtube.com/watch?v=pzyqFKC2x1Q">crime statistics</a> for the third quarter of 2023 show that people continue to face a serious problem of violent crime, especially murder and attempted murder. The country’s <a href="https://issafrica.org/events/understanding-escalating-levels-of-murder-in-south-africa">per capita murder rate for 2022/23</a> was the highest in 20 years at 45 per 100,000 (a 50% increase compared to 2012/13).</p>
<p>In response to this crisis, the South African Police Service has reconfigured its <a href="https://pmg.org.za/committee-meeting/37753/">policing strategies and plans</a>. Yet, these approaches offer very little innovation. They mostly reaffirm the way the police have typically pursued policing for the past three decades – fighting a <a href="https://www.tandfonline.com/doi/abs/10.1080/03057070.2018.1503831">“war” on crime</a> and <a href="https://ewn.co.za/topic/operation-fiela">“sweeping away”</a> criminals. </p>
<p>In my view the police have adopted unsuitable crime fighting strategies. This is a “war” the police can’t win on their own, because violent crime is a <a href="https://www.researchgate.net/publication/326462816_WHY_IS_CRIME_IN_SOUTH_AFRICA_SO_VIOLENT_Updated_Rapid_Evidence_Assessment_on_Violent_Crime_in_South_Africa">complex phenomenon</a>. It requires <a href="https://journals.co.za/doi/pdf/10.10520/EJC47702">whole-of-government</a> and <a href="https://www.csir.co.za/sites/default/files/Documents/Making%20South%20Africa%20Safe.pdf">whole-of-society</a> approaches. Government departments, civil society groups and the private sector should pool resources and <a href="https://gh.bmj.com/content/7/7/e009972">work together</a> in a co-ordinated manner. They must be guided by a common plan. Otherwise crime prevention efforts will be piecemeal, lacking effectiveness.</p>
<h2>Determinants and complexity of violent crime</h2>
<p>The scholarly literature on violent crime in South Africa, including <a href="https://www.researchgate.net/publication/326462816_WHY_IS_CRIME_IN_SOUTH_AFRICA_SO_VIOLENT_Updated_Rapid_Evidence_Assessment_on_Violent_Crime_in_South_Africa">my research</a>, indicates that interpersonal violence is typically the outcome of a combination of risk factors over time. </p>
<p>One of them is the idea that violence is a legitimate means to resolve conflict between people. </p>
<p>Another is <a href="https://www.researchgate.net/publication/326462669_Towards_a_more_comprehensive_understanding_of_the_direct_and_indirect_determinants_of_violence_against_women_and_children_in_South_Africa_with_a_view_to_enhancing_violence_prevention">childhood experiences</a> of violence.</p>
<p>Socio-economic elements, such as poverty, unemployment and inadequate living conditions, underpin violence, mainly for <a href="https://journals.sagepub.com/doi/abs/10.1177/1097184X17696171?journalCode=jmma">younger men</a>. Feelings of stress, frustration and humiliation, combined with substance abuse (chiefly alcohol), inequitable gender norms and the availability of weapons, especially <a href="https://www.dw.com/en/south-africa-spike-in-gun-crime-angers-citizens/a-64903654">firearms</a>, often results in violent behaviour.</p>
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<a href="https://theconversation.com/south-africa-wont-become-less-violent-until-its-more-equal-103116">South Africa won't become less violent until it's more equal</a>
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<p>Given what studies say about the determinants of violence, I predicted during the COVID-19 pandemic in 2020 that South Africa would soon face a <a href="https://www.saferspaces.org.za/blog/entry/the-coming-crime-catastrophe">crime catastrophe</a>. The pandemic and lockdown regulations had increased poverty, unemployment and food insecurity. This would exacerbate existing risk factors for violence, such as:</p>
<ul>
<li><p>domestic abuse </p></li>
<li><p>learners dropping out of school </p></li>
<li><p>diminishing prospects of meaningful jobs, especially for young, marginalised men. </p></li>
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<p>In 2021/22 there was a significant <a href="https://www.saps.gov.za/services/downloads/Annual-Crime-2021_2022-web.pdf">increase</a> in all categories of violent crime. </p>
<p>Since then there’s been no reduction in these risks, especially <a href="https://www.dailymaverick.co.za/article/2023-10-06-eight-million-hungry-children-new-report-about-the-shocking-impact-of-poverty-on-young-south-africans/">food insecurity</a>, <a href="https://www.news24.com/fin24/economy/sa-sees-job-growth-but-its-cold-comfort-for-millions-of-unemployed-youth-left-behind-20231115">youth unemployment</a>, <a href="https://www.unicef.org/southafrica/press-releases/crime-statistics-devastating-violence-against-children-and-women-continues">child abuse</a> and the <a href="https://businesstech.co.za/news/government/723902/south-africas-shocking-school-dropout-rate-revealed/">school dropout rate</a>. The <a href="https://issafrica.org/events/understanding-escalating-levels-of-murder-in-south-africa">murder rate per capita</a> has increased from 33.5 per 100,000 during the COVID-19 period (2020/21) to 45 per 100,000 in 2022/23. </p>
<h2>Police and the prevention of violent crime</h2>
<p>Even though the police are <a href="https://www.ojp.gov/ncjrs/virtual-library/abstracts/police-work-social-organization-policing">not able</a> to do anything directly about many of the underlying risk factors for violence, <a href="https://www.police1.com/chiefs-sheriffs/articles/law-enforcement-strategies-to-reduce-violence-wItHuxvLO0IHLEEk/">studies</a> have shown that specific policing interventions can make a difference in reducing violent crime. </p>
<p>The police can work closely with communities to devise <a href="https://ojjdp.ojp.gov/model-programs-guide/literature-reviews/community-oriented-problem-oriented-policing">cooperative solutions</a> to crime problems. They can also collect and use relevant <a href="https://www.osce.org/files/f/documents/d/3/327476.pdf">intelligence</a> to design and implement <a href="https://issafrica.org/crimehub/analysis/research/evidence-based-policing-for-south-africa-an-introduction-for-police-officers-researchers-and-communities">evidence-based</a> crime prevention actions. These should focus on the areas where criminal offending is most <a href="https://time.com/6227552/hotspot-policing-crime-effectiveness/">concentrated</a>, and on the <a href="https://www.gov.scot/publications/works-reduce-crime-summary-evidence/pages/6/">situations</a> that tend to drive that behaviour. </p>
<p>Interventions require a <a href="https://www.policechiefmagazine.org/successfully-reducing-violent-crime-with-multimodal-community-and-police-engagement-interventions/">competent, adequately resourced and professional</a> police organisation and a fair and effective <a href="https://www.oecd-ilibrary.org/effectiveness-and-fairness-of-judicial-systems_5jfrmmrhkcs2.pdf">criminal justice system</a>.</p>
<p>Since the 1990s the work of the police has included community-oriented approaches. <a href="https://www.police.govt.nz/resources/2008/community-policing-lit-review/elements-of-com-policing.pdf">Best practice</a> is for police to treat community safety groups as equal partners. Solutions to crime problems are <a href="https://www.policechiefmagazine.org/from-crisis-to-community-policing/">co-created</a>. </p>
<p>But the police’s approach has been the converse. They have <a href="https://www.groundup.org.za/article/community-policing-forums-should-be-holding-police-accountable/">co-opted</a> community safety groups, such as <a href="https://crimehub.org/iss-today/are-south-africas-community-police-forums-losing-their-impartiality">community police forums</a> and neighbourhood watches, to be <a href="https://www.saps.gov.za/newsroom/msspeechdetail.php?nid=45270">force multipliers</a>. Studies have shown that such a method is often <a href="https://www.ojp.gov/pdffiles/171676.pdf">ineffective</a>.</p>
<p>For the past three decades, South African police have prioritised <a href="https://www.tandfonline.com/doi/abs/10.1080/03057070.2018.1503831">militarised policing approaches</a>, such as <a href="https://www.saps.gov.za/newsroom/msspeechdetail.php?nid=47240">Operation Shanela</a> (“to sweep” in isiZulu). They encourage police to be more <a href="https://www.timeslive.co.za/sunday-times/news/2023-11-12-cele-doubles-down-on-cops-right-to-use-deadly-force/">forceful</a> in their interactions with alleged criminals.</p>
<p>There is very <a href="https://www.pnas.org/doi/10.1073/pnas.1805161115">little evidence</a> to suggest that militarised policing brings down violent crime rates. Instead, it can erode public trust in the police. This is certainly evident in South Africa, where only <a href="https://hsrc.ac.za/press-releases/dces/feeling-blue-changing-patterns-of-trust-in-the-police-in-south-africa/">27%</a> of the population view the police as trustworthy (from 47% in 1999). </p>
<p>Police effectiveness in combating crime has also been undermined by <a href="https://pmg.org.za/committee-meeting/37753/">declining personnel numbers</a>. In 2018, there were 150,639 police personnel, but this is now 140,048. There has also been a substantial decline in the <a href="https://www.news24.com/news24/politics/90-drop-in-police-reservists-devastating-to-high-crime-levels-20231114">police reserve force</a>. </p>
<p>High levels of crime have placed <a href="https://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S1991-38772020000100003">considerable pressure</a> on the criminal justice system too. Conviction rates for violent crime are very low. For example, between 2019/20 and 2021/22, police recorded 66,486 murder cases. Of these, only 8,103 (12%) resulted in a guilty verdict.</p>
<h2>What can be done?</h2>
<p>The good news is that the government does not exclusively depend on policing plans to tackle crime. It has also developed multi-departmental and evidence-based strategies and plans to prevent crime. These are derived from Chapter 12 of the <a href="https://www.nationalplanningcommission.org.za/assets/Documents/NDP_Chapters/devplan_ch12_0.pdf">National Development Plan</a>. It calls for: </p>
<ul>
<li><p>police to be more professional, demilitarised and work in partnership with communities</p></li>
<li><p>an improved criminal justice system </p></li>
<li><p>an integrated crime prevention strategy. </p></li>
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<p>In 2022 the cabinet approved the <a href="http://www.policesecretariat.gov.za/downloads/reports/Final%20Approved%20Integrated%20Crime%20Violence%20Prevention%20Strategy.pdf">Integrated Crime and Violence Prevention Strategy</a>. It seeks to achieve a whole-of-government and whole-of-society approach given the multi-dimensional nature of the risk factors that drive violent crime. Furthermore, this strategy encourages government and other elements of society to jointly address common crime problems and collaboratively determine prevention strategies, especially at the community level. </p>
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Read more:
<a href="https://theconversation.com/south-africans-are-feeling-more-insecure-do-ramaphosas-plans-add-up-176991">South Africans are feeling more insecure: do Ramaphosa's plans add up?</a>
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<p>There was also the recognition that various government departments (and not just the police) needed to work closely with civil society and the private sector to drive down crime levels.</p>
<p>The problem is that the implementation of strategy is in limbo. No government agency has been willing to take responsibility for it. That’s because there is no direct budgetary allocation, given the highly <a href="https://businesstech.co.za/news/budget-speech/664953/4-major-risks-that-godongwana-needs-to-address-in-the-2023-budget-next-week/">constrained government purse</a>. </p>
<p>High levels of crime and low levels of policing have substantial <a href="https://www.news24.com/citypress/business/the-crippling-cost-of-violence-20221125#:%7E:text=Violent%20crimes%20cost%20South%20Africa%20about%2019%25%20of%20GDP%20annually.">negative effects</a> on economic performance. So investing adequate resources to carry out the Integrated Crime and Violence Prevention Strategy will not only reduce violent crime, but also contribute to economic growth.</p><img src="https://counter.theconversation.com/content/218048/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Guy Lamb receives funding from Norwegian Research Council. He is a Commissioner on South Africa's National Planning Commission. </span></em></p>Government departments, civil society groups and the private sector should pool resources and work together in a co-ordinated manner to prevent violent crime.Guy Lamb, Criminologist / Senior Lecturer, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2118022023-09-26T14:03:09Z2023-09-26T14:03:09ZTyson Fury’s Netflix series highlights the mental health challenges faced by Gypsy, Roma and Traveller communities<p>The Netflix documentary series, <a href="https://www.netflix.com/gb/title/81615144">At Home With The Furys</a>, provides a fascinating look at the day to day life of Tyson Fury, family man and heavyweight boxing world champion. </p>
<p>A particular source of pride for Tyson is his heritage as a member of the Traveller community, his boxing moniker being “The Gypsy King”. Yet despite the glitz and glamour that comes with being a millionaire celebrity, Fury has had his internal, as well as external, battles to fight. These include a long history of anxiety and depression, bipolar disorder, substance abuse and suicidal thoughts. </p>
<p>Mental health issues within Gypsy, Roma and Traveller (GRT) communities have long been described as being at <a href="https://www.lenus.ie/handle/10147/111897">crisis point</a> due to a combination of complex factors that are not fully understood because of a <a href="https://www.cambridge.org/core/journals/irish-journal-of-psychological-medicine/article/rapid-review-of-irishtraveller-mental-health-and-suicide-a-psychosocial-and-anthropological-%20perspective/D15DCA7BC128965514E1476C065756E9">lack of research</a>. Indeed, GRT communities are among the most socially and economically <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/educationandchildcare/bulletins/gypsiesandtravellerslivedexperienceseducationandemploymentenglandandwales/2022">disadvantaged</a> groups in the UK and Republic of Ireland. </p>
<p>It is a situation which impacts housing, education, employment, and crucially, mental health and access to healthcare. But we don’t know enough about what the causes are or how to stop them from happening.</p>
<p>My team and I conducted <a href="https://www.researchgate.net/publication/355046420_Mental_Health_Support_Needs_Within_Gypsy_Roma_and_Traveller_Communities_A_Qualitative_Study_PDF_Proof">a study</a> on the mental health support needs of people from GRT communities. We interviewed nine people from across the UK about their mental health and their experiences with getting support: four women, four men and one non-binary individual. </p>
<p>Three main themes emerged from our interviews:</p>
<p><strong>1. Longing for acceptance</strong></p>
<p>This related to a feeling of being ostracised from wider society. One participant said: “We face a lot of racism and discrimination in our daily lives which affects our mental health. And also that even with medical professionals, there is internal racism and discrimination.” </p>
<p><strong>2. Increased vulnerability</strong></p>
<p>This theme related to the impact of economic deprivation, lack of educational prospects and future goals, as well as adverse life experiences. </p>
<p>Focusing on education, one person told us: “There’s a lot of people who think ‘it’s too late you know, my dad never went to school, his dad never went to school, I went for a bit and then I got bullied and then I didn’t go. So what am I going to do?’ There’s lots of people that feel proper stuck.” </p>
<p>The combination of economic deprivation and lack of educational prospects makes members of GRT communities more vulnerable to mental ill health. </p>
<p><strong>3. Barriers to seeking help</strong></p>
<p>The barriers to seeking help for poor mental health highlighted by our interviews were perhaps the most telling sign of a crisis in this community. We identified issues in terms of awareness of mental health support services, especially the challenges of knowing what support is available while travelling. </p>
<p>The unsuitability of services was another issue. One participant described the difficulties of even accessing emergency help: “An ambulance won’t actually come to the [Traveller] site until they have a police escort, and you are suicidal, and they treat you as if you’re a criminal and you might actually attack them.”</p>
<p>Stigmas surrounding mental health issues also cropped up. “My mother and my brother are very, very uncomfortable with me discussing my issues and they basically, they don’t acknowledge it and they don’t want to talk about it,” one person told us. </p>
<p>Participants described their lack of trust in support services too. One person said: “It’s a real driven, fear-based thing why a lot of the time we don’t access those things. It’s like a discrimination thing that’s gone down and a fear of like actual services coming and taking your kids. If you reach out with your mental health, that mental health issue may be used as a reason for taking away your children or involving social services.” </p>
<p>All of these factors negatively impacted the mental health of members of the GRT communities and prevented engagement with relevant support services. </p>
<p>Our research illustrates the importance of providing services to Gypsy, Roma and Traveller people with the cultural understanding, knowledge and resources to support them. A starting point for such an initiative would be an in-depth investigation of the psychological, social, environmental and institutional factors that make this community vulnerable and disadvantaged in their mental health care. </p>
<p>Building trust within these communities is also vital to improving their engagement with services. Dedicated outreach teams, alongside easier access to mainstream services, may be an effective method for achieving this. </p>
<p>The courage shown by Tyson Fury in discussing his mental health battles sets an example for other Gypsy, Roma and Traveller people to show that it is not a sign of weakness to experience mental ill health, and that support is beneficial and available for anyone in need.</p><img src="https://counter.theconversation.com/content/211802/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Philip Tyson wishes to thank Rebecca Thompson for her invaluable contribution to this research, particularly in terms of interviewing members of the GRT community. He would also like to thank Bridie Stone for her assistance in writing the journal article.</span></em></p>Tyson Fury has a history of mental ill health, something which is reflected in his series, At Home With The Furys on Netflix.Philip Tyson, Associate Professor of Psychology, University of South WalesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2125272023-09-13T12:26:32Z2023-09-13T12:26:32ZOffering treatment to drug users instead of arresting them reduces crime and addiction – new research into police diversion program shows<figure><img src="https://images.theconversation.com/files/547289/original/file-20230908-28933-n5gp3f.jpg?ixlib=rb-1.1.0&rect=16%2C8%2C5447%2C3628&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People mourn loved ones who have died from drug overdoses before replica tombstones in Binghamton, N.Y., on Aug. 19, 2023.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/friends-and-family-members-of-people-who-have-died-from-news-photo/1626209256?adppopup=true">Andrew Lichtenstein/Corbis via Getty Images</a></span></figcaption></figure><p>When police get suspected drug abusers treatment rather than arresting them, those people are less likely to abuse drugs or commit drug-related crimes in the future, <a href="https://sirow.arizona.edu/sites/sirow.arizona.edu/files/DefProg_Outcomes_Report_2022_final.pdf">new, limited research finds</a>. This kind of police intervention can help reduce opioid abuse.</p>
<p>The U.S. has been in the throes of <a href="https://www.npr.org/2021/12/30/1069062738/more-than-a-million-americans-have-died-from-overdoses-during-the-opioid-epidemi">rampant opioid abuse since the late 1990s</a>. Communities around the country have experienced <a href="https://doi.org/10.1016/j.drugpo.2021.103555">increases in opioid-related deaths</a> and crimes as a result. </p>
<p>One study <a href="https://doi.org/10.1001/jamanetworkopen.2018.0217">shows opioid-related deaths more than quadrupled</a> from 9,489 in 2001 to 42,245 in 2016. Another study indicates that people addicted to opioids are more likely than people who don’t use opioids <a href="https://doi.org/10.1001/jamanetworkopen.2018.0558">to have run-ins with police</a>. The rate of opioid-related crimes in the U.S. has increased substantially, <a href="https://doi.org/10.1016/j.drugpo.2021.103555">from 32 per 100,000 people in 2005 to 78 per 100,000 people in 2018</a>. </p>
<p>Historically, for public safety, <a href="https://ejournals.bib.uni-wuppertal.de/index.php/sws/article/view/432/817">police have arrested people suspected of using drugs</a>. Research <a href="https://doi.org/10.1186/s12954-022-00652-2">shows, though, that this approach has not been effective</a> at reducing drug abuse or related crimes. </p>
<p>But there is another way that appears to work better. In Arizona, the Tucson Police Department is trying an approach known as <a href="https://www.thenationalcouncil.org/program/deflection-and-pre-arrest-diversion-to-prevent-opioid-overdose/">pre-arrest diversion</a>. When officers respond to community calls about crime, they sometimes suspect the perpetrator may be abusing drugs. When they do, they don’t always arrest that person. Instead, officers connect that person with substance abuse treatment providers. I <a href="https://sirow.arizona.edu/sites/sirow.arizona.edu/files/DefProg_Outcomes_Report_2022_final.pdf">recently led a study</a> that found this approach is as effective as arrest at reducing both drug abuse and crime.</p>
<p>As a professor of social and behavioral sciences, <a href="https://sirow.arizona.edu/person/josephine-korchmaros-0">I study treatment models and policy improvement</a> regarding substance use and the criminal justice system. Following a <a href="https://doi.org/10.1146/annurev.publhealth.19.1.173">community-based approach</a>, I share the findings with other researchers and policymakers, as well as with the groups I studied.</p>
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<img alt="A man with his back to the camera points a heroin needle in the direction of his neck." src="https://images.theconversation.com/files/547867/original/file-20230912-29-oqgmpm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/547867/original/file-20230912-29-oqgmpm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=406&fit=crop&dpr=1 600w, https://images.theconversation.com/files/547867/original/file-20230912-29-oqgmpm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=406&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/547867/original/file-20230912-29-oqgmpm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=406&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/547867/original/file-20230912-29-oqgmpm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=510&fit=crop&dpr=1 754w, https://images.theconversation.com/files/547867/original/file-20230912-29-oqgmpm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=510&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/547867/original/file-20230912-29-oqgmpm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=510&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A man shoots heroin in a South Bronx park in New York on June 7, 2017.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/man-shoots-heroin-in-a-park-in-the-south-bronx-on-june-7-news-photo/693529400?adppopup=true">Spencer Platt/Getty Images</a></span>
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<h2>The shift in policing</h2>
<p>Before 2011, most police departments in the U.S. typically arrested people for drug abuse without giving them an option for substance abuse treatment.</p>
<p>Seattle’s Law Enforcement Assisted Diversion program, which was launched in 2011, <a href="https://www.fordfoundation.org/work/learning/research-reports/seattles-law-enforcement-assisted-diversion-program/">is the first known pre-arrest diversion program in the country</a>. Seattle police worked with <a href="https://kingcounty.gov/en/legacy/depts/community-human-services/mental-health-substance-abuse/diversion-reentry-services/lead">behavioral health providers, court officials and community groups</a> to set up the program, commonly referred to as LEAD.</p>
<p>LEAD focuses on <a href="https://ejournals.bib.uni-wuppertal.de/index.php/sws/article/view/432/817">addressing crime and community safety issues related to drug abuse</a>. The program also focuses on reducing problems such as difficulty finding a job when a person has a criminal record. </p>
<p>In 2015, the <a href="https://paariusa.org/about-us/">Police Assisted Addiction and Recovery Initiative</a> grew out of Gloucester, Massachusetts’ policy to send people who use drugs to substance abuse treatment instead of arresting them. The initiative has helped <a href="https://paariusa.org/about-us/">nearly 600 police departments, including Tucson’s, across 34 states</a> to put in place similar drug- and opioid-abuse diversion programs.</p>
<p>In Tucson, instead of arresting people for illicit drug use or related crimes such as trespassing, <a href="https://ptaccollaborative.org/wp-content/uploads/2019/11/11-12_Hall.pdf">officers may encourage those people</a> to enroll in substance abuse treatment and give them rides to treatment providers. In addition to <a href="https://doi.org/10.1176/foc.1.2.115">evidence-based substance abuse treatment</a>, such as providing medication that treats withdrawal symptoms, the providers offer <a href="https://www.codac.org/services/">other health care services</a>, mental health treatment and other support.</p>
<p>The department <a href="https://tucson.com/news/local/tucson-police-pushing-treatment-rather-than-jail-for-hundreds-of-drug-users/article_0d3dd2fa-83af-5457-acce-8dfb0168b100.html">rolled out the program in July 2018</a>. That year, Pima County, where Tucson is located, <a href="https://www.azdhs.gov/opioid/#dashboards-overdose-deaths">had 175 fatal opioid overdoses</a> and <a href="https://ptaccollaborative.org/wp-content/uploads/2019/11/11-12_Hall.pdf">an increase in property crime due to substance and opioid abuse</a>, and there were 1,116 opioid overdose deaths statewide in Arizona. </p>
<p>My <a href="https://sirow.arizona.edu/sites/sirow.arizona.edu/files/DefProg_FeasAccept_Report_2022_final.pdf">research shows</a> that 2,129 times in a three-year period, officers sent people to substance abuse treatment instead of arresting them. And officers gave <a href="https://sirow.arizona.edu/sites/sirow.arizona.edu/files/DefProg_FeasAccept_Report_2022_final.pdf">people rides to treatment</a> 965 times. The data I analyzed also shows this approach takes 25 minutes less time, per incident, on average, than arresting people.</p>
<p>Programs like these represent a shift from arrest and criminalization of people who abuse drugs toward a police response that focuses on longer-term reduction of drug abuse.</p>
<figure class="align-center ">
<img alt="Two women drop flowers on the pavement as five people sit with their arms locked and their backs against a building entrance." src="https://images.theconversation.com/files/547893/original/file-20230912-17-bmcxo7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/547893/original/file-20230912-17-bmcxo7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/547893/original/file-20230912-17-bmcxo7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/547893/original/file-20230912-17-bmcxo7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/547893/original/file-20230912-17-bmcxo7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/547893/original/file-20230912-17-bmcxo7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/547893/original/file-20230912-17-bmcxo7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Protesters calling for overdose prevention policies drop flowers at the New York governor’s New York City office on Aug. 28, 2019, to symbolize the lives lost to drug overdose.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/protesters-dropped-flowers-by-the-people-risking-arrest-news-photo/1164771437?adppopup=true">Erik McGregor/LightRocket via Getty Images</a></span>
</figcaption>
</figure>
<h2>The effectiveness of pre-arrest diversion programs</h2>
<p>Findings from research on the effectiveness of Seattle’s pre-arrest diversion program suggest that these criminal diversion programs result in <a href="https://doi.org/10.1016/j.evalprogplan.2017.05.008">fewer arrests for people with substance abuse disorders</a>. The findings also indicate that the program decreased homelessness, another program goal, with participants <a href="https://doi.org/10.1177/0011128716687550">twice as likely to have housing after participating</a>.</p>
<p>My team’s research shows that people who were offered substance abuse treatment, instead of being arrested, decreased their drug use more than people who were not offered substance abuse treatment and were arrested. On average, <a href="https://sirow.arizona.edu/sites/sirow.arizona.edu/files/DefProg_Outcomes_Report_2022_final.pdf">six months after their interaction with Tucson police</a>, people who accepted diversion to a substance abuse treatment program used illegal drugs less frequently than people who had been arrested. </p>
<p>In addition, diversion to substance abuse treatment in Tucson was as effective as arrest in <a href="https://sirow.arizona.edu/sites/sirow.arizona.edu/files/DefProg_Outcomes_Report_2022_final.pdf">decreasing criminal activity</a>. </p>
<p>That is why these programs may be an effective way to address the opioid epidemic.</p><img src="https://counter.theconversation.com/content/212527/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Josephine Korchmaros received funding from the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT) Grant Number H79TI081559 and Arnold Ventures to support a research study evaluating the Tucson Police Department's pre-arrest deflection program.</span></em></p>Police diversion programs for drug users shift officers’ focus from criminalization to treatment.Josephine Korchmaros, Professor of Social and Behavioral Sciences, University of ArizonaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2059652023-05-25T20:28:19Z2023-05-25T20:28:19ZIn B.C., Alberta and around the world, forcing drug users into treatment is a violent policy<figure><img src="https://images.theconversation.com/files/528425/original/file-20230525-19-h3emb.JPG?ixlib=rb-1.1.0&rect=0%2C11%2C3976%2C2023&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A man waits to enter a supervised consumption site at a health centre in Calgary, Alta., in August 2021. </span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Jeff McIntosh</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/in-b-c---alberta-and-around-the-world--forcing-drug-users-into-treatment-is-a-violent-policy" width="100%" height="400"></iframe>
<p>Intervention without human rights <a href="https://doi.org/10.1176/appi.ps.201800066">goes by many names</a> — involuntary institutionalization, compulsory drug treatment, “coerced care,” <a href="https://pressprogress.ca/recovery-industry-groups-attacking-safe-supply-in-bc-have-deep-ties-with-conservative-political-actors/">forced abstinence</a> or a combination of all of those terms.</p>
<p>Involuntary treatment in the Global South has been labelled inhumane by rights-based organizations, including the <a href="https://www.unodc.org/roseap/uploads/archive/documents/Publications/2022/Booklet_1_12th_Jan_2022.pdf">United Nations Office on Drugs and Crime</a>, <a href="https://www.unaids.org/en/resources/presscentre/featurestories/2023/march/20230301_drug-laws-asia-pacific">UNAIDS</a> and <a href="https://www.hrw.org/report/2012/07/24/torture-name-treatment/human-rights-abuses-vietnam-china-cambodia-and-lao-pdr">Human Rights Watch</a>.</p>
<p>But after years of <a href="https://financialpost.com/news/economy/canada-housing-affordability-crisis">housing unaffordability</a>, an <a href="https://news.gov.bc.ca/releases/2023PSSG0008-000109">increasingly poisonous drug supply</a> and <a href="https://www.lyrahealth.com/blog/barriers-mental-health/#:%7E:text=Research%20shows%20some%20people%20don,for%20mental%20health%20for%20some.">inaccessible voluntary mental health supports</a>, mainstream political parties in Canada — including Alberta’s United Conservative Party (UCP) as the May 29 provincial election approaches — are seemingly <a href="https://www.vancouverisawesome.com/highlights/bc-premier-responds-to-decampment-in-downtown-eastside-6816406">toying with the idea</a> of making <a href="https://themainlander.com/2023/04/14/an-open-letter-from-academics-against-vancouvers-encampment-evictions/">the people most affected by inequality and poverty simply disappear</a> via involuntary institutionalization.</p>
<p><a href="https://www.cbc.ca/news/canada/british-columbia/david-eby-involuntary-treatment-criticism-1.6664848">The British Columbia NDP under David Eby</a>, as well as <a href="https://www.pentictonherald.ca/news/article_6057aa30-9693-11ec-bc0b-5bb218ff7149.html">Kevin Falcon’s B.C. United Party</a>, have floated the idea of expanding forced institutionalization to include aspects of substance use.</p>
<p>In Alberta, <a href="https://calgary.ctvnews.ca/ucp-promises-to-allow-mandatory-drug-treatment-open-addiction-and-mental-health-beds-1.6399367?cache=uhposhkob">Danielle Smith’s UCP</a> has also proposed apprehending those with, in her words, “severe drug addiction.”</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1658298860425433089"}"></div></p>
<h2>Increased risk of overdose</h2>
<p>Pivot Legal Society, Eby’s former employer and a human rights organization, has <a href="https://assets.nationbuilder.com/pivotlegal/pages/3690/attachments/original/1679547073/Involuntary_Treatment_-_Criminalization_by_another_name_-_Finalized_2.pdf?1679547073">responded with a statement</a> condemning the practice. It was endorsed by 16 other community organizations.</p>
<p>The evidence shows that forced treatment leads to increased risk of death and <a href="https://bcombudsperson.ca/investigative_report/committed-to-change-protecting-the-rights-of-involuntary-patients-under-the-mental-health-act/">deprives survivors of autonomy</a>, while <a href="https://doi.org/10.1016/j.drugpo.2015.12.005">no positive benefits have been established</a>. The discretionary power to forcibly institutionalize people also <a href="https://doi.org/10.1080/10826080500260891">causes harm</a> <a href="https://doi.org/10.1016/j.drugpo.2013.05.017">and erodes trust</a> in health-care services on a systemic level.</p>
<p>From <a href="https://doi.org/10.1111/add.14159">Mexico</a> to <a href="https://doi.org/10.1016/j.drugalcdep.2022.109492">Sweden</a>, <a href="https://doi.org/10.1111/add.14769">Vancouver</a> <a href="https://doi.org/10.1371/journal.pmed.1003759">and England</a>, involuntary treatment has been found to increase risk of overdose and shows no significant impact on substance use patterns.</p>
<p>Studies on involuntary treatment for psychiatric reasons also show negative outcomes. Not only is forced institutionalization deeply traumatic, it’s associated with <a href="https://doi.org/10.1192/bjo.2019.19">longer stays</a> in hospital, increased hospital readmission rates and a greater likelihood of <a href="https://doi.org/10.1007/s00406-007-0777-4">dying by suicide</a> upon discharge.</p>
<figure class="align-center ">
<img alt="Protesters hold up an orange sign with white text that reads Join the Call to End Overdose Deaths." src="https://images.theconversation.com/files/527844/original/file-20230523-19-6uc39o.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/527844/original/file-20230523-19-6uc39o.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=351&fit=crop&dpr=1 600w, https://images.theconversation.com/files/527844/original/file-20230523-19-6uc39o.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=351&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/527844/original/file-20230523-19-6uc39o.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=351&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/527844/original/file-20230523-19-6uc39o.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=442&fit=crop&dpr=1 754w, https://images.theconversation.com/files/527844/original/file-20230523-19-6uc39o.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=442&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/527844/original/file-20230523-19-6uc39o.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=442&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Supporters attend a Calgary rally after a lawsuit was filed against the Alberta government, alleging that its rules governing supervised drug-use sites will have life and death impacts in August 2021.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Jeff McIntosh</span></span>
</figcaption>
</figure>
<h2>Lowered tolerance</h2>
<p>Being discharged after involuntary drug treatment <a href="https://doi.org/10.1136/bmj.326.7396.959">has long been linked</a> to overdose risk, even before the drug supply <a href="https://globalnews.ca/news/9403819/street-drugs-canada-toxic-naloxone-less-effective/">was as poisonous and unpredictable as it is now.</a></p>
<p>Data from the United States shows that from 2010 until 2017, <a href="https://doi.org/10.1001/jamanetworkopen.2020.29676">all inpatient</a> forms of substance use treatment, even those that included prescribed alternatives, increased the risk of overdose upon discharge.</p>
<p>The association between forced treatment and overdose has been made clear in studies of both existing pathways of involuntary institutionalization in B.C.: the <a href="https://www.leg.bc.ca/content/CommitteeDocuments/42nd-parliament/3rd-session/health/report/SSC-Health-Report_42-3_2022-11-01_Final.pdf">criminal justice system</a> and <a href="https://doi.org/10.1016/j.drugalcdep.2022.109492">public health mechanisms</a>.</p>
<p>These overdoses <a href="https://www.npr.org/sections/health-shots/2022/05/11/1098314220/overdose-deaths-continued-to-rise-in-2021-reaching-historic-highs">are trending away from being predominantly non-fatal to being deadly</a> due to the toxicity of the supply. People are being discharged into the same living conditions with lowered tolerance.</p>
<figure class="align-center ">
<img alt="A bearded man wearing blue rubber gloves tests drug samples with an infra-red machine." src="https://images.theconversation.com/files/527845/original/file-20230523-17-71x03r.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/527845/original/file-20230523-17-71x03r.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/527845/original/file-20230523-17-71x03r.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/527845/original/file-20230523-17-71x03r.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/527845/original/file-20230523-17-71x03r.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/527845/original/file-20230523-17-71x03r.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/527845/original/file-20230523-17-71x03r.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">An employee of Get Your Drugs Tested uses an infra-red spectrometer to test drug samples in Vancouver in 2022. An animal tranquilizer called Xylazine had been making its way into the drug supply and was linked to a growing number of deaths in Ontario.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Jimmy Jeong</span></span>
</figcaption>
</figure>
<h2>Settler colonial violence continues</h2>
<p>In B.C., young people cannot be involuntarily institutionalized for substance use alone. But <a href="https://rcybc.ca/reports-and-publications/detained/">reports suggest it is occurring through misuse of the province’s Mental Health Act</a>.</p>
<p>The B.C. NDP <a href="https://news.gov.bc.ca/releases/2020MMHA0032-001139">proposed involuntarily institutionalizing youth who experience overdoses in 2020</a>, but dropped the idea after <a href="https://doi.org/10.17269/s41997-020-00459-3">intense scrutiny</a> <a href="https://thetyee.ca/Opinion/2020/11/09/NDP-Bill-Youth-Detention-Overdose/">from advocates</a> with lived experience of forced detention, drug policy experts and academics.</p>
<p>Involuntary psychiatric detentions among youth, however, are at an all-time high in the province. </p>
<p>According to <a href="https://rcybc.ca/wp-content/uploads/2021/01/RCY_Detained-Jan2021.FINAL_.pdf">B.C.’s Representative for Children and Youth</a>, more than 2,500 children, some as young as 10 years old, were hospitalized against their will in 2018. That’s a 162 per cent increase since 2008.</p>
<p>As with most <a href="https://yellowheadinstitute.org/wp-content/uploads/2018/09/carceral-colonialism-in-canada-final-version.pdf">punitive and carceral</a> policies in Canada, the province’s Mental Health Act is used disproportionately against Indigenous people in British Columbia, including children — a <a href="https://www.drugdatadecoded.ca/p/clearing-the-plains-20-alberta-drug">disturbing continuation</a> of the violence against Indigenous children that <a href="https://www.nytimes.com/2021/06/07/world/canada/mass-graves-residential-schools.html">Canada is founded upon</a>.</p>
<p>The B.C. Ministry of Health has acknowledged the over-representation of Indigenous children involuntarily detained in the province, though it says it’s not aware of the extent because provinces aren’t required to record <a href="https://edmontonsocialplanning.ca/2021/02/24/feature-report-confronting-racism-with-data-why-canada-needs-disaggregated-race-based-data/">patient ethnicity</a>.</p>
<figure class="align-center ">
<img alt="A dark haired man places a pair of small shoes on a table with other shoes." src="https://images.theconversation.com/files/527847/original/file-20230523-23-duv06c.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/527847/original/file-20230523-23-duv06c.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=417&fit=crop&dpr=1 600w, https://images.theconversation.com/files/527847/original/file-20230523-23-duv06c.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=417&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/527847/original/file-20230523-23-duv06c.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=417&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/527847/original/file-20230523-23-duv06c.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=524&fit=crop&dpr=1 754w, https://images.theconversation.com/files/527847/original/file-20230523-23-duv06c.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=524&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/527847/original/file-20230523-23-duv06c.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=524&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Prime Minister Justin Trudeau places a pair of children’s shoes as he takes part in ceremonies for the National Day of Truth and Reconciliation in Ottawa on Sept. 30, 2022.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Sean Kilpatrick</span></span>
</figcaption>
</figure>
<h2>Relying on involuntary treatment</h2>
<p>Involuntary psychiatric hospitalizations under the B.C. Mental Health Act for those older than 14 also <a href="https://doi.org/10.1177/07067437221128477">increased to 23,531 from 14,195</a> from 2008 until 2018 in the province.</p>
<p>The liberal use of forced interventions is in part due to B.C.’s abysmal voluntary mental health service landscape characterized by <a href="https://www.cihi.ca/en/1-in-10-canadians-wait-4-months-or-more-before-receiving-community-mental-health-counselling">lengthy wait times</a>, <a href="https://www.psychologists.bc.ca/sites/default/files/2021-02/Suggested%20current%20market%20rates%202021%201.pdf">high access fees</a>, capacity shortages and a lack of culturally appropriate services. This creates barriers for people seeking timely support.</p>
<p>Relying on a system <a href="https://doi.org/10.1159/000052056">designed to criminalize</a> drug use, while <a href="https://www.health.gov.bc.ca/library/publications/year/2005/guide-mental-health-act.pdf">temporarily stabilizing</a> people via involuntary mental health treatment, risks causing further harm, trauma and death.</p>
<p>Forced institutionalization is weaponized against drug users already; <a href="https://doi.org/10.1177/07067437221128477">18.8 per cent</a> of apprehended people in B.C. had a primary diagnosis of substance use disorder. Likewise, 10 per cent of involuntarily hospitalized youth were labelled as having the disorder from 2013 to 2018.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/as-an-indigenous-doctor-i-see-the-legacy-of-residential-schools-and-ongoing-racism-in-todays-health-care-162048">As an Indigenous doctor, I see the legacy of residential schools and ongoing racism in today's health care</a>
</strong>
</em>
</p>
<hr>
<h2>Moral panics</h2>
<p>Expanding forced treatment in Canada and elsewhere stems from the same <a href="https://doi.org/10.3138/cbmh.16.1.65">moral panics</a> that drove earlier drug prohibition regimes imposed through <a href="https://publications.gc.ca/collections/collection_2017/aanc-inac/R5-158-2-1978-eng.pdf">colonial power</a>.</p>
<p>Instead of locking people up against their will, governments should intervene in the poisoned drug supply and turn to <a href="https://substanceuse.ca/heroin-compassion-clubs-cooperative-model-reduce-opioid-overdose-deaths-disrupt-organized-crimes">other more humane methods</a>, including compassion clubs for drug users as advocated by <a href="https://themainlander.com/2022/11/04/closing-gaps-reducing-barriers-another-report-for-the-pile-while-six-people-die-each-day/">drug user groups and front-line workers</a>.</p>
<p>Provinces should collaborate with municipalities and health boards to expand life-saving and life-affirming safe use sites, and all levels of government must urgently prioritize solutions to the housing crisis.</p><img src="https://counter.theconversation.com/content/205965/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Instead of forcing people into substance use treatment, provinces should work with municipalities and health boards to expand life-saving safe use sites and tackle the housing crisis.Tyson Singh Kelsall, PhD student, Health Sciences, Simon Fraser UniversityAlya Govorchin, MSc Candidate, Faculty of Health Sciences, Simon Fraser UniversityLyana Patrick, Assistant Professor of Indigenous Health, Simon Fraser UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2017162023-05-07T08:28:51Z2023-05-07T08:28:51ZMental health: almost half of Johannesburg students in new study screened positive for probable depression<figure><img src="https://images.theconversation.com/files/522267/original/file-20230421-15-slnlgo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Wesley Lazarus/Shutterstock </span></span></figcaption></figure><p>Depression is a mental health disorder characterised by a persistently low mood or loss of interest in activities. It causes significant impairment in daily life. Possible causes include a combination of biological, psychological and social sources of distress. </p>
<p>It’s a major mental illness that largely goes undiagnosed. Survey <a href="https://doi.org/10.1192/bjp.187.6.495">estimates</a> put the lifetime risk of depression at 10%. This makes depression one of the <a href="https://www.who.int/news-room/fact-sheets/detail/depression#:%7E:text=Approximately%20280%20million%20people%20in%20the%20world%20have%20depression%20(1)">most common mental illnesses</a>. In 2019, the World Health Organization estimated that <a href="https://www.who.int/news-room/fact-sheets/detail/depression#:%7E:text=Approximately%20280%20million%20people%20in%20the%20world%20have%20depression%20(1)">280 million</a> people in the world – about 3.8% of the population – had depression. </p>
<p>Projections for South Africa are alarming, with research suggesting that <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4038770/">one in three people</a> will experience depression, anxiety or a substance use disorder in their lifetime. </p>
<p>University students are particularly at <a href="https://pubmed.ncbi.nlm.nih.gov/30211576/">high risk</a> of depression. One South African study estimated that <a href="https://www.tandfonline.com/doi/full/10.1080/07448481.2016.1178120">24.2%</a> of university students have mild depression, and <a href="https://www.tandfonline.com/doi/full/10.1080/07448481.2016.1178120">12.4%</a> have moderate to severe depression. Globally, an average of about <a href="https://psycnet.apa.org/manuscript/2018-44951-001.pdf#page=17">21%</a> of university students have major depressive disorder.</p>
<p>This is concerning because students with depression face very specific challenges. These include: </p>
<ul>
<li><p>worse <a href="https://pubmed.ncbi.nlm.nih.gov/7793438/">academic outcomes</a></p></li>
<li><p>low productivity</p></li>
<li><p>more likely to struggle with <a href="https://pubmed.ncbi.nlm.nih.gov/15060400/">alcohol abuse</a> in their adulthood </p></li>
<li><p>and high <a href="https://pubmed.ncbi.nlm.nih.gov/21823951/">rates of suicide</a>. </p></li>
</ul>
<p>It is clear that this population group needs targeted interventions. Up-to-date research on the prevalence and drivers of depression among students is crucial to inform potential interventions in this group.</p>
<p>The studies that have been done in South Africa do not cover the student population across the country. There’s a lack of data on the prevalence and drivers of depression among students in Johannesburg. Johannesburg is South Africa’s main commercial city and has the country’s highest population of students. To address this gap, we recently conducted an <a href="https://www.frontiersin.org/articles/10.3389/fpsyt.2023.1018197/full">online survey</a> among undergraduate students at the University of the Witwatersrand in South Africa.</p>
<p>Almost half of the study participants screened positive for probable depression. Probable depression was associated with socio-demographic factors such as economic status, and modifiable behavioural factors such as substance use. These two factors are commonly identified correlates of depression in this group. The prevalence of probable depression among undergraduate students in this study was high relative to the general population. Our findings are an important step towards helping universities tailor mental health programmes to students’ needs.</p>
<h2>Our study</h2>
<p>We used the <a href="https://aidsetc.org/sites/default/files/resources_files/PHQ-2_English.pdf">Patient Health Questionnaire (PHQ-2)</a> to assess the prevalence of probable depression. We also identified factors associated with probable depression. These factors included age, marital status and substance use (alcohol, cannabis, tobacco and other substances). </p>
<p>We had a response rate was 8.4% (1,046/12,404). Though low, such response rates are common in online surveys. While our survey should be interpreted with caution, the key findings are similar to other <a href="https://pubmed.ncbi.nlm.nih.gov/32664032/">studies elsewhere</a>.</p>
<p>Forty-eight per cent (439/910) screened positive for probable depression.</p>
<p>Certain socio-demographic factors were associated with lower odds of screening positive for probable depression. Students who identified as white were 36% less likely than black students to screen positive for depression. Those who could afford the most important things – but few luxury goods – were 50% less likely to screen positive for depression than those who had enough money for food and clothes, but were short of many other things.</p>
<p>Students with enough money for luxury goods and extra things were 56% less likely than those who had enough money for food and clothes, but were short of many other things, to screen positive for depression. These findings are similar to a recent <a href="https://sajp.co.za/index.php/SAJP/article/view/1795">study</a> among undergraduate physiotherapy clinical students. </p>
<p>Students who reported substance use had higher odds of screening positive for probable depression. But the probabilities varied based on the substance used. </p>
<p>Those reporting using cannabis were 29% more likely than students who didn’t use cannabis to screen positive for probable depression. It’s important to note that the global <a href="https://www.cambridge.org/core/journals/psychological-medicine/article/association-between-cannabis-use-and-depression-a-systematic-review-and-metaanalysis-of-longitudinal-studies/B144B7AE5A3D973289DBDD99ADE21E58">findings</a> on the <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2723657">association</a> between cannabis use and depression <a href="https://pubmed.ncbi.nlm.nih.gov/17662880/">vary</a>. But our finding is an important consideration given the legal use of cannabis in South Africa.</p>
<p>Reported alcohol use was common in our study. But it was not associated with screening positive for probable depression. This is contrary to <a href="https://onlinelibrary.wiley.com/doi/10.1111/add.14935">findings</a> from other <a href="https://pubmed.ncbi.nlm.nih.gov/31733662/">studies</a>. Our study did not find an association between tobacco use and screening positive for probable depression. But other <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-9-356">researchers</a> have reported a strong association between smoking and depression in adolescents and adults. While we did not find significant associations between alcohol and tobacco use and screening positive for depression, we believe these are important correlates. Alcohol and tobacco are often used as coping mechanisms for individuals with depression. </p>
<h2>Recommendations</h2>
<p>The odds of screening positive for depression were associated with specific sociodemographic and selected behavioural factors. </p>
<p>Mental health professionals working with undergraduate students at the University of Witwatersrand should strengthen mental health (including depression) and risk factors (substance use) screening and referral for treatment services. </p>
<p>In addition, these findings call for strengthening the awareness and use of existing counselling services among undergraduate students at the campus and other services out of the university campus, such as the South African Depression and Anxiety Group’s <a href="https://www.sadag.org/index.php?option=com_content&view=article&id=11&Itemid=114">help line</a>.</p><img src="https://counter.theconversation.com/content/201716/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joel Msafiri Francis receives funding from the South Africa National Research Foundation (NRF) and the University of the Witwatersrand. </span></em></p>University students are particularly at high risk of depression. One global study suggests 21% of students have major depressive disorder.Joel Msafiri Francis, Senior Researcher, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1991972023-03-08T19:07:00Z2023-03-08T19:07:00ZI think I need therapy. Here are 5 types of psychotherapy to help with almost any mental health problem<figure><img src="https://images.theconversation.com/files/513579/original/file-20230306-22-3pj7o2.jpg?ixlib=rb-1.1.0&rect=0%2C230%2C5863%2C3566&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/person-in-black-pants-and-black-shoes-sitting-on-brown-wooden-chair-4101143/">Pexels/cottonbro studio</a></span></figcaption></figure><p>You have made a momentous decision: you will seek psychological treatment for your depression, anxiety, substance abuse, or other mental health issue. </p>
<p>Your mind then may turn to the question of what type of treatment would best suit you. To even ask this sophisticated question, you need to realise there are various types of psychological treatment. To make a wise choice, you must understand what each type of therapy provides. </p>
<p>Let’s look at several types of psychotherapy (also known as talking therapy) that have the potential to help with almost any mental health problem. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/think-therapy-is-navel-gazing-think-again-173312">Think therapy is navel-gazing? Think again</a>
</strong>
</em>
</p>
<hr>
<h2>1. Cognitive behaviour therapy</h2>
<p>Cognitive behaviour therapy (<a href="https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral">CBT</a>) is a common type of therapy where the therapist explores the thoughts and behaviours that relate to your therapy goal. </p>
<p>Let’s suppose you have been feeling depressed for months. Relevant thoughts might be that no one likes you and that you are worthless. Relevant behaviours might include staying in your home and avoiding contact with others. </p>
<p>The therapist would likely help you challenge the accuracy and usefulness of those thoughts and find replacement thoughts. The therapist might encourage you to do more for fun and to interact more with others.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-cognitive-behaviour-therapy-37351">Explainer: what is cognitive behaviour therapy?</a>
</strong>
</em>
</p>
<hr>
<h2>2. Acceptance and commitment therapy</h2>
<p>In <a href="https://www.racgp.org.au/afp/2012/september/acceptance-and-commitment-therapy">acceptance and commitment therapy</a>, you would instead be asked to accept your negative thoughts as yours (regardless of whether they are accurate) and also accept your negative emotions. </p>
<p>The therapist would encourage you to look at your thoughts and emotions as separate from you so you can examine them more objectively. Acceptance might reduce your negative feelings about yourself. </p>
<p>The therapist would explore your values and encourage you to commit to acting according to them. If you value kindness, for instance, the therapist might encourage you to show kindness to others. </p>
<h2>3. Psychodynamic therapy</h2>
<p>A <a href="https://psychcentral.com/lib/psychodynamic-therapy#your-therapists-role">psychodynamic</a> therapist would help you explore your childhood, searching for traumas and difficulties with your parents. </p>
<figure class="align-right ">
<img alt="Woman writing in notebook" src="https://images.theconversation.com/files/513577/original/file-20230306-14-pelyme.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/513577/original/file-20230306-14-pelyme.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=838&fit=crop&dpr=1 600w, https://images.theconversation.com/files/513577/original/file-20230306-14-pelyme.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=838&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/513577/original/file-20230306-14-pelyme.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=838&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/513577/original/file-20230306-14-pelyme.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1054&fit=crop&dpr=1 754w, https://images.theconversation.com/files/513577/original/file-20230306-14-pelyme.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1054&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/513577/original/file-20230306-14-pelyme.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1054&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Some therapies look deep into your past.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/ewRSEBHyO_c">Kateryna Hliznitsova/Unsplash</a></span>
</figcaption>
</figure>
<p>If you felt unloved by your parents as a child, you would consider whether your parents provide a fair representation of the entire world. </p>
<p>You might consider to what extent you deserve love now as an adult. You might also gain insight into how your early experiences colour your current expectations, and affect your emotions and behaviour. </p>
<p>You might find yourself transferring to the therapist your feelings toward your parents and then realise that others are not your parents and you are no longer an unloved child.</p>
<h2>4. Narrative therapy</h2>
<p>In <a href="https://www.verywellmind.com/narrative-therapy-4172956">narrative therapy</a>, you would explore the stories of your life, particularly the stories that seem to persist. </p>
<p>If you were an outsider in school, reluctant to join in social activities, you may think of yourself as a loner. As an adult, even though you engage fully and successfully in social interactions at work, you may continue to think of yourself as a loner. </p>
<p>In other words, the story you tell yourself remains unchanged despite your social success at work, and you feel depressed about being alone. </p>
<p>In becoming aware of the story of your life, you create distance from the story and you may find ways to change the story (the narrative). In essence, you rewrite the story in a realistic way to develop toward being the person you want to be. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/psychologists-are-starting-to-talk-publicly-about-their-own-mental-illnesses-and-patients-can-benefit-177716">Psychologists are starting to talk publicly about their own mental illnesses – and patients can benefit</a>
</strong>
</em>
</p>
<hr>
<h2>5. Person-centred therapy</h2>
<p>In <a href="https://www.goodtherapy.org/learn-about-therapy/types/person-centered">person-centered therapy</a>, sometimes called supportive counselling, the therapist would listen attentively, try hard to understand life as you experience it and try to understand and even feel your emotions. </p>
<p>The therapist would show caring and an interest in helping you, in the expectation that you can find your own way to overcome feeling depressed. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/513586/original/file-20230306-16-jjlxae.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/513586/original/file-20230306-16-jjlxae.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/513586/original/file-20230306-16-jjlxae.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/513586/original/file-20230306-16-jjlxae.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/513586/original/file-20230306-16-jjlxae.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/513586/original/file-20230306-16-jjlxae.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/513586/original/file-20230306-16-jjlxae.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Supportive therapists listen attentively and try to understand and feel your emotions.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/a-woman-talking-at-a-couple-s-therapy-session-5217833/">Antoni Shkraba/Pexels</a></span>
</figcaption>
</figure>
<h2>A mix of styles to suit you</h2>
<p>You can ask potential therapists what type of therapy they provide. Many will say they are <a href="https://www.verywellmind.com/eclectic-therapy-2671584">eclectic</a>, meaning they try to choose methods to suit each client and specific problem. They may combine methods of different therapy types. </p>
<p>They may also use popular methods such as <a href="https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/mindfulness-exercises/art-20046356">mindfulness training</a> that do not fit any specific therapy type. Mindfulness training involves focusing on your breathing and being aware of the here and now. </p>
<p>You can request an eclectic therapist to provide a certain type of therapy or certain therapy methods. Once the therapist gets to know you, you can discuss your preferences and decide on the therapy methods to use.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/meditation-and-mindfulness-offer-an-abundance-of-health-benefits-and-may-be-as-effective-as-medication-for-treating-certain-conditions-195276">Meditation and mindfulness offer an abundance of health benefits and may be as effective as medication for treating certain conditions</a>
</strong>
</em>
</p>
<hr>
<h2>How can you decide which one?</h2>
<p>You might wonder which type of therapy usually works best. The answer is unclear. Much depends on the specific client, the problem and the therapist. </p>
<p>Most types of therapy work <a href="https://www.cambridge.org/core/journals/epidemiology-and-psychiatric-sciences/article/is-psychotherapy-effective-a-reanalysis-of-treatments-for-depression/5D8EC85B6FA35B5CEE124381F18E51B9">moderately well</a> for treating people with depression. Psychotherapy also appears to be <a href="https://onlinelibrary.wiley.com/doi/10.1002/wps.20941">reasonably effective</a> for other types of psychological problems.</p>
<p>CBT has the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5797481/">strongest evidence</a> for treating a broad range of psychological problems (including <a href="https://www.sciencedirect.com/science/article/abs/pii/S0272735817302271">post-traumatic stress disorder</a>). However, CBT has the most evidence in part because it is heavily studied (for example to treat <a href="https://www.sciencedirect.com/science/article/abs/pii/S0005796722001747">specific phobias</a>).</p>
<p>Acceptance and commitment therapy is also backed by <a href="https://www.sciencedirect.com/science/article/pii/S0005796714001211">substantial evidence</a>, as is <a href="https://psycnet.apa.org/doiLanding?doi=10.1037%2Fa0018378">psychodynamic therapy</a>.</p>
<p>The effects of narrative therapy and person-centred therapy have not been studied so much.</p>
<p>Some people, including those with depression or psychosis, can benefit by receiving psychotherapy and taking medication <a href="https://www.nimh.nih.gov/health/topics/mental-health-medications">prescribed</a> by a GP or psychiatrist.</p>
<hr>
<p><em>If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14.</em></p><img src="https://counter.theconversation.com/content/199197/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Malouff does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>So you want to start therapy for your anxiety, depression or other mental health issue. What type of therapist should you choose? Here’s a quick guide to get you started.John Malouff, Associate Professor, School of Behavioural, Cognitive and Social Sciences, University of New EnglandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1867812022-07-29T09:47:30Z2022-07-29T09:47:30ZDrug misuse and suicidal behaviour more common on the anniversary of a parent’s death – new research<figure><img src="https://images.theconversation.com/files/476475/original/file-20220728-26342-iqbmrs.jpg?ixlib=rb-1.1.0&rect=14%2C0%2C4938%2C3297&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Risk of hospitalisation was higher in the same month their parent died, as well as during the two months following.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-sad-woman-sitting-on-window-593195693">Marjan Apostolovic/ Shutterstock</a></span></figcaption></figure><p>Losing a parent during adolescence and young adulthood can be particularly damaging to <a href="https://www.jahonline.org/article/S1054-139X(18)30084-3/fulltext">mental health and wellbeing</a>. Our <a href="https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(22)00158-X/fulltext">latest research</a> has now shown that young people who lost a parent were more likely to be admitted to hospital for treatment for substance misuse use problems or suicidal behaviour around the anniversary of their parents’ death. </p>
<p>We conducted a large study of nearly 2 million people using population data collected in Sweden between 2001 and 2014. To understand whether there was a greater risk of substance misuse or suicidal behaviour around the anniversaries of a parent’s death, we connected the dates of parental deaths with the dates that participants were admitted to hospital for drug misuse, self-harm or attempted suicide. We tracked participants for a period of four anniversaries.</p>
<p>Almost 3% of the study population experienced the death of a parent between ages 12 and 24. To make certain that any raised risk was specific to the anniversary of a parent’s death, we compared hospital admissions for drug use or suicidal behaviour around anniversaries with those that happened on different dates in the same year among those who had lost a parent.</p>
<p>We found that young people who had lost a parent were more likely to suffer substance use disorder or suicidal behaviour in the same month that their parent died, as well as during the following two months. This raised risk was seen again around the same dates during the following year.</p>
<p>One year after losing a parent, there was a 121% increased risk of hospital treatment for substance misuse in the two months following the anniversary among men, and a 91% increase among women compared with people who had not lost a parent. The increased risk for suicidal behaviour during the same period was 218% for males, but there was no notable increase among females. This pattern continue among those who had lost a parent for the next three years – though they became less common over time. Fortunately, fatal events were extremely rare.</p>
<figure class="align-center ">
<img alt="A young person wearing a hoodie is sitting alone in a hallway, holding their head in their hands." src="https://images.theconversation.com/files/476476/original/file-20220728-20112-mm5ak8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/476476/original/file-20220728-20112-mm5ak8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/476476/original/file-20220728-20112-mm5ak8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/476476/original/file-20220728-20112-mm5ak8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/476476/original/file-20220728-20112-mm5ak8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=565&fit=crop&dpr=1 754w, https://images.theconversation.com/files/476476/original/file-20220728-20112-mm5ak8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=565&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/476476/original/file-20220728-20112-mm5ak8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=565&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Not every young person who had lost a parent exhibited these behaviours.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-girl-student-sitting-alone-sad-1918573640">arrowsmith2/ Shutterstock</a></span>
</figcaption>
</figure>
<p>But it’s important to stress that substance misuse or instances of suicidal behaviour were not common in people who had lost a parent. Only around 2% of those who were bereaved were admitted to hospital during the study period for substance use disorder. Only around 1% were identified as exhibiting suicidal behaviour. But this behaviour did occur more frequently in people who had lost a parent at a relatively young age compared to those who did not.</p>
<p>Our study also showed that the risk of hospital treatment due to substance misuse or suicidal behaviour was higher in the initial years for men than women. But there was also a greater risk of prolonged substance use disorder among women – which persisted over four anniversaries. Women were also more likely to be treated in hospital for substance use disorder in the month before an anniversary, suggesting that anticipation of the anniversary date resulted in painful feelings. </p>
<h2>Grief and mental health</h2>
<p>Loss of a parent at a relatively young age will clearly be a source of intense grief for most people. But our study shows that, while it is uncommon, for some this anniversary may lead to harmful behaviour. But our study has also shown that grief-related distress diminishes over time – and so does the risk for substance misuse and suicidal behaviour.</p>
<p>Anniversaries of the loss of a loved one can be particularly distressing for people, <a href="https://link.springer.com/article/10.1007/s10654-015-9989-5">no matter their age</a>. But it’s uncertain why the anniversary of a loved one’s death seems to trigger mental ill-health to a greater extent than <a href="https://link.springer.com/article/10.1007/BF00756507">other important anniversaries</a> do – such as the bereaved family member’s birthday. This is something researchers will need to continue investigating. </p>
<p>Our research shows that there’s a clear need to support people who have lost parents around the time of loss – and that this support should also be given around the anniversary they lost a parent, possibly for many years. It’s also important to recognise that mental health risks may differ between men and women. Providing the right kind of support – including grief counselling, help with alcohol and other drug-related problems and mental health help – will be essential for reducing harm among people who have lost a parent.</p><img src="https://counter.theconversation.com/content/186781/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This study was supported by grants from the Swedish Research Council
(2017–03266; recipient: MR), the Swedish Research Council for Health,
Working Life and Welfare (2019–01236; recipient: AH), the UK
Economic and Social Research Council to the International Centre for
Life Course Studies (ES/R008930/1), and Nyckelfonden (OLL-695391;
recipient: SM). AH was also supported by Osaka University
International Joint Research Promotion Programme (type A) 2019–22
with University College London (integrated research on prevention,
treatment, and care for dementia). JSa was supported by the
Åbo Akademi University Foundation’s funding of the DemSwed Internal
Centre of Excellence 2019–24.</span></em></p>In men alone, the risk of being hospitalised due to suicidal behaviour one year after losing a parent was 218% greater than in people who hadn’t lost a parent.Scott Montgomery, Honorary Professor, Epidemiology, UCLLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1783922022-03-25T12:08:56Z2022-03-25T12:08:56ZDrugs that treat opioid use disorder are a good use for multibillion-dollar settlement funds<figure><img src="https://images.theconversation.com/files/453407/original/file-20220321-5945-7ns7ol.jpg?ixlib=rb-1.1.0&rect=181%2C375%2C3988%2C2363&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Dr. Laura Kehoe gives a presentation about why emergency room physicians should prescribe buprenorphine for people recovering from opioid overdoses.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/dr-laura-kehoe-gives-a-presentation-at-mass-general-news-photo/1071170128?adppopup=true">Jonathan Wiggs/The Boston Globe via Getty Images</a></span></figcaption></figure><p>States, cities, counties and <a href="https://www.nbcnews.com/news/us-news/native-american-tribes-reach-590-million-opioid-settlement-rcna14508">tribal governments</a> <a href="https://americanhealth.jhu.edu/news/preparing-states-and-local-governments-opioid-settlement-money">across the nation</a> are starting to receive a windfall through several <a href="https://www.opioidsettlementtracker.com/globalsettlementtracker/#statuses">major opioid settlements</a>. The <a href="https://www.npr.org/2022/11/02/1133523740/cvs-health-agrees-to-a-5-billion-settlement-in-opioid-lawsuits">Walgreens and CVS drugstore chains</a>, drug distributors and <a href="https://www.cbsnews.com/newyork/news/teva-pharmaceuticals-to-pay-4-2-billion-opioid-settlement-new-york-to-get-523-million/">opioid manufacturers</a>, including <a href="https://theconversation.com/the-opioid-crisis-isnt-just-the-sacklers-fault-and-making-purdue-pharma-pay-isnt-enough-on-its-own-to-fix-the-pharmaceutical-industrys-deeper-problems-178710">Purdue Pharma and the Sackler family members</a> who own it, will <a href="https://apnews.com/article/health-business-lawsuits-rhode-island-epidemics-50f3aa9cbe82b775cd3d7520c286ef25">relinquish a total of about US$50 billion</a> for their role in the overdose crisis. </p>
<p><a href="https://scholar.google.com/citations?user=eEr0Q90AAAAJ&hl=en">I am a sociologist</a> who studies how the overdose crisis affects patient care. My research shows why these funds cannot come quickly enough for the communities poised to receive them.</p>
<p>Fatal drug overdoses reached <a href="https://nida.nih.gov/news-events/news-releases/2022/07/percentage-of-overdose-deaths-involving-methadone-declined-between-january-2019-august-2021">a record high of 107,000</a> in 2021, and <a href="https://www.cdc.gov/washington/testimony/2022/t20220726.htm">75% of those deaths involved at least one opioid</a>, according to the most recent data available. But, two decades after this crisis began, only 6.5% of Americans with <a href="https://www.psychiatry.org/Patients-Families/Addiction-Substance-Use-Disorders">substance use disorders</a> receive <a href="https://www.samhsa.gov/data/sites/default/files/reports/rpt35325/NSDUHFFRPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf">any kind of treatment</a>. And only 11% of those with opioid use disorders receive medications tailored to treat them. </p>
<p>In my view, money spent increasing access to <a href="https://www.hhs.gov/opioids/treatment/medications-to-treat-opioid-addiction/index.html">methadone</a> and <a href="https://www.hhs.gov/opioids/treatment/medications-to-treat-opioid-addiction/index.html">buprenorphine</a>, drugs <a href="https://doi.org/10.1001/jamanetworkopen.2019.20622">backed with strong evidence</a>, would significantly narrow this treatment gap. </p>
<h2>More treatment funding</h2>
<p>The settlements could help because they recommend that at least some of those <a href="https://www.npr.org/2022/02/25/1082901958/opioid-settlement-johnson-26-billion">billions fund treatment</a>. However, <a href="https://www.nashp.org/how-states-administering-opioid-settlement-funds/">state legislatures</a> will <a href="https://www.statnews.com/2021/07/30/states-could-get-billions-from-opioid-lawsuits-they-have-to-decide-how-to-spend-it/">ultimately decide</a> where most of this money goes.</p>
<p>If settlements lead to a significant increase in treatment, it would mark an improvement over what happened to the <a href="https://www.publichealthlawcenter.org/topics/commercial-tobacco-control/master-settlement-agreement">Big Tobacco settlements reached in 1998</a>. Most of the funds <a href="https://www.pbs.org/wgbh/pages/frontline/shows/settlement/timelines/fullindex.html">from those deals</a> that were supposed to support smoking cessation and prevention have <a href="https://doi.org/10.1177%2F0033354917751131">instead padded state budgets and funded unrelated projects</a>.</p>
<h2>3 drugs are prescribed for opioid use disorder</h2>
<p>Ensuring that the settlement funds support what they’re supposed to pay for is only one hurdle.</p>
<p>A separate challenge is defining what counts as treatment – including who can provide it. <a href="https://us.macmillan.com/books/9781250257093/americanfix">The field is vast and varied</a>. Treatment can come in a pill or consist of talk therapy. It can require a residential rehab stint or outpatient programs.</p>
<p>Anyone from physicians to peers can provide this care, and it’s hard to determine what will work for a specific person. While no approach works for everyone, <a href="https://doi.org/10.1001/jamanetworkopen.2019.20622">clear evidence suggests</a> that more people should have access to medications for opioid use disorder.</p>
<p>It might seem strange that the best treatment for people hooked on drugs is another drug. However, providing methadone and buprenorphine isn’t just substituting one drug for another. These medications interrupt chaotic drug use and remove the highs and lows of addiction. They regulate the body just as <a href="https://www.nytimes.com/2018/01/17/opinion/treating-opioid-addiction.html">antidepressants or insulin</a> do.</p>
<p>The FDA has approved three drugs: <a href="https://www.hhs.gov/opioids/treatment/medications-to-treat-opioid-addiction/index.html">methadone</a>, a solution taken by mouth dispensed in specialized clinics; <a href="https://www.hhs.gov/opioids/treatment/medications-to-treat-opioid-addiction/index.html">buprenorphine</a>, a tablet or film taken in doctors’ offices; and <a href="https://www.hhs.gov/opioids/treatment/medications-to-treat-opioid-addiction/index.html">naltrexone</a>, a pill or injection physicians may administer.</p>
<p><a href="https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/how-much-does-opioid-treatment-cost">Their costs vary</a>. Buprenorphine and methadone, which <a href="https://www.samhsa.gov/medication-assisted-treatment/medications-counseling-related-conditions/methadone">reduce opioid cravings</a> and <a href="https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/how-do-medications-to-treat-opioid-addiction-work">withdrawal symptoms</a>, cost an average $6,250 per year. Naltrexone, which <a href="https://www.samhsa.gov/medication-assisted-treatment/medications-counseling-related-conditions/naltrexone">blocks the feelings of euphoria opioids create</a>, costs about $14,000 annually. These costs include related services like office visits and counseling. </p>
<p>People treated for opioid use disorder take these drugs for a year or longer. </p>
<p>A study found that patients on methadone or buprenorphine were significantly less likely to <a href="https://doi.org/10.7326/M17-3107">die by overdose than patients who didn’t take them</a>. Methadone was associated with a 53% reduction in overdose risk, and buprenorphine was associated with a 37% decline.</p>
<p>In contrast, people who took naltrexone were just as likely to overdose as those taking no medication. More <a href="https://doi.org/10.1002/14651858.CD006140.pub2">research is needed</a> to determine whether <a href="https://doi.org/10.7326/M17-3107">naltrexone makes a difference</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/453409/original/file-20220321-19-8jrcak.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A nurse hands a cup to a woman in a black and white photo." src="https://images.theconversation.com/files/453409/original/file-20220321-19-8jrcak.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/453409/original/file-20220321-19-8jrcak.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=396&fit=crop&dpr=1 600w, https://images.theconversation.com/files/453409/original/file-20220321-19-8jrcak.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=396&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/453409/original/file-20220321-19-8jrcak.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=396&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/453409/original/file-20220321-19-8jrcak.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=498&fit=crop&dpr=1 754w, https://images.theconversation.com/files/453409/original/file-20220321-19-8jrcak.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=498&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/453409/original/file-20220321-19-8jrcak.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=498&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A nurse hands a cup of methadone to a patient at a clinic in 1971.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/an-unidentified-nurse-hands-a-cup-of-methadone-to-a-patient-news-photo/926365512?adppopup=true">US News & World Report Collection/Warren K Leffler/PhotoQuest/Getty Images</a></span>
</figcaption>
</figure>
<h2>Evidence for detox and inpatient programs</h2>
<p>Research suggests that residential programs, which can cost as much as <a href="https://www.addictioncenter.com/rehab-questions/cost-of-drug-and-alcohol-treatment/">$60,000 for 90 days of inpatient rehab</a>, and other nonmedical approaches are less effective at treating opioid use disorder than drugs. </p>
<p>A study that <a href="https://doi.org/10.1001/jamanetworkopen.2019.20622">reviewed different kinds of treatments</a> found that patients who got detoxification or intensive behavioral health therapy were as likely to overdose or need acute care as those who received no treatment at all. </p>
<p>Sadly, some <a href="https://us.macmillan.com/books/9781250257093/americanfix">people enrolled inpatient, abstinence-based programs</a> may even experience harm, because someone with an opioid use disorder is vulnerable to relapse right after treatment ends. Since abstaining from drugs altogether lowers tolerance, taking the the same amount of a substance as before rehab increases overdose risks.</p>
<h2>Cost isn’t the only obstacle</h2>
<p>If medication works well for treating opioid use disorders, why is it so hard for people who need help to get these drugs? I see four main barriers.</p>
<p>First, <a href="https://doi.org/10.1016/j.drugpo.2019.07.006">federal laws tightly restrict</a> distribution. <a href="https://www.mayoclinic.org/drugs-supplements/methadone-oral-route/proper-use/drg-20075806">Methadone</a>, used to treat opioid use disorders in the U.S. <a href="https://www.ncbi.nlm.nih.gov/books/NBK232111">since 1972</a>, can be provided only in federally certified opioid treatment programs, and physicians who prescribe it must register annually with the Drug Enforcement Administration. Patients getting methadone must attend counseling and visit a clinic daily to receive a single dose.</p>
<p>People on methadone call it “<a href="https://www.liquidhandcuffsdoc.com/">liquid handcuffs</a>” because of the strict rules they must follow to get it.</p>
<p>Some restrictions have relaxed during the COVID-19 pandemic. The federal government now <a href="https://www.networkforphl.org/news-insights/covid-19-pandemic-prompts-federal-agencies-to-reduce-restrictions-on-medications-for-opioid-use-disorder/">allows states to apply for an exemption</a> that permits treatment programs to provide up to a month’s supply to take home. Many patients say they like not having to make <a href="https://undark.org/2020/05/07/covid-19-opioid-methadone/">daily trips to a clinic</a>.</p>
<p>A second barrier is that physicians are reluctant to prescribe buprenorphine, which <a href="https://www.accessdata.fda.gov/drugsatfda_docs/nda/2002/20-732_20-733_subutex.cfm#:%7E:text=Approval%20Date%3A%2010%2F08%2F2002">the FDA approved to treat opioid use disorders in 2002</a>. Physicians can prescribe buprenorphine from their offices as long as they get a <a href="https://getwaivered.com/dea-x-waiver-protocol-following-training/">Drug Enforcement Administration waiver</a>.</p>
<p><a href="https://www.samhsa.gov/medication-assisted-treatment/become-buprenorphine-waivered-practitioner">Until 2021</a>, doctors had to complete eight hours of training to obtain waivers, but as of 2021 they can treat up to 30 patients without it. Still, <a href="https://doi.org/10.7326/M19-2403">fewer than 10% of general practitioners</a> prescribe buprenorphine, and those who do <a href="https://doi.org/10.1001/jamanetworkopen.2020.14045">see an average of only eight patients each month</a>. Physicians <a href="https://doi.org/10.1016/j.jsat.2017.04.005">say more education and resources would make them more likely to prescribe</a> it. </p>
<p>Pharmacists could also take on this task. Pilot studies have shown that <a href="https://doi.org/10.1111/add.15353">they can effectively treat patients with buprenorphine</a> through collaboration with physicians. If scaled up, pharmacy-based programs could significantly expand access. Pharmacists in <a href="https://doi.org/10.1016/j.japh.2021.06.019">Canada, England and elsewhere already provide methadone</a>, and pharmacy organizations in the U.S. have <a href="https://nabp.pharmacy/news/blog/pharmacists-are-key-to-expanding-access-to-medication-assisted-treatment/%22%22">called for similar programs</a>.</p>
<p>However, some pharmacists shy away from dispensing buprenorphine because <a href="https://khn.org/news/article/as-overdose-deaths-soar-dea-wary-pharmacies-shy-from-dispensing-addiction-medication/">they fear being targeted by law enforcement</a>.</p>
<p>The third barrier is that although <a href="https://doi.org/10.1001/jamanetworkopen.2020.5852">patients run a high risk of dying after surviving an overdose</a>, most emergency departments send them away without helping them find long-term treatment.</p>
<p>Emergency medicine physicians I have <a href="https://www.nsf.gov/awardsearch/showAward?AWD_ID=1753308&HistoricalAwards=false">interviewed tell me</a> they don’t have ways to make these referrals, so they revive patients from overdose and discharge them without additional care. Some hospitals see this as a missed opportunity.</p>
<p><a href="https://dellmed.utexas.edu/blog/b-team">Dell Seton Medical Center</a> in Austin, Texas, and Boston’s <a href="https://doi.org/10.1097/ADM.0000000000000875">Massachusetts General Hospital</a> have developed programs to put people on buprenorphine after an overdose and to connect them to physicians authorized to prescribe it long-term. Expanding access to treatment based in emergency departments would reduce the risk of overdose death.</p>
<p>Finally, studies show that <a href="https://harmreduction.org/about-us/principles-of-harm-reduction/">harm reduction organizations</a> such as <a href="https://doi.org/10.1007/s10461-013-0593-y">syringe exchange programs</a> and <a href="https://drugpolicy.org/issues/supervised-consumption-services">overdose prevention centers</a>, along with efforts to <a href="https://theconversation.com/this-overdose-reversal-medicine-could-reduce-opioid-deaths-so-why-dont-more-people-carry-it-121928">distribute and administer</a> the <a href="https://nida.nih.gov/publications/drugfacts/naloxone">drug naloxone</a> to quickly reverse an opioid overdose, can expedite the start of <a href="https://www.hachettego.com/titles/maia-szalavitz/undoing-drugs/9780738285757/">treatment for opioid use disorders</a>. </p>
<p>However, political opposition to these programs persists, even in West Virginia and the other <a href="https://www.wvpublic.org/health-science/2021-07-15/judge-rules-law-restricting-west-virginia-needle-exchange-programs-can-stand">places hardest hit by the overdose crisis</a>. When programs manage to take root, <a href="https://doi.org/10.1186/s12954-017-0178-6">they are underfunded</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/453405/original/file-20220321-27-xkgsij.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A tray holding syringes and vials" src="https://images.theconversation.com/files/453405/original/file-20220321-27-xkgsij.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/453405/original/file-20220321-27-xkgsij.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/453405/original/file-20220321-27-xkgsij.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/453405/original/file-20220321-27-xkgsij.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/453405/original/file-20220321-27-xkgsij.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/453405/original/file-20220321-27-xkgsij.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/453405/original/file-20220321-27-xkgsij.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Syringes and vials of naloxone, a drug that can reverse opioid overdoses.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/in-this-november-30-2021-photo-syringes-and-vials-of-news-photo/1236946382?adppopup=true">Yuki Iwamura/AFP via Getty Images</a></span>
</figcaption>
</figure>
<h2>Making the settlement money count</h2>
<p>Many kinds of programs will compete for the funds made available through the settlements. </p>
<p>But the research is clear: Medications for opioid use disorder offer a substantial return on investment.</p>
<p>To be sure, these are <a href="https://archives.drugabuse.gov/publications/media-guide/science-drug-use-addiction-basics">chronic, relapsing conditions</a>. People struggling with them <a href="https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/treatment-recovery">need an array of services</a> to get their lives on track. Still, medications are a critical tool. </p>
<p>Americans have lost more than <a href="https://www.npr.org/2021/12/30/1069062738/more-than-a-million-americans-have-died-from-overdoses-during-the-opioid-epidemi">1 million loved ones</a> to overdoses since 1999. I believe that states would save lives if they used money from legal settlements to make medications that treat opioid use disorders more widely available.</p>
<p><em>This is an updated version of an article originally published on March 25, 2022.</em></p><img src="https://counter.theconversation.com/content/178392/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elizabeth Chiarello receives funding from a National Science Foundation CAREER Award. </span></em></p>After battling drug manufacturers and distributors in court for years, local and state governments are about to receive a windfall that could expand access to treatments that can save lives.Elizabeth Chiarello, Associate Professor of Sociology, Saint Louis UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1794842022-03-18T13:36:11Z2022-03-18T13:36:11ZSocial security is the bedrock of South Africa’s human rights protection. But there are gaps<figure><img src="https://images.theconversation.com/files/453013/original/file-20220318-17-1sap9zt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">South Africa has an extensive social security network, but poverty levels remain obstinately high.</span> <span class="attribution"><span class="source">Photo by Dan Kitwood/Getty Images</span></span></figcaption></figure><p>Since South Africa adopted its post-apartheid <a href="https://www.justice.gov.za/legislation/constitution/saconstitution-web-eng.pdf">constitution</a> in 1996, the country has made important strides in realising the right to social security and in reducing poverty and inequality. </p>
<p>Policies, legislation and administrative infrastructure have enabled the government to create an expansive social security system. Two out of three households <a href="https://www.oxfordhandbooks.com/view/10.1093/oxfordhb/9780192894199.001.0001/oxfordhb-9780192894199-e-38#oxfordhb-9780192894199-e-38-div1-256">receive a social grant</a> and <a href="https://www.oxfordhandbooks.com/view/10.1093/oxfordhb/9780192894199.001.0001/oxfordhb-9780192894199-e-38#oxfordhb-9780192894199-e-38-div1-256">60% of the workforce</a> is covered by social insurance. </p>
<p>South Africa is now <a href="https://openknowledge.worldbank.org/bitstream/handle/10986/36338/South-Africa-Social-Assistance-Programs-and-Systems-Review-Policy-Brief.pdf?sequence=1&isAllowed=y">an exemplar</a> of an upper middle-income country that has <a href="https://openknowledge.worldbank.org/handle/10986/36514?show=full&locale-attribute=fr">gone further than many others</a> in growing social protection to promote development. </p>
<p>Nevertheless, the country still has persistent and extraordinarily high rates of <a href="https://www.globalcitizen.org/en/content/1-in-5-south-africans-living-extreme-poverty-un/">poverty</a>, <a href="http://www.statssa.gov.za/?p=14957">unemployment</a>, <a href="https://www.worldbank.org/en/news/press-release/2022/03/09/new-world-bank-report-assesses-sources-of-inequality-in-five-countries-in-southern-africa">inequality</a> and <a href="https://www.afdb.org/en/countries/southern-africa/south-africa/south-africa-economic-outlook">low levels of economic growth</a>.</p>
<p>As South Africa marks <a href="https://www.gov.za/HumanRightsMonth2022">Human Rights Day</a> on 21 March, it is worth reflecting on what has been achieved, what policies and interventions are needed, and what the future trajectories might be.</p>
<h2>What’s in place</h2>
<p>Social security consists of several pillars. One of these is social assistance. This is paid by the state to different categories of vulnerable people such as the aged, people with physical and mental disabilities and children and their families. </p>
<p>The net of support was expanded from three million beneficiaries in 1995 to <a href="https://www.gov.za/speeches/president-cyril-ramaphosa-2022-state-nation-address-10-feb-2022-0000">over 18 million</a> in 2022.</p>
<p>The second pillar is social insurance. This takes the form of contributory schemes linked to employment, such as unemployment, health and pension benefits. Informal social and family provision of support also play an important role. </p>
<p>Some other interventions are not generally classified as part of the country’s social security system. These include <a href="https://mg.co.za/business/2021-03-04-will-job-creation-schemes-fix-the-unemployment-crisis/">public employment schemes</a>, school feeding and a social package of free basic services. Free primary health care, free education for poor children, as well as subsidies for early childhood development centres and to NGOs to deliver welfare services, also fall into this category. </p>
<p>More recently, to mitigate the impact of the COVID-19 pandemic, a new temporary Social Relief of Distress grant was implemented. It <a href="https://www.gov.za/speeches/president-cyril-ramaphosa-2022-state-nation-address-10-feb-2022-0000">grew</a> from 5.3 million beneficiaries in 2020 to 10 million in 2022. It is targeted at the unemployed and informal workers who are unable to support themselves. </p>
<p>Social assistance is clearly the bedrock of the country’s social security system. It operates alongside minuscule budgetary allocations for welfare services such as community mental health, substance abuse and gender-based violence among others. Welfare services have historically been underfunded and this trend continues.</p>
<p>But there are some problems with the social security system.</p>
<p>Importantly, it doesn’t adequately address or cater for the problem of unemployment whereas most poor people are unemployed, or employed in <a href="https://theconversation.com/employed-but-still-poor-the-state-of-low-wage-working-poverty-in-south-africa-118018">precarious and low-wage work</a> and in the informal sector.</p>
<p>In addition, the system is poorly coordinated. There are weak linkages between the different programmes. For example, caregivers who receive child support grants do not have ready access to other services such social and nutrition support, public employment and early childhood education. This undermines the structural efficiency, effectiveness and responsiveness of the system to meet a diversity of needs over the life cycle.</p>
<h2>Policy gaps and interventions</h2>
<p>The role of social assistance is now widely accepted as the bedrock of the country’s efforts to speed up poverty reduction and income redistribution. What is at issue is how best to achieve this. </p>
<p>Several high-level policy solutions emerged from a <a href="https://www.oxfordhandbooks.com/view/10.1093/oxfordhb/9780192894199.001.0001/oxfordhb-9780192894199-e-38#oxfordhb-9780192894199-e-38-div1-256">policy review I recently conducted</a> for <a href="https://global.oup.com/academic/product/the-oxford-handbook-of-the-south-african-economy-9780192894199?facet_narrowbybinding_facet=Ebook&facet_narrowbyprice_facet=100to200&lang=en&cc=gb">a new book</a>.</p>
<p>Firstly, social security reforms are needed that centre on filling the gaps. These include support for the long-term and chronically unemployed and informal workers. </p>
<p>Secondly, the benefit levels of social grants, especially the child support grant, must be increased to address malnutrition more effectively. The current grant amount is below the <a href="https://www.news24.com/news24/southafrica/news/stats-sa-adjusts-national-food-poverty-line-to-r624-a-person-per-month-20210909">food poverty line</a>.</p>
<p>Innovative outreach is also needed to improve inclusion of large numbers of children who qualify, but do not receive the grant. These are <a href="https://www.unicef.org/southafrica/media/1226/file/ZAF-removing-barriers-to-accessing-child-grants-2016.pdf">estimated to be 17.5%</a> of eligible children.</p>
<p>There is also a <a href="https://cramsurvey.org/wp-content/uploads/2021/07/13.-Van-der-Berg-S.-Patel-L-and-Bridgeman-G.-2021-Food-insecurity-in-South-Africa-%E2%80%93-Evidence-from-NIDS-CRAM-Wave-5.pdf">growing acknowledgement</a> that unless employment grows – through various public and private measures – and such work is sustainable, social assistance on its own has a limited effect on lifting people out of poverty and in improving income mobility. Employment growth and better-quality jobs would bring more people into the social insurance system and build a larger middle class. </p>
<p>Social and economic challenges that were intensified by the pandemic are likely to continue. This may further deepen structural unemployment, with some jobs being lost permanently. Ongoing monitoring of the economic recovery and of social development indicators over time is likely to aid more effective policy making. </p>
<p>Social policy solutions are needed that extend interim social relief in the short to medium term. These must also address systemic improvements to overcome delivery challenges. South Africa may do well to follow other countries that maintain <a href="https://documents1.worldbank.org/curated/en/698441502095248081/pdf/117971-REVISED-PUBLIC-Discussion-paper-1704.pdf">social registers</a> such as those in Latin America, Indonesia and Mauritius. These enable authorities to identify potential beneficiaries in need and aid in planning. This will in turn improve the responsiveness of social support.</p>
<p>The temporary expansion of social assistance due to the pandemic brings new challenges. If the COVID-19 relief of distress grant is terminated or gradually phased out as the economy begins to recover and generates employment, tricky political issues may arise. There is the potential for significant political destabilisation. This is because the social and humanitarian crises the grant sought to alleviate would persist.</p>
<p>It is thus likely that the COVID-19 relief of distress grant may by default <a href="https://businesstech.co.za/news/business-opinion/568428/new-grant-for-south-africa-is-a-done-deal-and-you-will-foot-the-bill-for-it-analyst/">become a basic income grant</a>. It’s not clear what form this might take but the government <a href="https://www.gov.za/SONA2022">has announced</a> that it is exploring its options.</p>
<p><a href="https://theconversation.com/basic-income-support-in-south-africa-risks-rewards-and-what-it-will-take-176821">Questions remain </a> as to how affordable these policy options are. Cost-benefit analyses will be needed to aid policy engagement and decision making. The costs – and outcomes – will differ depending on whether a basic income grant prioritises those in greatest need or is given to all income groups. </p>
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Read more:
<a href="https://theconversation.com/basic-income-support-in-south-africa-risks-rewards-and-what-it-will-take-176821">Basic income support in South Africa: risks, rewards and what it will take</a>
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<p>Given the country’s <a href="https://theconversation.com/south-africas-fiscal-squeeze-warning-signs-ignored-for-too-long-177188">fiscal constraints</a>, consideration needs to be given to the fact that other social policies and social development programmes are likely to be crowded out by the further expansion of income support.</p>
<p>Growing cash transfers at the expense of non-monetary forms of social provision – including health and mental health services, education, early childhood education, social work services, housing and basic services, such as water, sanitation and electricity – could be equally counterproductive.</p>
<p>Carefully designed, innovative and evidence-based complementary interventions are needed. These must build human capital and human agency, strengthen families and boost community-level livelihoods. Alongside other similar interventions, these should ultimately aim at breaking the <a href="https://bettercarenetwork.org/library/social-welfare-systems/social-protection-policies-and-programmes/connecting-cash-transfers-with-care-for-better-child-and-family-well-being-evidence-from-a">inter-generational cycles of disadvantage</a>.</p><img src="https://counter.theconversation.com/content/179484/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Leila Patel receives funding from the Department of Science and Innovation (DSI) and the National Research Foundation for her Chair in Welfare and Social Development, the Faculty of Humanities, and the University of Johannesburg's Research Committee. </span></em></p>Social security reforms are needed that include support for the long-term and chronically unemployed and informal workers.Leila Patel, Professor of Social Development Studies, University of JohannesburgLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1761322022-02-10T20:24:26Z2022-02-10T20:24:26ZChildhood adversity is a ‘cause of causes’ of adult illnesses and mental health problems<figure><img src="https://images.theconversation.com/files/443792/original/file-20220201-22-127qj18.png?ixlib=rb-1.1.0&rect=16%2C663%2C4497%2C2948&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">One child in three is physically or sexually abused or witnesses violence between adults in their home. Other adversities including emotional neglect, living in an unsafe neighbourhood or experiencing prejudice and bullying are even more common.</span> <span class="attribution"><span class="source">(iStock)</span></span></figcaption></figure><iframe style="width: 100%; height: 175px; border: none; position: relative; z-index: 1;" allowtransparency="" src="https://narrations.ad-auris.com/widget/the-conversation-canada/childhood-adversity-is-a--cause-of-causes--of-adult-illnesses-and-mental-health-problems" width="100%" height="400"></iframe>
<p>Every day we are exposed to things like pollution and ultraviolet light which increase our risk of illness. Many people take on additional risks — due to tobacco smoke, fast food or alcohol, for example. </p>
<p>But there is a less-recogized exposure that is even more common than smoking and increases the risk of <a href="https://doi.org/10.1161/cir.0000000000000536">heart disease, diabetes</a>, <a href="https://doi.org/10.1002/cncr.24372">cancer</a>, <a href="https://doi.org/10.1016/s0749-3797(98)00017-8">chronic lung diseases</a>, <a href="https://dx.doi.org/10.2105%2FAJPH.2007.131599">sexually transmitted infections</a>, <a href="https://doi.org/10.1001/jama.2009.1091">chronic pain</a>, <a href="https://doi.org/10.1503/cmaj.131792">mental illness</a> and <a href="https://doi.org/10.1016/j.amepre.2009.06.021">reduces one’s life by as much as 20 years</a>. </p>
<p>This public health hazard that hides in plain sight is childhood adversity: experiences like physical abuse, sexual abuse and neglect.</p>
<h2>Childhood adversity is common</h2>
<p>In Canada, <a href="https://doi.org/10.1503/cmaj.131792">one child in three is physically or sexually abused or witnesses violence between adults in their home</a>. Other adversities such as <a href="https://doi.org/10.1016/j.amepre.2015.02.001">emotional neglect, living in an unsafe neighbourhood or experiencing prejudice and bullying</a> are even more common. Studies in the United States show about <a href="https://doi.org/10.1016/j.amepre.2014.09.006">60 per cent of children and teenagers have these adverse childhood experiences</a>, or ACEs. The more severe the exposure, the greater the health risk. </p>
<p>The reason that ACEs contribute to so many diseases is that they are associated with many things that trigger other causes of disease. Think of ACEs as a “cause of causes.”</p>
<h2>Health risk behaviours and physiological changes</h2>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/445491/original/file-20220209-1970-18lmi5a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Illustration of two people standing at a starting line. One lane is clear while the other has a pitfall." src="https://images.theconversation.com/files/445491/original/file-20220209-1970-18lmi5a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/445491/original/file-20220209-1970-18lmi5a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/445491/original/file-20220209-1970-18lmi5a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/445491/original/file-20220209-1970-18lmi5a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/445491/original/file-20220209-1970-18lmi5a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/445491/original/file-20220209-1970-18lmi5a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/445491/original/file-20220209-1970-18lmi5a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Adverse childhood events may contribute to cascading health risks over a lifetime.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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</figure>
<p>As kids who have had adverse experiences grow up, they are more likely to <a href="https://dx.doi.org/10.1016%2Fj.jadohealth.2007.08.029">smoke</a>, to <a href="https://doi.org/10.1111/acer.12053">drink excessively</a> and to <a href="https://dx.doi.org/10.1016%2Fj.jaac.2016.05.010">use nonprescription drugs</a>. They are more likely to <a href="https://doi.org/10.1016/j.chiabu.2016.11.023">engage in risky sexual activities</a> and to <a href="https://doi.org/10.1038/s41598-021-93242-4">become obese</a>. Not all kids with ACEs take on risky activities, of course, but enough to contribute to ACEs’ health consequences.</p>
<p>Growing up in conditions that are consistently frightening or stressful affects the biology of developing bodies, <a href="https://pubmed.ncbi.nlm.nih.gov/24426793/">especially the development of the systems that regulate our reactions to threats</a>, from predators to viruses. ACEs are even associated with <a href="https://doi.org/10.1038/mp.2012.32">changes in our chromosomes</a> that are linked to early mortality. </p>
<h2>Interpersonal and psychological effects</h2>
<p>As psychiatrists for adults who experience physical and mental illness in combination, our patients often tell us about the personal impact of ACEs. One man said he did not “have even the slightest shadow of a doubt that a loss of human connection is the most substantial negative impact” of these experiences. The health costs of human disconnection are profound. Indeed, <a href="https://doi.org/10.1371/journal.pmed.1000316">lacking interpersonal support may hasten mortality as much or more than smoking, excessive drinking, inactivity, obesity or untreated high blood pressure</a>. </p>
<p>The psychological effects of ACEs may be more obvious and can include fearful expectations, a conviction that one is unworthy of love or protection, unregulated anger or shame and discombobulating memories of bad events. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/445498/original/file-20220209-25-rl380b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Illustration of five red hot-air balloons rising into the air, with one held back by a large rock tied to it." src="https://images.theconversation.com/files/445498/original/file-20220209-25-rl380b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/445498/original/file-20220209-25-rl380b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/445498/original/file-20220209-25-rl380b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/445498/original/file-20220209-25-rl380b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/445498/original/file-20220209-25-rl380b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/445498/original/file-20220209-25-rl380b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/445498/original/file-20220209-25-rl380b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">ACEs greatly increase the risk of depression, anxiety disorders, post-traumatic stress disorder and addictions.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>It greatly increases the risk of depression, anxiety disorders, post-traumatic stress disorder and addictions. The one in three adults who experienced childhood sexual or physical abuse or witnessed interpersonal violence at home <a href="https://doi.org/10.1503/cmaj.131792">have at least twice the incidence of these disorders</a> compared to others.</p>
<p>And then the dominoes fall: mental illness greatly increases the likelihood, burden and consequences of physical illness. To give just one example, <a href="https://doi.org/10.1016/s0006-3223(03)00111-2">in the months after experiencing a heart attack, those who are depressed are several times more likely to die</a>.
So, we see that ACEs don’t only lead to one kind of trouble, but to many. </p>
<h2>Social determinants of health</h2>
<p>Finally, the burden of illness is not distributed fairly. Maintaining health is more challenging for those who are disadvantaged by poverty, lack of education, language barriers, discrimination and living with the continuing systemic harms of colonization and multi-generational trauma.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/445493/original/file-20220209-19735-1q36hq5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Illustration of a child climbing up one side of a pyramid in steady steps, helped by an adult. On the other side, another child climbs over a substance-using parent and struggles to find a route up the pyramid." src="https://images.theconversation.com/files/445493/original/file-20220209-19735-1q36hq5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/445493/original/file-20220209-19735-1q36hq5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=521&fit=crop&dpr=1 600w, https://images.theconversation.com/files/445493/original/file-20220209-19735-1q36hq5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=521&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/445493/original/file-20220209-19735-1q36hq5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=521&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/445493/original/file-20220209-19735-1q36hq5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=655&fit=crop&dpr=1 754w, https://images.theconversation.com/files/445493/original/file-20220209-19735-1q36hq5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=655&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/445493/original/file-20220209-19735-1q36hq5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=655&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Childhood trauma has a complex relationship with social determinants of health.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Childhood trauma has a complex relationship with these social determinants of health. On one hand, ACEs are not unique to marginalized groups and can occur across all strata of society. On the other hand, the risk of experiencing ACEs may be greater in some groups and the consequences of ACEs may multiply as social forces interact. </p>
<p>For example, <a href="https://doi.org/10.1016/s0749-3797(99)00084-7">childhood trauma is strongly associated with behaviours that increase the risk of sexually transmitted infections</a>. About <a href="https://doi.org/10.1016/j.psym.2014.10.006">half of the people living with HIV have experienced childhood abuse</a>. HIV is also more common in groups that face discrimination, including <a href="https://www.catie.ca/the-epidemiology-of-hiv-in-canada">men who have sex with men, people who use injectable drugs, Indigenous people</a> and <a href="https://www.ohtn.on.ca/research-portals/priority-populations/african-caribbean-and-black-communities/">immigrants from countries in which HIV is endemic</a>. </p>
<p>Intersecting components of personal experience and identity attract stigma and discrimination, which in turn influences mental health, self-care and one’s ability to navigate a healthcare system that has multiple barriers and gaps. <a href="https://doi.org/10.1016/j.psym.2014.10.006">It is a complex web and ACEs contribute to this complexity</a>.</p>
<h2>A cause of causes</h2>
<p>Events that occur in childhood may contribute to cascading health risks over one’s lifetime. There are so many paths to illness interacting with one another over decades and compromising health in so many ways, that it should be no surprise that <a href="https://doi.org/10.1016/s2468-2667(21)00237-1">childhood adversity is a profound public health problem</a>. </p>
<p>It is time that we, as a society, recognized ACEs as the malignant force that they are. Those affected need to be treated with compassion and also with awareness of the long-lasting effects of early adversity on health. Research that helps us understand the lifelong impact of ACEs could help guide prevention of chronic illnesses and mental health issues in the many people who experience adversity during childhood.</p><img src="https://counter.theconversation.com/content/176132/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robert Maunder receives funding from Sinai Health and the University of Toronto as Chair of Health and Behaviour at Sinai Health and receives royalties from the University of Toronto Press for Damaged: Childhood Adversity, Adult Illness, and the Need for a Health Care Revolution.</span></em></p><p class="fine-print"><em><span>Jon Hunter receives funding from Sinai Health and is The Pencer Family Chair in Applied General Psychiatry at Sinai Health. He receives royalties from the University of Toronto Press for Damaged: Childhood Adversity, Adult Illness, and the Need for a Health Care Revolution. </span></em></p>One in three children experiences abuse or neglect. These adverse events increase lifelong risks for chronic diseases and mental health issues, creating a public health hazard hiding in plain sight.Robert Maunder, Professor of Psychiatry, University of TorontoJon Hunter, Professor of Psychiatry, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1730702021-12-16T13:28:54Z2021-12-16T13:28:54ZLatest trials confirm the benefits of MDMA – the drug in ecstasy – for treating PTSD<figure><img src="https://images.theconversation.com/files/435683/original/file-20211204-25-1atx7vt.jpg?ixlib=rb-1.1.0&rect=18%2C0%2C6020%2C4019&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">MDMA has therapeutic potential for the treatment of PTSD.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/close-up-of-a-reflected-pill-on-a-reflective-royalty-free-image/1286653300?adppopup=true">Aitor Diago/Moment via Getty Images</a></span></figcaption></figure><p>For people with <a href="https://www.ptsd.va.gov/understand/common/common_adults.asp">post-traumatic stress disorder</a>, recalling memories of physical or sexual assault, combat or disaster-related events can induce intense anxiety or panic attacks as well as debilitating flashbacks.</p>
<p>In the U.S., about <a href="https://doi.org/10.1017/S0033291717000708">7% of people suffer from PTSD</a> and lose an average of about four working days each month as a result. Trauma-specific psychotherapy, like <a href="https://doi.apa.org/doiLanding?doi=10.1037%2F0022-006X.70.4.867">cognitive processing</a> or “talk” therapy, is the cornerstone of treatment for PTSD. But for approximately half of people, these traditional approaches are ineffective at fully addressing PTSD symptoms over the long term. <a href="https://doi.org/10.3389/fpsyt.2019.00650">Antidepressant drugs</a> are frequently used if psychotherapy fails, or in combination with it, but the effects are usually modest.</p>
<p>MDMA (3,4-methylenedioxymethamphetamine) is an active ingredient in the illicit street drug known as ecstasy or molly. People in dance clubs and <a href="https://doi.org/10.1002/jcph.266">raves use illicit MDMA</a> because it elevates mood and energy levels, induces a feeling of bonding with others and produces a surreal psychedelic effect. These same effects have been hypothesized to <a href="https://doi.org/10.1177/1060028014532236">support people with PTSD</a> during psychotherapy sessions, since they can make people more willing and able to share and explore their traumatic experiences. Our new <a href="https://doi.org/10.1002/jcph.1995">meta-analysis of clinical trials</a> confirms the benefits of MDMA-assisted psychotherapy in the treatment of PTSD.</p>
<p>We are a pharmacist and physician team who investigate the benefits and harms associated with substances of abuse like <a href="https://doi.org/10.1002/jcph.742">bath salts</a>, <a href="https://doi.org/10.1002/jcph.1922">phenibut</a>, <a href="https://doi.org/10.1001/jama.2015.6358">cannabis</a> and <a href="https://doi.org/10.1002/jcph.827">synthetic marijuana</a>. Through this work we have become intrigued about the therapeutic potential for some psychedelic drugs in the treatment of myriad psychiatric disorders, from PTSD to major depression, especially MDMA and psilocybin (hallucinogenic mushrooms). </p>
<p>It is important to state that using ecstasy or molly products from the street would not help PTSD symptoms because the MDMA needs be used along with carefully crafted psychotherapy in a safe, controlled environment. Ecstasy or molly products purchased illicitly never specify the exact amount of MDMA they contain, so it is impossible to dose it properly for PTSD. Taking too much MDMA or exercising while taking MDMA can cause <a href="https://doi.org/10.1002/jcph.266">heart attacks, strokes, seizures and arrhythmias</a> and can damage muscles and kidneys.</p>
<h2>What is MDMA-assisted psychotherapy?</h2>
<p>In an <a href="https://doi.org/10.1002/jcph.1995">MDMA-assisted psychotherapy session</a>, patients take MDMA as a pill upon entering a psychiatrist’s office and then work with a team of therapists who help them divulge traumatic events or discuss aspects of those events over the course of several hours. They usually have non-MDMA sessions before the first MDMA session so they know what to expect. And they have at least one non-MDMA session after each MDMA one to work through the traumatic memories that were revealed and to learn coping strategies. A standard treatment course includes two or three multihour MDMA-assisted psychotherapy sessions and several non-MDMA sessions. </p>
<p>The MDMA products used in these sessions are pharmaceutical grade. This means that, unlike illicitly obtained street products, they do not contain <a href="https://doi.org/10.1002/jcph.1860">other substances of abuse</a>, such as methamphetamine, or contaminants like heavy metals, bacteria or mold. People with hypertension or those at high risk of heart attacks, strokes or arrhythmias should not participate, because they can have unsafe elevations in blood pressure and heart rate. In addition, patients are not allowed to leave for eight hours, until the effects of MDMA have fully worn off. </p>
<h2>Assessing the effectiveness of MDMA-assisted psychotherapy</h2>
<p>In 2014, we reviewed the available animal data and the few preliminary human studies of <a href="https://doi.org/10.1177/1060028014532236">MDMA-assisted psychotherapy</a>, but at the time, higher-quality clinical trials had not yet been completed. But in the past few years, larger and higher-quality trials have been published, warranting an in-depth assessment. </p>
<p>So we recently reviewed the data comparing antidepressant use to placebos for patients with PTSD and <a href="https://doi.org/10.1002/jcph.1995">performed a meta-analysis study</a> of the six different clinical trials that assessed the usefulness of MDMA-assisted psychotherapy versus psychotherapy alone. All of the trials we analyzed included both men and women who had experienced a multitude of traumatic events that led to PTSD. The studies used the same <a href="https://www.ptsd.va.gov/professional/assessment/adult-int/caps.asp">points scale</a> to determine the effectiveness of therapy, making it easier to compare data across studies. Scores above approximately 50 points mean a patient has severe PTSD, and scores reduced by more than 10 points from baseline are clinically meaningful. </p>
<p>We found that daily antidepressant therapy reduced PTSD by <a href="https://doi.org/10.1002/jcph.1995">6 to 14 points compared with the placebo</a>, but a range of 27% to 47% of patients across the studies withdrew before the end of the trials. In contrast, MDMA-assisted psychotherapy reduced the scores by 22 points compared with those receiving psychotherapy with placebo, and <a href="https://doi.org/10.1002/jcph.1995">patients were twice as likely</a> to no longer meet the criteria for PTSD diagnosis by the end of the trials. In addition, only 8% of patients withdrew from MDMA-assisted psychotherapy trials. The main adverse effects included teeth grinding, jitteriness, headache and nausea. One of these MDMA trials found that participants’ <a href="https://doi.org/10.1038/s41591-021-01336-3">blood pressure and heart rate</a> were elevated in the course of MDMA therapy, but not to a concerning extent.</p>
<figure class="align-center ">
<img alt="A young woman sits on a couch facing another woman." src="https://images.theconversation.com/files/435974/original/file-20211206-141979-1dot1re.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/435974/original/file-20211206-141979-1dot1re.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/435974/original/file-20211206-141979-1dot1re.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/435974/original/file-20211206-141979-1dot1re.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/435974/original/file-20211206-141979-1dot1re.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/435974/original/file-20211206-141979-1dot1re.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/435974/original/file-20211206-141979-1dot1re.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">One year after their last MDMA-assisted psychotherapy session, more than 80% of study participants reported improved feelings of well-being.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/problem-shared-is-a-problem-halved-royalty-free-image/1271550771">PeopleImages/E+ via Getty Images</a></span>
</figcaption>
</figure>
<p>For several of the trials in our meta-analysis, investigators sent a <a href="https://doi.org/10.1007/s00213-020-05548-2">questionnaire to participants</a> 12 months after their last MDMA session to assess the long-term impact. Overall, 86% of participants said they received substantial benefits from the combined MDMA-assisted psychotherapy. Eighty-four percent of participants reported having improved feelings of well-being, 71% had fewer nightmares, 69% had less anxiety and 66% had improved sleep. The results from across all of the studies suggested that MDMA-assisted therapy was helping to alleviate the PTSD itself, not simply suppressing symptoms.</p>
<h2>Looking ahead</h2>
<p>The U.S. Drug Enforcement Administration identifies MDMA and psilocybin as <a href="https://medicalboard.iowa.gov/sites/default/files/documents/2018/04/controlled_substance_defs-20180301.pdf">Schedule I controlled substances</a>. According to the DEA, these substances have no currently accepted medical use in the U.S. and come with high abuse potential.</p>
<p>However, it’s worth noting an important exception. <a href="https://doi.org/10.1002/jcph.1387">Cannabadiol, or CBD,</a> a chemical that comes from the plant <em>Cannabis sativa</em>, is classified as a Schedule I drug. But the Food and Drug Administration approved its use in 2018 for the treatment of <a href="https://doi.org/10.1002/jcph.1387">two rare and severe childhood seizure disorders</a>. That doesn’t mean that the CBD in your <a href="https://theconversation.com/no-cbd-is-not-a-miracle-molecule-that-can-cure-coronavirus-just-as-it-wont-cure-many-other-maladies-its-proponents-claim-132492">lotion or seltzer</a> has proof of benefit for most of the ills people are using it for, but its full therapeutic potential is still being explored. Given the strong consistent beneficial effects and manageable adverse events in the newer trials designed with FDA input, we suspect that MDMA-assisted psychotherapy will become an FDA-approved option for PTSD by the end of 2023. Psilocybin – commonly known as hallucinogenic mushrooms – <a href="https://doi.org/10.1056/NEJMoa2032994">also shows promise</a> for treating major depression, but further research is needed. </p>
<p>The DEA’s stringent policies made it exceptionally hard for scientists to <a href="https://doi.org/10.1002/jcph.1995">conduct research</a> on Schedule I drugs for decades by <a href="https://sgp.fas.org/crs/misc/R45948.pdf">criminalizing the possession of the products</a>, even in research settings. But in 2018, the agency <a href="https://www.dea.gov/press-releases/2018/01/18/dea-speeds-application-process-research-schedule-i-drugs">streamlined the application process</a> for securing a waiver for research purposes. This made it easier for researchers to conduct trials into the pharmaceutical value of psychedelic drugs. Within the next decade, this shift will almost certainly accelerate the discovery of new treatments for patients suffering from mental illness.</p>
<p>[<em>Get the best of The Conversation, every weekend.</em> <a href="https://theconversation.com/us/newsletters/weekly-highlights-61?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=weeklybest">Sign up for our weekly newsletter</a>.]</p><img src="https://counter.theconversation.com/content/173070/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Some psychedelic drugs – paired with therapy – hold great potential for helping sufferers of PTSD, depression and other mental health disorders.C. Michael White, Distinguished Professor and Head of the Department of Pharmacy Practice, University of ConnecticutAdrian V. Hernandez, Associate Professor of Comparative Effectiveness and Outcomes Research, University of ConnecticutLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1667012021-09-01T22:00:43Z2021-09-01T22:00:43ZHow the Purdue opioid settlement could help the public understand the roots of the drug crisis<figure><img src="https://images.theconversation.com/files/418136/original/file-20210826-13-v1fcqw.jpg?ixlib=rb-1.1.0&rect=114%2C73%2C5349%2C3186&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Esther Nesbitt lost two of her children to drug overdoses.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/esther-nesbitt-who-has-lost-two-of-her-children-to-drug-news-photo/1335688676">Andrew Lichtenstein/Corbis via Getty Images</a></span></figcaption></figure><p>There’s a long history of U.S. courts being called upon to fix large-scale public health crises.</p>
<p>Lawyers and judges, for instance, were key in settling claims related to <a href="https://www.asbestos.com/mesothelioma-lawyer/settlements/">asbestos</a>, <a href="https://www.pbs.org/newshour/nation/lead-paint-suppliers-to-pay-305-million-to-settle-california-lawsuit">lead paint</a>, <a href="https://www.benefits.va.gov/COMPENSATION/claims-postservice-agent_orange-settlement-settlementFund.asp">Agent Orange</a> and <a href="https://www.publichealthlawcenter.org/topics/commercial-tobacco-control/commercial-tobacco-control-litigation/master-settlement-agreement">tobacco</a>. More recently, they have dealt with the fallout of the <a href="https://theconversation.com/opioid-overdoses-spiked-during-the-covid-19-pandemic-data-from-pennsylvania-show-161635">U.S. opioid epidemic</a>, which is linked to the deaths of some <a href="https://wkow.com/2021/08/27/judge-urges-talks-between-purdue-pharma-and-holdout-states/">500,000 Americans</a> over the past two decades. </p>
<p>This litigation can serve several important goals. It can identify wrongdoers and hold them accountable. It can repair damage by compensating the victims. And it can protect the public by producing evidence regarding dangerous products and practices.</p>
<p>When cases are settled, however, the litigation rarely accomplishes all three goals together. <a href="https://www.reuters.com/investigates/special-report/usa-courts-secrecy-lobbyist/">Settlements deny plaintiffs their day in court</a> and can bypass admissions of guilt or allow companies to evade public scrutiny. They frustrate and disappoint almost by design.</p>
<p><a href="https://www.youtube.com/watch?v=uaCaIhfETsM">Frustration and disappointment</a> have been evident in the <a href="https://www.npr.org/2021/09/01/1031053251/sackler-family-immunity-purdue-pharma-oxcyontin-opioid-epidemic">settlement reached on Sept. 1, 2021</a>, that ended thousands of the lawsuits filed by states, cities, counties and native tribes against Purdue Pharma. Even as <a href="https://twitter.com/BrianMannADK/status/1433131417664466948">Robert Drain</a>, a federal bankruptcy judge in White Plains, New York, approved the deal he observed that it would fail to fully hold Purdue’s owners, the <a href="https://www.newyorker.com/magazine/2017/10/30/the-family-that-built-an-empire-of-pain">Sackler family</a>, accountable for their role in the opioid crisis.</p>
<p>Still, the deal is about more than a single family’s fate. As a <a href="https://history.ucr.edu/people/antoine-lentacker">historian of drugs and the pharmaceutical industry</a>, I see promise in it.</p>
<h2>Settling with the Sacklers</h2>
<p>If the deal holds up, it will cap 20 years of litigation against Purdue Pharma, a privately held drugmaker. The company <a href="https://www.justice.gov/opa/pr/justice-department-announces-global-resolution-criminal-and-civil-investigations-opioid">pleaded guilty twice</a> to <a href="https://www.addictioncenter.com/news/2020/11/purdue-pharma-plead-guilty-opioid-criminal-charges/">federal criminal charges</a> in connection with its marketing of OxyContin. No lawsuit against Purdue ever advanced to trial. Cases were settled out of court and records were sealed. The company continued to <a href="https://www.npr.org/sections/health-shots/2018/02/13/585402385/doctors-in-maine-say-halt-in-oxycontin-marketing-comes-20-years-late">promote OxyContin to doctors through 2018</a>.</p>
<p>By that time, the Sacklers had reaped an estimated <a href="https://www.businessinsider.com/who-are-the-sacklers-wealth-philanthropy-oxycontin-photos-2019-1">US$10.7 billion from sales of Purdue’s signature product</a>. But the <a href="https://apnews.com/article/8c84158a0cab4bd4b58be2315b4558fb">family</a> <a href="https://www.propublica.org/article/we-are-releasing-the-full-video-of-richard-sacklers-testimony-about-purdue-pharma-and-the-opioid-crisis">denies that it</a> <a href="https://www.nytimes.com/2021/08/18/health/richard-sackler-purdue-testimony.html">bears any responsibility for the devastation</a> wrought by the opioid crisis and has sought protection from lawsuits.</p>
<p>Under the terms of the <a href="https://apnews.com/article/purdue-pharma-opioid-settlement-6fd3e10dcd6b0eeffd2f0b885efd4693">settlement</a>, the Sacklers will hand over a total of $4.5 billion over nine years provided they can be released of any liability for their role in the opioid crisis. This immunity would extend to members of the family as well as to <a href="https://www.npr.org/2021/08/20/1028761427/sacklers-immunity-opioid-bankruptcy-trial">hundreds of foundations, trusts</a>, business associates, attorneys, lobbyists, Purdue subsidiaries and <a href="https://www.npr.org/2021/06/02/1002085031/sackler-family-empire-poised-to-win-immunity-from-opioid-lawsuits">other entities</a>.</p>
<p>The prospect of extensive immunity has attracted <a href="https://www.npr.org/2021/08/31/1032778376/purdue-pharma-bankruptcy-doj-justice-department-sackler-oxycontin-opioid">fierce criticism</a> and <a href="https://www.reuters.com/legal/transactional/states-seek-direct-appeal-purdue-pharma-plan-2nd-circuit-2021-09-30/">legal challenges</a> from eight states and the <a href="https://www.npr.org/2021/09/16/1037806819/opioids-purdue-pharma-sackler-settlement-bankruptcy-deal">Justice Department</a>.</p>
<p>On Dec. 16, 2021, a federal judge <a href="https://apnews.com/article/business-health-lawsuits-opioids-colleen-mcmahon-1e96ea41f783d8f5db0a024fbb304c1f">ruled against the plan</a>, but the company has vowed to appeal her decision.</p>
<p>If the deal holds up, however, the Sacklers will still retain most of the <a href="https://oversight.house.gov/news/press-releases/committee-releases-documents-showing-sackler-family-wealth-totals-11-billion">fortune</a> they amassed from the sales of OxyContin fully insulated against future lawsuits brought in connection with Purdue’s opioids.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/418492/original/file-20210830-19-jjhb1s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A sign hanging in the Metropolitan Museum of Art's Sackler Wing names all three brothers, Arthur, Mortimer and Raymond." src="https://images.theconversation.com/files/418492/original/file-20210830-19-jjhb1s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/418492/original/file-20210830-19-jjhb1s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/418492/original/file-20210830-19-jjhb1s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/418492/original/file-20210830-19-jjhb1s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/418492/original/file-20210830-19-jjhb1s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/418492/original/file-20210830-19-jjhb1s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/418492/original/file-20210830-19-jjhb1s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Metropolitan Museum of Art’s Sackler wing is named for the three brothers who built Purdue Pharma into a massive privately held drugmaker.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/sign-welcomes-visitors-to-the-sackler-wing-at-the-news-photo/1138930605">Spencer Platt/Getty Images</a></span>
</figcaption>
</figure>
<h2>Compensating the plaintiffs</h2>
<p>The abuse of prescription opioids <a href="https://www.cdc.gov/media/releases/2017/a0315-Business-Pulse-opioids.html">costs the U.S. economy $78.5 billion every year</a>, according to a Centers for Disease Control and Prevention estimate. The funds pledged by the Sacklers fall far short of paying this tab. However, the deal offers a creative way to help resolve the crisis.</p>
<p>The centerpiece of the deal is a plan to <a href="https://theconversation.com/oxycontin-maker-purdue-pharma-may-settle-legal-claims-with-a-new-public-trust-that-would-still-be-dedicated-to-profit-148604">dissolve Purdue</a> and reestablish it as a <a href="https://www.law.cornell.edu/wex/public_benefit_corporation">public benefit corporation</a>. The new entity will continue to sell some of Purdue’s signature products – including opioid painkillers, opioid substitution therapies like <a href="https://www.samhsa.gov/medication-assisted-treatment/medications-counseling-related-conditions/buprenorphine">buprenorphine</a> and anti-overdose medications like <a href="https://theconversation.com/explainer-naloxone-the-antidote-to-opioid-overdose-32481">naloxone</a> – and use the profits of these sales to fund addiction treatment and prevention programs.</p>
<p>Members of the Sackler family will have no stake in the new entity. Resuscitated as a public trust, the new Purdue will be bound to refrain from the kind of <a href="https://www.washingtonpost.com/graphics/2019/investigations/opioid-marketing/">pill-pushing methods</a> that made its fortune. </p>
<p>If successful, this new arrangement would show that a different way of producing and distributing drugs is possible.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/uaCaIhfETsM?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">John Oliver has repeatedly skewered the Sacklers in his “Last Week Tonight” show.</span></figcaption>
</figure>
<h2>Informing the public</h2>
<p>Lawsuits against the industry have produced millions of internal company documents that shed light on the origins of the opioid catastrophe. Together with other historians, I drafted an <a href="https://www.statnews.com/2019/09/12/historians-push-for-opioid-documents-archive/">amicus brief</a> in 2019 that made the case for the full disclosure of all the evidence unearthed in the course of the litigation.</p>
<p>When 46 U.S. states reached another sweeping <a href="https://www.publichealthlawcenter.org/topics/commercial-tobacco-control/commercial-tobacco-control-litigation/master-settlement-agreement">settlement with the tobacco industry in 1998</a>, we explained, the companies were asked to turn over their internal documents and pay for their collection and preservation.</p>
<p><a href="https://www.industrydocuments.ucsf.edu/tobacco/">Posted to the internet, these documents exposed</a> how the tobacco industry misled the public about the consequences of smoking and the nature of nicotine addiction for decades after these risks were discovered.</p>
<p>Overall, more than 1,000 books, research papers and articles about the impact of corporate behavior on public health were written based on this trove of evidence. The same approach, we argued, needs to be taken with the <a href="http://www.doi.org/10.1086/713409">opioid industry documents</a>.</p>
<p>We filed our brief just as Purdue made its opening settlement bid. The <a href="https://www.reuters.com/investigates/special-report/usa-courts-secrecy-judges/">Sacklers fought long</a> and <a href="https://www.statnews.com/2019/08/26/kentucky-supreme-court-allows-release-of-purdue-oxycontin-records/">hard to guard their secrets</a>, concealing some of the most incriminating evidence behind claims of attorney-client privilege. They were forced to relent to get <a href="https://www.mass.gov/news/ag-healey-announces-resolution-with-purdue-pharma-and-the-sackler-family-for-their-role-in-the-opioid-crisis">more states</a> on board.</p>
<p>As a result, 30 million documents – business plans, memos, emails, meeting minutes, legal records and even deposition videos – will be turned over to archivists and made available in text-searchable form through a user-friendly portal. Purdue’s inner workings will be exposed like those of few U.S. corporations before. This will help researchers, journalists and the public better understand the causes of the opioid epidemic.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/418519/original/file-20210830-19-1n2e6et.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Men in suits move large boxes of documents around outside a courthouse." src="https://images.theconversation.com/files/418519/original/file-20210830-19-1n2e6et.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/418519/original/file-20210830-19-1n2e6et.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/418519/original/file-20210830-19-1n2e6et.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/418519/original/file-20210830-19-1n2e6et.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/418519/original/file-20210830-19-1n2e6et.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=425&fit=crop&dpr=1 754w, https://images.theconversation.com/files/418519/original/file-20210830-19-1n2e6et.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=425&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/418519/original/file-20210830-19-1n2e6et.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=425&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Boxes of opioid-related evidence are transported in Central Islip, N.Y., in 2021 amid litigation against opioid manufacturers, distributors and drugstore chains.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/boxes-are-wheeled-out-in-a-landmark-case-before-a-jury-news-photo/1326472902">Raychel Brightman/Newsday RM via Getty Images</a></span>
</figcaption>
</figure>
<h2>Looking ahead</h2>
<p>By a striking quirk of timing, the court order compelling the release of the tobacco industry documents <a href="https://twitter.com/industrydocs/status/1430576443810062340">expired on Sept. 1, 2021</a>. The yearslong effort to collect the documents obtained from the tobacco industry will wind down just as the work to bring Purdue’s documents to the public begins.</p>
<p>Public access to industry documents altered the course of the <a href="https://www.washingtonpost.com/outlook/minnesota-tobacco-document-depository/2021/08/25/cdc1ecfc-050c-11ec-a654-900a78538242_story.html">litigation against Big Tobacco</a>. For decades, cigarette makers beat back lawsuits with claims that the science about the risks of smoking remained unsettled and that the companies were sincerely trying to mitigate known harms. They also held that smokers were making a choice and denied knowing anything about nicotine’s addictive potential. These defenses crumbled when the documents came to light and <a href="https://truthinitiative.org/who-we-are/our-history/master-settlement-agreement">more plaintiffs prevailed</a> in court. </p>
<p>Given the broad immunity granted to the Sacklers, the disclosure of Purdue’s opioid litigation documents may not lead to new lawsuits against them. But it might strengthen future litigation against other defendants in opioid cases. </p>
<p><a href="https://www.reuters.com/world/us/six-us-states-will-not-join-26-bln-opioid-settlements-with-distributors-jj-2021-08-23/">Drug distributors</a>, <a href="https://www.legalexaminer.com/health/first-pharmacy-settlements-in-nationwide-opioid-crisis/">pharmacies</a>, other <a href="https://www.nejm.org/doi/full/10.1056/NEJMp1710756">drugmakers</a> and even <a href="https://www.justice.gov/opa/pr/justice-department-files-lawsuit-against-tampa-area-physician-pharmacy-and-clinic-owners">some doctors are embroiled in their own lawsuits</a> and negotiating their own settlements.</p>
<p>Historians like me, public health experts, journalists, lawyers, survivors and the public need access to the evidence underpinning all of that litigation too. If only Purdue’s opioid-related documents are made public, the world would be left with a distorted picture of what caused this catastrophe.</p>
<p>The Sacklers, I fear, would continue to play their role as useful villains, diverting attention from the <a href="https://www.doi.org/10.1001/amajethics.2020.743">broader</a> <a href="https://www.washingtonpost.com/national/congressional-report-drug-companies-dea-failed-to-stop-flow-of-millions-of-opioid-pills/2018/12/18/5bc750ee-0300-11e9-b6a9-0aa5c2fcc9e4_story.html">systemic</a> <a href="https://www.nytimes.com/2020/05/27/health/opioids-pharmacy-cvs-litigation.html">failures</a> that allowed one <a href="https://www.justice.gov/opa/pr/justice-department-announces-global-resolution-criminal-and-civil-investigations-opioid">company</a> to cause so much damage.</p>
<p><em>Editor’s note: The descendants of <a href="https://www.theguardian.com/us-news/2018/feb/13/meet-the-sacklers-the-family-feuding-over-blame-for-the-opioid-crisis">Arthur Sackler</a>, the brother of Mortimer and Raymond Sackler, sold their stake in Purdue before the launch of OxyContin. They aren’t involved in opioid-related litigation against the company or Purdue’s related settlements. This article was updated on Dec. 17, 2021, with the latest details regarding the settlement’s status.</em></p>
<p>[<em>Over 110,000 readers rely on The Conversation’s newsletter to understand the world.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=100Ksignup">Sign up today</a>.]</p><img src="https://counter.theconversation.com/content/166701/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Antoine Lentacker is a member of the National Advisory Committee for the Opioid Industry Documents Archive, a partnership of the University of California, San Francisco, and Johns Hopkins University. </span></em></p>The multibillion-dollar settlement will trigger the release of troves of documents that may shine new light on what caused the opioid crisis.Antoine Lentacker, Assistant Professor of History, University of California, RiversideLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1510552021-01-04T17:26:24Z2021-01-04T17:26:24ZThe need to say it nicer: The language we choose when we talk about substance use matters<figure><img src="https://images.theconversation.com/files/376467/original/file-20201222-50514-qq2lrn.jpg?ixlib=rb-1.1.0&rect=49%2C24%2C5472%2C3612&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">How we talk to — and talk about — people who use substances is often pathologizing and hurtful.
</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>When Hunter Biden, son of President-elect Joe Biden, was recently <a href="https://abcnews.go.com/GMA/News/video/hunter-biden-relationship-dad-addiction-battle-66280562">interviewed by Amy Robach at ABC News</a>, Robach brought up Hunter’s substance use issues, noting that he had been “in and out of rehab seven, eight times.” </p>
<p>Hunter responded, “Say it nicer to me.” He went on to correct Robach’s language, saying that he had “sought treatment for an issue, like most people” and noted that the interviewer was “insensitive.” </p>
<p>What was surprising about this exchange was sadly not what Robach said, but that Hunter Biden challenged it. </p>
<p>As a researcher who studies the lived experiences of individuals with substance use issues, I am frequently disheartened by the words chosen to talk about substance use treatment and people who use drugs. </p>
<p>The language used when talking to or about people who use substances is often hurtful. Instead of recognizing and understanding the chronic relapsing nature of addiction, this language regards individuals who struggle with substance use as morally reprehensible. </p>
<h2>Negative language</h2>
<p>Terminology such as, “addict,” “junkie” and “abuser” continue to be commonplace. In Hunter Biden’s case, the interviewer’s characterization was that his multiple episodes of treatment indicated a personal failure. </p>
<p>Negative language about individuals who use substances contributes to how society views these individuals. For example, <a href="https://doi.org/10.1016/j.drugpo.2009.10.010">one study had clinicians read case vignettes</a> that either used the term “substance abuser” or “substance use disorder.” The clinicians who read the “substance abuser” vignettes were more likely to conclude that the character in the vignette was personally culpable, and were more likely to support punitive treatment for the character. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/376474/original/file-20201222-13-lin1xa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A word cloud about substance use and addiction" src="https://images.theconversation.com/files/376474/original/file-20201222-13-lin1xa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/376474/original/file-20201222-13-lin1xa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=422&fit=crop&dpr=1 600w, https://images.theconversation.com/files/376474/original/file-20201222-13-lin1xa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=422&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/376474/original/file-20201222-13-lin1xa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=422&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/376474/original/file-20201222-13-lin1xa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=530&fit=crop&dpr=1 754w, https://images.theconversation.com/files/376474/original/file-20201222-13-lin1xa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=530&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/376474/original/file-20201222-13-lin1xa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=530&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The language used when talking to or about people who use substances is often pathologizing and hurtful.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>I recently completed a study for which I interviewed 10 individuals attending outpatient treatment for substance use and 10 clinicians providing outpatient counselling. </p>
<p>I asked all of the participants how they perceived language around substance use, particularly as it related to relapse and recovery. I heard multiple stories of how disempowering the language around substance use can be, and how many of the participants who struggled with substance addictions felt judged and misunderstood by broader society. </p>
<h2>Recovery and relapse</h2>
<p>Relapse has become a negative word that is equated with failure instead of as a normal part of an individual’s treatment trajectory. One participant identified: </p>
<blockquote>
<p>“The reality is one day something is going to happen in your life that is going to be so overwhelming that you’re going to reach for that bottle or that drug, and it just depends what you do with it afterward.” </p>
</blockquote>
<p>Another participant shared a similar view: </p>
<blockquote>
<p>“I’ve been trying since I was 23. So, if I didn’t understand relapse, there’s not a chance I’d still be alive talking to you today. Because, um, I would just figure that I’ve failed at recovery and that’s it.” </p>
</blockquote>
<p>Treating relapse as personal failure, is another example of how language around substance use continues to stigmatise the individual, and ignore the complex realities of substance addiction.</p>
<p>As another participant described, individuals who are no longer using substances are described as “clean.” From his perspective, the implication is that if you are not “clean,” you are somehow “dirty.” This participant shared how his parents use this language when talking to him about his own experience: </p>
<blockquote>
<p>“Well, especially my mother’s husband, which is a trigger. Like, ‘are you still clean? Have you made a mistake yet?’ You know they’re asking me if I’ve slipped up.” </p>
</blockquote>
<h2>Avoiding words that perpetuate bias</h2>
<p>There continues to be an ingrained hierarchy of social acceptability when it comes to drugs. Caffeine and alcohol are seen to be socially acceptable, whereas other drugs such as crack cocaine, methamphetamine and opiates are considered unacceptable and the individuals who use these drugs are viewed as social outcasts.</p>
<p>Community members, academics and researchers continue to call for a change in the language we use to talk about substance use and addictions. For example, in 2014 the editorial team of the journal <em>Substance Abuse</em>, <a href="https://doi.org/10.1080/08897077.2014.930372">called for an increased consideration of the language used</a> to describe the experiences of substance use disorders, including incorporating people-first language, promoting the recovery process and avoiding slang that perpetuates stereotypes and biases. </p>
<p>As we leave behind the holiday season, when <a href="https://www.alcohol.org/statistics-information/holiday-binge-drinking/">imbibing and celebrating are socially normalized</a>, it is important to consider the internalized judgment placed on individuals who use substances and struggle with their use. The words we choose to talk to and about individuals who use substances are critical, as they contribute to how drug policy, substance use treatment and societal understanding are framed.</p>
<p>As a study participant concluded: </p>
<blockquote>
<p>“I certainly didn’t intend for this to happen to me. Nobody does. Yeah, I wish society would understand. But how can you understand when you have not been there yourself, right? Some do, some do. But in general, I don’t think so.” </p>
</blockquote>
<p>Individuals who live this experience, like Hunter Biden, continue to highlight that we need to learn to “say it nicer,” to speak without judgment, and a willingness to learn to understand.</p><img src="https://counter.theconversation.com/content/151055/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kara Fletcher receives funding from SSHRC and SHRF</span></em></p>The words we choose to talk to and talk about individuals who use substances are critical, as they contribute to how drug policy, substance use treatment and societal understanding are framed.Kara Fletcher, Assistant Professor, Faculty of Social Work, University of ReginaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1469782020-10-15T13:41:38Z2020-10-15T13:41:38ZTo build back better after COVID-19, we must support parents<figure><img src="https://images.theconversation.com/files/361433/original/file-20201002-18-tes8fs.jpg?ixlib=rb-1.1.0&rect=0%2C59%2C5725%2C3625&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">During the COVID-19 pandemic, parents need support now more than ever — including via universal parental support programs.</span> <span class="attribution"><span class="source">(Ketus Subiyanto/Pexels)</span></span></figcaption></figure><p>The COVID-19 pandemic has exposed several failures in Canada’s social safety net: rates of anxiety, depression and substance abuse have <a href="http://www.camh.ca/-/media/files/pdfs---public-policy-submissions/covid-and-mh-policy-paper-pdf.pdf">increased dramatically</a>, women have become <a href="https://www6.royalbank.com/assets/di-secure/images/article/now-and-noteworthy/2020/women-in-labour-force-2020.pdf">disproportionately unemployed</a> and Canadian children — whose mental and physical health ranked <a href="https://oneyouth.unicef.ca/sites/default/files/2020-09/UNICEF%20RC16%20Canadian%20Companion%20EN_Web.pdf">30th out of 38 wealthy countries</a> before this pandemic — are <a href="https://vanierinstitute.ca/covid-19-impacts-youth-well-being-in-canada/">suffering even more</a>. </p>
<p>Prime Minister Justin Trudeau’s plans to build back better include efforts to <a href="https://www.macleans.ca/news/throne-speech-2020-governor-general-julie-payette-transcript/">increase access to mental health resources</a> and create a <a href="https://www.cbc.ca/news/business/throne-speech-child-care-1.5735899">universal child-care system</a>. These plans, if followed through, will <a href="https://www.mentalhealthcommission.ca/English/resources/mhcc-reports/case-for-investing">undoubtedly benefit</a> <a href="https://www.oxfam.ca/publication/who-cares/">children, families and the economy</a>. But they are missing one of the most promising and cost-effective ways to support parent and child mental health — universal parent support programs.</p>
<h2>Parents need support, now more than ever</h2>
<p>Parenting is a tough job. Though it comes with some of the <a href="https://www.npr.org/2014/01/24/265365876/a-parenting-paradox-how-kids-manage-to-be-all-joy-and-no-fun">highest highs</a>, children’s unrelenting needs can often be relentlessly draining. Universally, children <a href="https://doi.org/10.1093/sleep/zsz015">deprive their parents of sleep</a>, <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2318106">deprive them economically</a> and <a href="https://doi.org/10.4054/DemRes.2017.36.4">deprive them of alone time with their partners</a>. </p>
<figure class="align-center ">
<img alt="A baby boy in a plaid shirt throws his head back and cries." src="https://images.theconversation.com/files/363435/original/file-20201014-19-1ogivxg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/363435/original/file-20201014-19-1ogivxg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/363435/original/file-20201014-19-1ogivxg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/363435/original/file-20201014-19-1ogivxg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/363435/original/file-20201014-19-1ogivxg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/363435/original/file-20201014-19-1ogivxg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/363435/original/file-20201014-19-1ogivxg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Children’s needs are often draining for parents.</span>
<span class="attribution"><span class="source">Marcos Paulo Prado/Unsplash</span></span>
</figcaption>
</figure>
<p>All of this has been <a href="https://www.cbc.ca/news/canada/hamilton/covid-parents-1.5714412">exacerbated by COVID-19</a>. The fact that many parents have had to spend more time on childcare, received less support and are experiencing greater financial stress — especially <a href="https://newsroom.td.com/featured-news/td-survey-covid19-financial-impact-young-diverse-canadians">racialized Canadians</a>, <a href="https://www.iser.essex.ac.uk/files/news/2020/single-mother-income-loss-covid-19/covid-briefing-paper-economic-effects.pdf">single parents</a>, <a href="https://globalnews.ca/news/7038903/statistics-canada-low-income-families-coronavirus/">low-income parents</a> and <a href="https://www.cyda.org.au/images/pdf/covid_report_compressed_1.pdf">parents of children with disabilities</a> — does not come without consequences. </p>
<p>Across the board, the mental health of both parents and children <a href="https://doi.org/10.1542/peds.2020-016824">has worsened</a>. </p>
<p>In many cases, it’s a reinforcing cycle. For instance, new and soon-to-be mothers in Canada are now <a href="https://doi.org/10.3389/fgwh.2020.00001">two and a half times more likely to be anxious or depressed</a>, which we know has significant negative impacts on children’s <a href="https://doi.org/10.1176/appi.ajp.2018.17091031">early neurodevelopment</a> and <a href="https://doi.org/10.1111/j.1469-7610.2006.01714.x">long-term mental health</a>. </p>
<p>Studies have also shown that COVID-19 is <a href="https://doi.org/10.3389/fpsyg.2020.01713">impairing parents’ ability to provide emotional support</a> to their children and <a href="https://doi.org/10.1007/s10578-020-01037-x">increasing parent-child conflict</a>, exacerbating children’s mental health in these difficult times. </p>
<p>But some parents are faring better than others. Before the pandemic, parents with good <a href="https://doi.org/10.1080/01674820802000467">social support systems, coping strategies</a>, <a href="https://doi.org/10.1002/imhj.20044">high self-efficiency</a> and a strong sense of <a href="https://doi.org/10.1097/01.NNR.0000313502.92227.87">family cohesion</a> tended to be less stressed. Through the pandemic, these same patterns have remained true: parents receiving more emotional and social support have experienced <a href="https://doi.org/10.1016/j.chiabu.2020.104699">less stress and are at a lower risk of committing child abuse</a>.</p>
<h2>Parent support programs benefit us all</h2>
<p>Luckily, there is a simple and effective way to extend support to parents and equip them with helpful coping strategies. Parenting support programs are psycho-education programs that help parents adjust to and manage the challenges of parenthood. They come in a variety of formats, from <a href="https://doi.org/10.1007/s11121-020-01128-0">phone call or SMS check-ins</a> to <a href="https://doi.org/10.1007/s10802-007-9104-9">multi-component individual therapy</a>, though the most common are group workshops (for example, <a href="https://www.triplep-parenting.ca/ont-en/triple-p/">Triple P</a> and <a href="http://www.incredibleyears.com/">Incredible Years</a>).</p>
<p>After participating in these programs, parents are often less <a href="https://doi.org/10.1037/a0019691">stressed</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314244/">depressed or anxious</a>, more <a href="https://doi.org/10.1016/j.cpr.2014.04.003">confident and more satisfied with their marriages</a>. They also display <a href="https://doi.org/10.1111/jcpp.12781">more positive parenting and less harsh</a> <a href="https://doi.org/10.1177/1049731505284391">or abusive</a> parenting styles. Their children also tend to show <a href="https://doi.org/10.1016/j.cpr.2013.07.006">more pro-social behaviour</a>, <a href="https://doi.org/10.1017/S0954579419001068">are less disruptive</a> and exhibit <a href="https://doi.org/10.1007/s11292-016-9256-0">less destructive antisocial behaviour</a>. </p>
<figure class="align-center ">
<img alt="A man and his daughter wash dishes together." src="https://images.theconversation.com/files/363433/original/file-20201014-21-hw2bng.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/363433/original/file-20201014-21-hw2bng.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/363433/original/file-20201014-21-hw2bng.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/363433/original/file-20201014-21-hw2bng.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/363433/original/file-20201014-21-hw2bng.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/363433/original/file-20201014-21-hw2bng.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/363433/original/file-20201014-21-hw2bng.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Parenting support programs can help stressed-out parents cope.</span>
<span class="attribution"><span class="source">Unsplash</span></span>
</figcaption>
</figure>
<p>This translates into many cost-saving outcomes for our society: reduced need for <a href="https://doi.org/10.1111/j.1467-8624.2010.01563.x">special education services</a>, reduced involvement in the <a href="https://rhyclearinghouse.acf.hhs.gov/sites/default/files/docs/18064-Developmental_and_Economic_Effects_of_Parenting_Programs.pdf">child welfare and criminal justice systems</a> and reduced use of <a href="https://doi.org/10.1007/978-3-319-94598-9_35">mental and physical health treatments</a>, as wall as increased <a href="https://doi.org/10.1016/j.psc.2011.11.005">productivity</a> and <a href="https://doi.org/10.1177/1049731512449873">tax revenues</a>. </p>
<p>In fact, for every dollar invested in these programs, returns range from <a href="https://doi.org/10.1177%2F1049731512449873">87 cents</a> to up to <a href="https://doi.org/10.1111/j.1467-8624.2010.01563.x">$10.83</a>, with higher benefits for those at greater risk. </p>
<p>Parent support programs can also be provided at a low cost. <a href="https://education.mn.gov/MDE/fam/elsprog/ECFE/">Minnesota’s Early Childhood Family Education program</a> offers a weekly support class hosted in public schools (or <a href="https://ece.mpls.k12.mn.us/ecfe">currently online</a>) to all families with children under age five. Parents who can afford it pay on a sliding scale, while those who can’t pay nothing. </p>
<h2>What could we do better?</h2>
<p>The Public Health Agency of Canada currently administers a parent support program called <a href="https://nobodysperfect.ca/home/">Nobody’s Perfect</a> that’s implemented by local public health agencies across the country. Parents who participate in this program <a href="https://www.bccf.ca/media/uploads/Resource%20PDF/nobody's_perfect_evaluation.pdf">love it</a>, and it has <a href="https://nobodysperfect.ca/about/evaluations/">proven effective</a> across many metrics, though it has not been evaluated in a randomized trial or for its cost-effectiveness. We could certainly use <a href="https://doi.org/10.1503/cmaj.1030676">more research on this program</a>. </p>
<p>But given the overwhelming evidence on the efficacy of parent support programs, the time to expand access is now. Although some provinces have additional programming (Ontario’s <a href="https://www.ontario.ca/page/find-earlyon-child-and-family-centre">EarlyON drop-in programs</a> and Alberta’s <a href="https://www.alberta.ca/family-resource-networks.aspx">Family Resource Networks</a>, for example), currently no province offers support programs to all of its parents. </p>
<p>In fact, there is often only selective access by urban parents who know about them. But these programs benefit all parents, regardless of <a href="https://doi.org/10.1007/s11121-016-0733-5">ethnicity</a> or <a href="https://doi.org/10.1080/15374416.2013.769169">income</a>. They also work in-person <a href="https://doi.org/10.1016/j.jaac.2017.02.010">or online</a>. So there is no reason they should not be made equitably accessible to all. </p>
<h2>Investing now for a better future</h2>
<p>The mental health of parents and children in Canada was bad before the pandemic. Now it’s worse. </p>
<p>If we want a more productive workforce, today and tomorrow, we should invest wisely by providing universal access to proven and cost-effective parent support programs. </p>
<p>By helping parents build up their support networks, parenting skills and adaptive coping strategies, we will be ensuring that not only parents, but also their children, our society and our economy, will be better off throughout the COVID-19 pandemic and for decades to come.</p><img src="https://counter.theconversation.com/content/146978/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nina Sokolovic is the author of a parent support program implemented by the Novak Djokovic Foundation in Serbia. She receives no monetary compensation related to the program. She currently receives funding from the Social Sciences and Humanities Research Council of Canada.</span></em></p>Our mental health and economy are suffering from this pandemic. Parent support programs are a proven way to improve both.Nina Sokolovic, Doctoral Candidate, Developmental Psychology and Education, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1476662020-10-12T18:46:14Z2020-10-12T18:46:14ZWhy do some people struggle to make ‘healthy’ decisions, day after day?<figure><img src="https://images.theconversation.com/files/362874/original/file-20201012-21-1ahvfj5.jpg?ixlib=rb-1.1.0&rect=88%2C50%2C8299%2C3684&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>To navigate our way through the world, we constantly make choices. While we’ve all made our fair share of regrettable ones, most of us eventually learn from these – and we generally take this ability for granted.</p>
<p>For some people suffering from illnesses such as schizophrenia and substance use disorder – previously referred to as “<a href="https://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2013.12060782">substance abuse</a>” – making the right choices can be extremely difficult.</p>
<p>In fact, many mental illnesses feature problems with <a href="https://doi.org/10.1192/bjo.2020.12">cognition</a> (thinking and comprehension), including depression and bipolar disorder. Decision-making ability varies in healthy people, too, sometimes as a consequence of differences in <a href="https://doi.org/10.1016/j.neuron.2013.08.030">genetics</a>.</p>
<p>What’s happening in the brains of these people that puts them on unequal footing to the rest of us?</p>
<h2>Even simple decisions are complex</h2>
<p>It’s important to note in day-to-day situations, there’s often no distinctly “right” or “wrong” choice to be made. However, some choices do result in healthier or more productive outcomes for us and those around us. </p>
<p>Our brains carry out a suite of complex processes when making decisions. And there are four important factors in each decision we make: value, motivation, action and strategy. </p>
<p>When choosing between two options, say A and B, we first need to understand which choice will be more rewarding, or provide more <em>value</em>. Our personal <em>motivation</em> to attain this reward then acts to bias which option we choose, or whether we make a choice at all. </p>
<p>Understanding what <em>action</em> is required to obtain A, or B, is also important. Combining all this information, we try to understand which <em>strategy</em> will maximise our rewards. And this lets us improve our decision-making ability over time.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/362815/original/file-20201011-17-1te41u5.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/362815/original/file-20201011-17-1te41u5.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=598&fit=crop&dpr=1 600w, https://images.theconversation.com/files/362815/original/file-20201011-17-1te41u5.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=598&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/362815/original/file-20201011-17-1te41u5.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=598&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/362815/original/file-20201011-17-1te41u5.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=751&fit=crop&dpr=1 754w, https://images.theconversation.com/files/362815/original/file-20201011-17-1te41u5.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=751&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/362815/original/file-20201011-17-1te41u5.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=751&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There are multiple decision-making processes in the brain that help determine the choices we make.</span>
<span class="attribution"><span class="source">James P. Kesby</span></span>
</figcaption>
</figure>
<h2>Interrupted connections</h2>
<p>We refer to our personal history and past experiences to guide our future choices. But mental disorders often cause problems in the decision-making process. </p>
<p>Research shows people with schizophrenia can have trouble understanding the relationship between their <a href="https://doi.org/10.1038/s41398-017-0071-9">actions and the outcomes</a>. This means they might keep selecting A, even if they know it’s no longer as valuable as B. </p>
<p>They’re also more willing to adopt strategies based on less information, in other words “<a href="https://doi.org/10.1017/S003329171900357X">jump to conclusions</a>”, about outcomes. </p>
<p>Substance use disorder, particularly with stimulants such as methamphetamine or cocaine, often leads to people getting stuck when <a href="https://doi.org/10.1016/j.biopsych.2011.06.033">certain outcomes change</a>. </p>
<p>For example, if we reversed all the street lights so red meant “go” and green meant “stop” without telling anyone, most people would get an initial shock but would eventually alter their behaviour. </p>
<p>People with stimulant dependence, however, would take longer to learn to stop on the green light – even if they kept getting into car accidents. This is because excessive stimulant use impacts regions in the brain that are crucial to adapting to changing environments.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-parents-and-teachers-can-identify-and-help-young-people-self-medicating-trauma-with-drugs-and-alcohol-104482">How parents and teachers can identify and help young people self-medicating trauma with drugs and alcohol</a>
</strong>
</em>
</p>
<hr>
<h2>How the brain decodes each decision</h2>
<p>The human brain contains multiple circuits (like pathways) and chemical messengers called “neurotransmitters”. These are responsible for guiding the processes discussed above.</p>
<p>The decision-making circuits commonly associated with schizophrenia and substance use disorder include areas of the “cortex” – the outer part of our brain important for complex thought (especially the frontal lobe) – that “talk” to hub areas such as the “striatum”. The striatum lets us select and then initiate an action to achieve a specific goal.</p>
<p>Different cortical areas are used to compute different <a href="https://doi.org/10.1016/j.neubiorev.2020.07.010">processes</a> in the brain. The prefrontal cortex helps us understand when a strategy needed for success changes. So, if we replaced all the traffic lights with sirens, the prefrontal cortex would help us realise this and adjust. </p>
<p>When the anticipated outcome of a choice changes (such as if A was better, but then suddenly B became better), the orbitofrontal cortex helps us identify this. Similarly, the striatum is key for anticipating what an outcome will be and when we will get the reward.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/362888/original/file-20201012-17-l6gj2e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A basic anatomy diagram of the human brain." src="https://images.theconversation.com/files/362888/original/file-20201012-17-l6gj2e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/362888/original/file-20201012-17-l6gj2e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=418&fit=crop&dpr=1 600w, https://images.theconversation.com/files/362888/original/file-20201012-17-l6gj2e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=418&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/362888/original/file-20201012-17-l6gj2e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=418&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/362888/original/file-20201012-17-l6gj2e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=525&fit=crop&dpr=1 754w, https://images.theconversation.com/files/362888/original/file-20201012-17-l6gj2e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=525&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/362888/original/file-20201012-17-l6gj2e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=525&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The cortex is the wrinkly layer that covers our brain. The striatum sits underneath the cortex, in the forebrain.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>Dopamine helps make your choices a reality</h2>
<p>Extensive research efforts have found the brains of people experiencing schizophrenia function differently in multiple areas. It’s believed this could contribute to decision-making problems.</p>
<p>For the psychotic symptoms observed in schizophrenia (such as hallucinations and delusions), alterations in the neurotransmitter dopamine are important. <a href="https://neuro.psychiatryonline.org/doi/full/10.1176/appi.neuropsych.24.1.1">Dopamine</a> is a chemical in the brain that’s key for anticipating rewards, making decisions and controlling the physical actions necessary to act on our choices.</p>
<p>In our <a href="https://doi.org/10.3389/fnins.2020.00542">research</a>, we’ve argued increases in dopamine in the striatum may cause problems with how the brain integrates information from the cortex, resulting in decision-making difficulties. However, this may only be the case in <a href="https://doi.org/10.1016/j.biopsych.2013.06.011">some individuals</a>.</p>
<p>Stimulants also cause excessive dopamine release. They can alter the balance between goal-directed behaviours, which are flexible and respond to environmental changes – and habits, which are automatic and hard to break.</p>
<p>Usually, when we learn something new our brain keeps adapting and incorporating new information. But this is slow and cognitively demanding. Substance dependence can accelerate a person’s progression to habitual behaviour, wherein a set strategy or response become ingrained. </p>
<p>This then makes it hard to stop seeking drugs, even if the individual no longer finds them <a href="https://doi.org/10.1016/j.neubiorev.2013.02.010">enjoyable</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-that-cigarette-chocolate-bar-or-new-handbag-feels-so-good-how-pleasure-affects-our-brain-91773">Why that cigarette, chocolate bar, or new handbag feels so good: how pleasure affects our brain</a>
</strong>
</em>
</p>
<hr>
<h2>How we can we help people make better decisions</h2>
<p>Unfortunately, problems with cognitive ability are hard to treat. There are no medications for schizophrenia or stimulant dependence shown to reliably improve <a href="https://doi.org/10.1176/ps.2008.59.5.500">cognition</a>. This is a consequence of the human brain’s complexity. </p>
<p>That said, there are ways we can all improve our memory and decision-making, which may also help those with mental illnesses causing cognition problems. </p>
<p>For instance, <a href="https://www.psychologytools.com/professional/techniques/cognitive-remediation/">cognitive remediation therapy</a> is a behavioural approach that trains the brain to respond to certain situations better. For people with schizophrenia, it may improve <a href="https://doi.org/10.1017/S0033291717001234">visual memory</a> and perhaps more complex decision-making. </p>
<p>Not being able to navigate decisions day-to-day is one of the most debilitating aspects of <a href="https://doi.org/10.1016/j.schres.2019.10.011">disorders</a> that impact cognition. This leads to difficulties in maintaining work, keeping friends and leading a fulfilling life. </p>
<p>We need more research to understand how different brains make different decisions. Hopefully then we can improve the lives of those living with mental illness.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/five-things-you-need-to-know-about-mental-health-32581">Five Things You Need To Know About Mental Health</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/147666/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>James Kesby receives funding fromthe National Health and Medical Research Council (NHMRC), the Brain & Behavior Research Foundation (BBRF) and Philanthroic Funding through the Queensland Brain Insititute (QBI). He is affiliated with QIMR Berghofer Medical Research Institute. </span></em></p><p class="fine-print"><em><span>Shuichi Suetani has received funding from the National Health and Medical Research Council, Metro South Health Research Support, Brisbane Diamantina Health Partners Brain and Mental Health Theme, Princess Alexandra Hospital Research Foundation, Society of Mental Health Research, AVANT and Australian and New Zealand College of Psychiatrists. Shuichi Suetani works for Queensland Health. He has received honoraria for advisory work from Seqirus and is affiliated with Queensland Brain Institute (QBI) and Griffith University.
</span></em></p>During Mental Health Week, let’s look at why some people, such as those experiencing depression or substance dependency, struggle to make decisions like everyone else.James Kesby, UQ Amplify Researcher, The University of QueenslandShuichi Suetani, Psychiatrist, Queensland Brain Institute, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1446722020-09-24T20:42:27Z2020-09-24T20:42:27ZThe designated driver role gets a modern update, covering dangers from COVID-19 to social media<figure><img src="https://images.theconversation.com/files/357828/original/file-20200914-20-1s1sx0i.jpg?ixlib=rb-1.1.0&rect=332%2C0%2C5658%2C3997&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The concept of Buddy Circles expands the designated driver role to include broader substance use and other risks.</span> <span class="attribution"><span class="source">(Pexels/Martin Lopez)</span></span></figcaption></figure><p>The designated driver (DD) is a successful public health strategy dating back to the late 1980s. To better reflect the realities of today’s society, now is a good time to evolve the initiative to help mitigate the harms tied to broader substance use and beyond drinking and driving.</p>
<p>The promotion of “buddy circles,” as an expanded harm reduction strategy, is one possible way to achieve these ends. Similar to the DD, the aim of the proposed buddy circle initiative is to challenge norms and promote behaviour change in order to reduce harm. </p>
<p>The buddy circle concept, however, expands on that of the designated driver, taking into account other substances and risks — including COVID-19 and social media — in order to build a more comprehensive harm mitigation strategy for the 21st century.</p>
<h2>The designated driver and beyond</h2>
<p>In North America the concept of designated driving began in 1988 as part of <a href="http://www.designateddriving.net/historyofdesignateddriving.html">Harvard University’s School of Public Health’s Alcohol Project</a>. The project involved a partnership with major television networks and Hollywood studios. Over the past 30 years this program <a href="https://www.hsph.harvard.edu/news/features/harvard-center-helped-to-popularize-solution-to-a-national-problem/">has achieved its goals</a>, integrating the DD into our language and culture.</p>
<figure class="align-right ">
<img alt="A martini glass and a key in a circle with a red line through it." src="https://images.theconversation.com/files/357822/original/file-20200914-14-1rjb652.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/357822/original/file-20200914-14-1rjb652.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/357822/original/file-20200914-14-1rjb652.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/357822/original/file-20200914-14-1rjb652.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/357822/original/file-20200914-14-1rjb652.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/357822/original/file-20200914-14-1rjb652.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/357822/original/file-20200914-14-1rjb652.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Over the past 30+ years, the concept of the designated driver has become integrated into our language and culture.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>According to <a href="https://www.hsph.harvard.edu/news/features/harvard-center-helped-to-popularize-solution-to-a-national-problem/">Jay Winsten</a>, founding director of the Center for Health Communication at the Harvard T.H. Chan School of Public Health, there were two crucial elements involved in the successful promotion of the DD to the public. The first was that it was framed as a positive message, one that “lent social legitimacy to the option of refraining from drinking and created social pressure to conform.” The second was that the DD “needed to be viewed as an integral part of the evening’s fun and not as a bystander.”</p>
<p>Since its inception, the DD has been associated with alcohol consumption. That original focus still dominates our popular understanding of the program (for example see the <a href="https://www.dictionary.com/browse/designated-driver?s=t">online dictionary definition</a> of DD). </p>
<p>Today, as an increasing number of countries explore relaxing their drug polices in response to and/or as a result of greater awareness of drug using behaviours and the <a href="https://www.cato.org/publications/commentary/hidden-costs-drug-prohibition">harms associated with prohibitionist policies</a> and practices, including Canada where recreational <a href="https://laws-lois.justice.gc.ca/eng/acts/C-24.5/">cannabis was legalized</a> in 2018 and there is increasing pressure to <a href="https://www.huffingtonpost.ca/entry/canada-decriminalize-drugs_ca_5f3ec307c5b6763e5dc08913">decriminalize possession of all drugs</a> — similar to <a href="https://www.theguardian.com/news/2017/dec/05/portugals-radical-drugs-policy-is-working-why-hasnt-the-world-copied-it">Portugal</a>, a broader approach to substance use behaviour and its associated risks is needed.</p>
<figure class="align-center ">
<img alt="A blonde woman wearing heart-shaped sunglasses smoking a joint at an outdoor event." src="https://images.theconversation.com/files/359156/original/file-20200921-20-d3d12d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/359156/original/file-20200921-20-d3d12d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/359156/original/file-20200921-20-d3d12d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/359156/original/file-20200921-20-d3d12d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/359156/original/file-20200921-20-d3d12d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/359156/original/file-20200921-20-d3d12d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/359156/original/file-20200921-20-d3d12d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A woman smokes a joint during the annual 4/20 cannabis culture celebration at Sunset Beach in Vancouver, B.C., on April 20, 2017.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
</figcaption>
</figure>
<h2>Program expansion</h2>
<p>There are a variety of potential risks or harms that a buddy circle initiative may address. Four are highlighted here: </p>
<ul>
<li>overconsumption of substances</li>
<li>unintended or non-consensual consumption of substances</li>
<li>social media exposure</li>
<li>COVID-19 </li>
</ul>
<p>The harms associated with over-consumption of substances include overdosing, passing out, vomiting, choking on vomit, sexual or physical assault or engaging in dangerous and/or embarrassing behaviour.</p>
<p>There is also a danger of unintended consumption, such as having a drink or other substance <a href="https://edmonton.citynews.ca/2020/02/07/spiked-drinks/">spiked by a more potent drug</a> (for example, fentanyl-laced heroin) or via “date-rape” drugs (e.g., GHB and rohypnol). </p>
<figure class="align-right ">
<img alt="A smartphone in the foreground filming as a man in a costume pours liquor into a young woman's mouth" src="https://images.theconversation.com/files/357826/original/file-20200914-24-m0l76i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/357826/original/file-20200914-24-m0l76i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/357826/original/file-20200914-24-m0l76i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/357826/original/file-20200914-24-m0l76i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/357826/original/file-20200914-24-m0l76i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/357826/original/file-20200914-24-m0l76i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/357826/original/file-20200914-24-m0l76i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Images taken while people are impaired can have negative consequences if posted to social media.</span>
<span class="attribution"><span class="source">(Pexels/Hygor Sakai)</span></span>
</figcaption>
</figure>
<p>Another area of risk in the 21st century is associated with smart phones and social media. Taking and posting photographs of oneself and one’s friends is an everyday occurrence. These include photos of intoxicated individuals, that can be (and often are) posted to social media sites by friends or by strangers.</p>
<p>Despite <a href="https://mcmillan.ca/Files/152270_social%20media%20background%20checks.pdf">laws protecting privacy rights</a>, such posts can have severe negative consequences for individuals. Elements of one’s social media behaviour that are viewed as evidence of questionable “<a href="https://www.usnews.com/news/national-news/articles/2017-06-05/harvard-pulls-student-admission-offers-after-explicit-facebook-posts">honesty, maturity or moral character</a>” can result in loss of <a href="https://online.maryville.edu/blog/student-guide-to-social-media/">jobs or job offers</a>, loss of scholarships, <a href="https://www.cbc.ca/news/world/there-is-a-huge-consequence-a-foolish-social-media-post-can-dash-your-post-secondary-dreams-1.4148705">rescinding of offers for school admission</a> or other lost opportunities.</p>
<p>Now in 2020, COVID-19 adds an additional layer to evolving substance-use harm-mitigation strategies. As communities lift COVID-19 restrictions, we see young people in particular participating in social gatherings <a href="https://www.msn.com/en-ca/news/canada/just-offensive-large-vancouver-beach-party-draws-outrage-amid-covid-19/ar-BB174aln">on beaches</a>, at <a href="https://minnesota.cbslocal.com/2020/08/20/17-st-olaf-college-students-suspended-50-in-quarantine-after-covid-19-exposure-at-off-campus-party/">house parties</a>, <a href="https://wnyt.com/news/college-party-with-over-400-people-shut-down-in-north-carolina-coronavirus-pandemic-east-carolina-university-/5826711/">on and</a> <a href="https://minnesota.cbslocal.com/2020/08/20/17-st-olaf-college-students-suspended-50-in-quarantine-after-covid-19-exposure-at-off-campus-party/">off college campuses</a>, and <a href="https://www.theglobeandmail.com/canada/article-montreal-urging-all-bar-patrons-employees-to-get-covid-19-test-after/">at bars</a>, typically engaging in substance consumption and related behaviours that can increase the risk of COVID-19 transmission.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/357817/original/file-20200914-14-iquyiy.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A group of young adults at the beach with young men playing beach volleyball in the foreground." src="https://images.theconversation.com/files/357817/original/file-20200914-14-iquyiy.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/357817/original/file-20200914-14-iquyiy.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/357817/original/file-20200914-14-iquyiy.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/357817/original/file-20200914-14-iquyiy.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/357817/original/file-20200914-14-iquyiy.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/357817/original/file-20200914-14-iquyiy.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/357817/original/file-20200914-14-iquyiy.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Young people gather at the Break Water Park, near Gord Edgar Downie Pier, without any physical distancing in Kingston, Ont., on Aug. 30, 2020.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Lars Hagberg</span></span>
</figcaption>
</figure>
<h2>Buddy circles</h2>
<p>The promotion of buddy circles as a harm reduction strategy can address these concerns. The idea builds on the successes of the DD, re-imagining how lessons learned can be applied to enhance the norms tied to socially responsible substance use behaviour. It also incorporates familiar elements from the more recent COVID-19 “<a href="https://www.cbc.ca/news/canada/toronto/covid-social-bubbles-1.5727136">social circle</a>” campaigns, such as limiting our exposure to others to reduce risk. </p>
<p>Buddy circles are small groups of individuals who get together socially and look out for each others’ well-being. Buddy circles can work whether the group is staying in or going out, attending parties (small or large, indoors or outdoors), or going to bars or other indoor public venues.</p>
<p>On successive social occasions, members of the circle take turns playing the integral role of “buddy guard” (similar to the DD) — abstaining from substance use and taking the lead in encouraging the group to watch out for each other in order to mitigate harm. This can include reminding members to: stay together, maintain social distance, wear masks, clean their hands and avoid taking and sharing inappropriate photos of members. The buddy guard can also get help when needed and make sure that everyone arrives home safely at the end of the night, whatever the mode of transportation.</p><img src="https://counter.theconversation.com/content/144672/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jacqueline Lewis does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Buddy circles expand on the concept of a designated driver, encompassing other substances and risks — including COVID-19 and social media — to build a harm mitigation strategy for the 21st century.Jacqueline Lewis, Associate Professor, Sociology, University of WindsorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1456862020-09-14T06:36:50Z2020-09-14T06:36:50ZWe can’t ignore mental illness prevention in a COVID-19 world<figure><img src="https://images.theconversation.com/files/356693/original/file-20200907-24-1spertl.jpg?ixlib=rb-1.1.0&rect=100%2C108%2C4989%2C2149&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Despite the <a href="https://www.vic.gov.au/coronavirus-covid-19-restrictions-roadmaps">incremental easing of Victoria’s restrictions</a>, it’s clear the journey towards COVID-normal is far slower than many people had hoped. </p>
<p>Australians – particularly Victorians – have shown remarkable resilience, but many are suffering emotionally. </p>
<h2>The mental health impacts of COVID-19</h2>
<p>During the early days of the pandemic, <a href="https://www.mja.com.au/journal/2020/mental-health-people-australia-first-month-covid-19-restrictions-national-survey">surveys</a> showed a sharp increase in symptoms of anxiety and depression across Australia. These difficulties <a href="https://www.abs.gov.au/ausstats/abs%40.nsf/mediareleasesbyCatalogue/8F3E1A983C0BF4C7CA25854F0083C5A9?OpenDocument">continued into mid-August</a>. More than 40% of Australians aged 18 years and older feel high levels of anxiety, and around one in six report depressive symptoms. </p>
<p>To target this, federal and state governments have increased telephone, online and face-to-face mental health supports. While this is vital, more needs to be done to prevent people suffering severe mental health problems in the first place.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/356694/original/file-20200907-24-ffrbya.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Girl wearing mask looking out window" src="https://images.theconversation.com/files/356694/original/file-20200907-24-ffrbya.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/356694/original/file-20200907-24-ffrbya.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/356694/original/file-20200907-24-ffrbya.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/356694/original/file-20200907-24-ffrbya.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/356694/original/file-20200907-24-ffrbya.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/356694/original/file-20200907-24-ffrbya.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/356694/original/file-20200907-24-ffrbya.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Over 40% of Australians aged 18 years and older feel high levels of anxiety, and around 1 in 6 report depressive symptoms.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>Prevention is better than cure</h2>
<p>There’s good <a href="https://link.springer.com/article/10.1007/s00127-018-1501-6">evidence</a> we can <a href="https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(18)30057-9/fulltext">prevent</a> many cases of depression, anxiety and substance abuse. But Australia doesn’t have a mental health prevention plan or policy, and government <a href="https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/expenditure-on-mental-health-related-services">funding</a> for prevention is just 1% of the total <a href="https://www.mentalhealthcommission.gov.au/Monitoring-and-Reporting/national-reports/2014-Contributing-Lives-Review">mental health budget</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/women-are-drinking-more-during-the-pandemic-and-its-probably-got-a-lot-to-do-with-their-mental-health-139295">Women are drinking more during the pandemic, and it's probably got a lot to do with their mental health</a>
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</em>
</p>
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<p>The <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/mental-fifth-national-mental-health-plan">Fifth National Mental Health and Suicide Prevention Plan</a>, the government’s key mental health blueprint, focuses on improving mental health-care services and suicide prevention, but not on <a href="https://everymind.org.au/resources/prevention-first">preventing</a> the mental health conditions that are a major risk factor for suicide. </p>
<h2>What about illness prevention?</h2>
<p>Last month the federal government released a <a href="https://consultations.health.gov.au/national-preventive-health-taskforce/consultation-paper-for-the-national-preventive-hea/">consultation paper</a> on its proposed <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/national-preventive-health-strategy">National Preventive Health Strategy</a>, setting out what the strategy will aim to achieve and how it might be done.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-government-will-spend-48-million-to-safeguard-mental-health-extending-jobkeeper-would-safeguard-it-even-more-138778">The government will spend $48 million to safeguard mental health. Extending JobKeeper would safeguard it even more</a>
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</em>
</p>
<hr>
<p>The document’s exciting because it focuses on health promotion and illness prevention, acknowledging we can’t improve the health of the Australian community through health-care measures alone. </p>
<p>But unfortunately, the proposed strategy’s fundamentally focused on physical health issues. In its 20 pages, the consultation paper only mentions mental health three times.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/356692/original/file-20200907-24-dryw1l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Folders labelled with mental health conditions" src="https://images.theconversation.com/files/356692/original/file-20200907-24-dryw1l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/356692/original/file-20200907-24-dryw1l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=346&fit=crop&dpr=1 600w, https://images.theconversation.com/files/356692/original/file-20200907-24-dryw1l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=346&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/356692/original/file-20200907-24-dryw1l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=346&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/356692/original/file-20200907-24-dryw1l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=435&fit=crop&dpr=1 754w, https://images.theconversation.com/files/356692/original/file-20200907-24-dryw1l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=435&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/356692/original/file-20200907-24-dryw1l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=435&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Government funding for prevention is just 1% of the total mental health budget. The National Preventive Health Strategy provides an opportunity to shed light on prevention measures for mental health conditions.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>The same principles outlined in the strategy to prevent conditions such as diabetes also apply to preventing mental health conditions such as depression. To prevent either, we need to minimise risk factors and increase protective factors linked to the condition, before it occurs. But some adaptation would be needed for the plan to address both physical and mental health.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/if-australia-really-wants-to-tackle-mental-health-after-coronavirus-we-must-take-action-on-homelessness-139840">If Australia really wants to tackle mental health after coronavirus, we must take action on homelessness</a>
</strong>
</em>
</p>
<hr>
<h2>What prevention measures should be added?</h2>
<p>A focus on physical activity, healthy eating, and non-smoking will help to promote good mental health as well as physical health. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/356695/original/file-20200907-22-1cb9mjh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Man carrying box of office supplies" src="https://images.theconversation.com/files/356695/original/file-20200907-22-1cb9mjh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/356695/original/file-20200907-22-1cb9mjh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/356695/original/file-20200907-22-1cb9mjh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/356695/original/file-20200907-22-1cb9mjh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/356695/original/file-20200907-22-1cb9mjh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/356695/original/file-20200907-22-1cb9mjh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/356695/original/file-20200907-22-1cb9mjh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Unemployment, a risk factor for a number of mental health conditions, is on the rise due to COVID-19.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>To <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7255235/">prevent</a> mental health issues we should focus on building people’s health literacy and self-care skills through public information campaigns and online learning programs. Supportive social environments can be encouraged by <a href="https://pubmed.ncbi.nlm.nih.gov/27969003/">parenting programs</a>, and <a href="https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-018-0242-3">school</a> and <a href="https://journals.sagepub.com/doi/10.1177/0004867417726174">workplace</a> mental health promotion initiatives. </p>
<p>Local communities could also be mobilised to take positive action on local issues that contribute to poor health and mental health through <a href="https://pubmed.ncbi.nlm.nih.gov/24322060/">place-based strategies</a>. Place-based strategies aim to tackle issues existing at a neighbourhood level, such as social isolation and poor housing. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/melbournes-second-lockdown-will-take-a-toll-on-mental-health-we-need-to-look-out-for-the-vulnerable-142172">Melbourne's second lockdown will take a toll on mental health. We need to look out for the vulnerable</a>
</strong>
</em>
</p>
<hr>
<p>Services could be reoriented towards prevention. Primary care professionals might provide advice on self-care and use <a href="https://www1.racgp.org.au/newsgp/clinical/is-social-prescribing-a-remedy-to-chronic-health-p">social prescribing</a> to address stress and enhance social supports. Social prescribing involves medical professionals linking patients to non-medical supports. For example, they may provide an “exercise prescription” or “art prescription”. </p>
<p>Finally, appropriate public policy solutions, such as JobSeeker and JobKeeper, that tackle the social and economic determinants of ill-health are needed.</p>
<h2>Social factors matter too</h2>
<p>Research also points to a strong link between mental health conditions and experience of childhood adversity, family violence, <a href="https://www.sciencedirect.com/science/article/pii/S0033350617302731?via%3Dihub">loneliness</a>, <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0138511">racism</a>, <a href="https://doi.apa.org/doiLanding?doi=10.1037%2F0033-2909.129.5.674">homophobia</a> and transphobia. <a href="https://www.workwell.vic.gov.au/how-can-we-create-mentally-healthy-workplace">Workplace stressors</a>, financial stress, <a href="https://connect.springerpub.com/content/sgrrrpe/29/3/261">unemployment</a> and <a href="https://www.ahuri.edu.au/research/ahuri-briefs/understanding-links-between-mental-health-housing-homelessness">homelessness</a> are also risk factors.</p>
<p>Many of these issues are on the increase because of COVID-19, so to safeguard mental health we need to tackle them and their impact. This will require the use of evidence-based preventive programs outlined above - many of which already exist but are not being implemented well or to sufficient scale. It will also require public policies to soften the economic blow and ease financial stress.</p>
<p>Targeting these issues will not only help to prevent mental health conditions, but physical health conditions as well. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/feeling-hopeless-there-are-things-you-can-do-to-create-and-maintain-hope-in-a-post-coronavirus-world-140330">Feeling hopeless? There are things you can do to create and maintain hope in a post-coronavirus world</a>
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</em>
</p>
<hr>
<p>While <a href="https://journals.sagepub.com/doi/full/10.1177/0004867414546387">better access to mental health-care services</a> is important, it can’t solve all the mental health challenges posed by COVID-19. We also need to strengthen the factors that buffer people against stress, and tackle the underlying factors that contribute to poor mental health.</p>
<p>Whether we create a National Preventive Mental Health Plan, or embed mental health in the current National Preventive Health Strategy, one thing’s for sure: continuing to ignore the prevention of mental health conditions is not an option in a COVID-19 world.</p><img src="https://counter.theconversation.com/content/145686/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Carbone works for Prevention United, a mental health promotion charity that focuses on the prevention of mental disorders.</span></em></p>As we clear the path towards a COVID-normal, mental illness prevention must be prioritised. Including it as a focus of the National Preventive Health Strategy could be a start.Stephen Carbone, Honorary, School for Population and Global Health, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1442362020-08-11T13:23:13Z2020-08-11T13:23:13ZAlcohol addiction: could the brain’s immune system be the key to understanding and treating alcoholism?<figure><img src="https://images.theconversation.com/files/352256/original/file-20200811-19-1cqb7w7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Even moderate alcohol consumption changes the brain's structure.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/alcoholism-alcohol-addiction-people-concept-male-1130260130">Syda Productions/ Shutterstock</a></span></figcaption></figure><p>Alcohol abuse is a serious problem worldwide. In <a href="https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-alcohol/2020">England alone</a>, over 350,000 alcohol-related hospital admissions – and over 5,000 alcohol-related deaths – were reported in 2018. Long-term alcohol abuse can have many <a href="https://www.nhs.uk/conditions/alcohol-misuse/risks/">harmful effects</a> on our body. But one of the organs most affected by alcohol is the brain. Even moderate consumption changes <a href="https://www.bmj.com/content/357/bmj.j2353.full">brain structure</a> and leads to cognitive issues, such as declines in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6875727/">memory and problem-solving</a>. </p>
<p>Alcohol use is habit forming and can eventually lead to alcoholism. And though there are many treatments available for alcoholism, research shows these interventions often fail – with <a href="https://emedicine.medscape.com/article/285913-followup">less than 20%</a> of patients remaining alcohol free after intervention. Like every addiction, alcoholism is a disease and not a choice, so finding the root cause of it will make treatment easier.</p>
<p>Although <a href="https://www.drinkaware.co.uk/facts/health-effects-of-alcohol/mental-health/alcohol-dependence#whatcausesalcoholdependence">genetics and the environment</a> you live in are known to play a role in developing alcoholism, these factors don’t tell us how dependence occurs. </p>
<p>However, past research has found hints that the brain’s immune system cells (known as microglia) may be involved in addiction, including to <a href="https://www.nature.com/articles/s41467-019-14173-3">cocaine</a> and <a href="https://www.sciencedirect.com/science/article/abs/pii/S0028390820302252">tobacco</a>). One study even found that <a href="https://academic.oup.com/alcalc/article/37/5/421/182524">alcohol exposure and withdrawal</a> in rats increased microglia numbers in the brain, before any other signs of alcohol-induced decline. </p>
<p>Another two recent studies have investigated brain changes seen in people and animals with alcohol dependence. Each of these studies found a common culprit: inflamed <a href="https://theconversation.com/microglia-the-brains-immune-cells-protect-against-diseases-but-they-can-also-cause-them-139232">microglia</a>.</p>
<p>Microglia are the brain’s resident immune system cells. Their main role is to guard and maintain balance in the brain. When microglia detect a threat, they respond by becoming inflamed and attacking. Normally, they return to normal after the threat is gone, but sometimes when inflammation becomes uncontrollable – such as with Alzeimer’s disease – it can lead to brain degeneration.</p>
<h2>Microglia and addiction</h2>
<p>One <a href="https://www.sciencedirect.com/science/article/abs/pii/S0006322320315985">recent study</a> used mice to study the effect of alcohol dependence on the brain. </p>
<p>In the brains of male mice that had alcohol dependency, research found there were more microglia cells in the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3562704/">medial prefrontal cortex</a>, a region associated with pain, decision making, and memory processes. Similar results have also previously been found in <a href="https://www.sciencedirect.com/science/article/abs/pii/S0014488607004220">humans</a>. </p>
<p>They then examined what effects microglia depletion had on alcohol dependent mice by looking at their alcohol seeking behaviour, and anxious behaviour during alcohol withdrawal. The researchers found both factors were lowered when the microglia cells were reduced in the brain.</p>
<p>They also saw gene changes with microglia depletion. Genes involved in inflammation and immune responses were expressed less after depletion. The expression of genes involved in alcohol consumption, and alcohol dependence also changed when microglia had decreased. They also found that microglia depletion weakens brain circuits involved in the development of dependence and relapse behaviour in rodents.</p>
<p>A <a href="https://advances.sciencemag.org/content/6/26/eaba0154">second study</a> looking at both rodent and human brains also showed microglia is involved in alcohol dependence. </p>
<p>The researchers of this study used brain imaging, microglia depletion, and studies of post mortem brains, to examine changes that occur in alcohol dependence. For the brain imaging part, they used a variation of <a href="https://www.nhs.uk/conditions/mri-scan/">MRI scans</a>, called <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2041910/">DTI-MRI</a> in humans and rats, focusing on a measure called mean diffusivity. </p>
<figure class="align-center ">
<img alt="A microglia cell." src="https://images.theconversation.com/files/352258/original/file-20200811-18-1facmxa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/352258/original/file-20200811-18-1facmxa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/352258/original/file-20200811-18-1facmxa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/352258/original/file-20200811-18-1facmxa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/352258/original/file-20200811-18-1facmxa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/352258/original/file-20200811-18-1facmxa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/352258/original/file-20200811-18-1facmxa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Microglia are involved in alcohol dependence.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/microglia-cell-plays-important-role-pathogenesis-1421648234">Juan Gaertner/ Shutterstock</a></span>
</figcaption>
</figure>
<p>As DTI-MRI is based on the diffusion of water in tissues, mean diffusivity essentially shows the amount of diffusion of water molecules in tissues, with more dense and structurally-intact tissues having lower mean diffusivity. Mean diffusivity has previously been shown to change in the brain in <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0041441">inflammatory and degenerative conditions</a> (including <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4487800/">Alzheimer’s Disease</a> and even <a href="https://www.karger.com/Article/Fulltext/442605">psychosis</a>). The researchers therefore chose to look at mean diffusivity as neuroinflammation is also <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/acer.12367">involved in alcoholism</a>. The researchers wanted to examine whether changes in mean diffusivity would be found between alcoholics and non-alcoholics, which hasn’t been done before. </p>
<p>Indeed their findings showed that mean diffusivity is overall higher in the brain of alcohol dependent rats and humans. They also found additional changes in how certain neurotransmitters – including dopamine, which is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4120286/">involved in alcohol dependence</a> – move and are distributed in the brain.</p>
<p>The researchers went on to examine the microglia in the brains of rats with alcohol dependence, and rats with previous dependence who had abstained from alcohol for a week. They found a decreased amount of microglia in specific brain regions of dependent rats (including the hippocampus, which is involved in memory, and the nucleus accumbens, which is involved in the reward system). The microglia in the brains of alcohol dependent rats were also in their inflamed form. </p>
<p>Although this study showed a decrease in microglia numbers – whereas the previous study saw an increase – this might be because the researchers looked at different brain regions and used different research methods and animal models. However, both studies give hints towards how microglia functions during alcohol consumption and dependence, may differ in different brain regions.</p>
<p>The researchers also found that depleting microglia from the brain, or inducing microglia’s inflammatory response, led to similar results to each other, as both increased the mean diffusivity. Changes in microglia’s form when inflamed were also similar to the ones they observed in dependent rats. They concluded that the changes in the brain areas they studied could be explained by an inflammatory reaction of microglia caused by alcohol.</p>
<p>One limitation of both studies’ findings is that they used both only male rodents and male humans. However, both studies exhibit how alcoholism is a complex disease that produces clear changes in the brain. </p>
<p>Examining how exactly microglia is involved, and being able to interfere with their responses, could lead to better understanding and detection of addiction to alcohol, and give a good stepping stone for future targeted interventions.</p><img src="https://counter.theconversation.com/content/144236/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Eleftheria Kodosaki does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The brain’s immune system cells (called microglia) have already been shown to be involved in addiction to other substances.Eleftheria Kodosaki, Academic associate in Biomedical Sciences, Cardiff Metropolitan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1422642020-07-29T18:33:05Z2020-07-29T18:33:05ZPolice encounters reveal a mental health system in distress<figure><img src="https://images.theconversation.com/files/349915/original/file-20200728-13-1gkpusv.JPG?ixlib=rb-1.1.0&rect=0%2C0%2C3000%2C1931&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The family of D’Andre Campbell, a Black man in a mental health crisis who was shot and killed by Peel police in April in his home in Brampton, is pictured outside their lawyer's office in Toronto. Left to right: Sister Michelle Campbell, mother Yvonne Campbell and brother Dajour Campbell.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Carlos Osorio</span></span></figcaption></figure><p>Too many Canadians in mental health distress die at the hands of police after <a href="https://globalnews.ca/news/7092621/police-wellness-checks-experts-change/">calling for help</a>. The case of <a href="https://www.cbc.ca/news/canada/toronto/d-andre-campbell-black-police-1.5607750">D'Andre Campbell</a> is just the latest example; he was fatally shot by police in April after calling them to his home for help in Brampton, Ont.</p>
<p>These deaths justify a deeper look at the societal response to those with episodic mental health and substance use issues.</p>
<p>Seventy per cent of 460 Canadians who died in police encounters from 2000 to 2017 reportedly suffered from <a href="https://www.cbc.ca/news/investigates/most-canadians-killed-in-police-encounters-since-2000-had-mental-health-or-substance-abuse-issues-1.4602916">mental health or substance use issues</a>. Racial minorities <a href="https://www.cbc.ca/news/canada/toronto/police-deaths-blacks-data-1.4599215">were over-represented</a>.</p>
<p>Canadian and Ontario chiefs of police argue insufficient investment in community mental health care has made police “<a href="https://globalnews.ca/news/1472443/dont-want-cops-to-be-psychiatrists-in-blue-fund-mental-health-services/">psychiatrists in blue</a>.” More than 30 per cent of people with serious mental illness who were turned away from emergency departments as they tried to access care experienced <a href="https://cmha.bc.ca/wp-content/uploads/2016/07/policereport.pdf">police encounters</a>, according to a study by the Canadian Mental Health Association (CMHA). </p>
<p>But while police budgets increase annually, research I helped conduct has found that investments in mental health <a href="https://doi.org/10.1016/j.socscimed.2020.113007">declined from 2000 to 2014</a> compared to other health-care areas. Savings from psychiatric hospital closures were shifted to other sectors, even though funding community supports <a href="https://doi.org/10.1111/j.1754-7121.2005.tb00231.x">could avert mental-health crises</a>. This holdover of what’s known as “<a href="https://www.mentalhealthcommission.ca/English/structural-stigma">structural stigma</a>” enables systemic neglect.</p>
<h2>Mental health system in distress</h2>
<p>From an international perspective, Canada lags in addressing mental health. Only one in five children receive the care <a href="https://cmha.ca/fast-facts-about-mental-illness">they require</a>, enduring wait-lists of a year or more, according to the CMHA. Although mental illness and substance use account for 23 per cent of <a href="https://cmha.ca/ending-health-care-disparity-canada">disease burden</a> — more than 1.5 times that of all cancers combined — they represent only seven per cent of <a href="https://www.camh.ca/en/driving-change/the-crisis-is-real/mental-health-statistics">health-care spending</a>. </p>
<p>The World Health Organization denotes a care gap of 35 to 50 per cent in developed countries, resulting in <a href="https://doi.org/10.1016/S0140-6736(07)61239-2">delayed care</a> and <a href="https://doi.org/10.1001/jama.291.21.2581">treatment failures</a>. Ensuring access to co-ordinated community care, psychotherapy, substance-use rehabilitation, court diversion and housing <a href="https://www.mentalhealthcommission.ca/English/case-for-investing-backgrounder">would prevent hospitalization</a>, employment disability, homelessness, imprisonment and police encounters. </p>
<p>While societal savings from psychotherapy for depression <a href="https://ps.psychiatryonline.org/doi/pdf/10.1176/appi.ps.201600395">are double</a> their cost, they are uninsured unless offered by physicians whose supply is limited, constraining access. </p>
<h2>Insuring psychotherapy</h2>
<p>The United Kingdom and Australia publicly <a href="https://doi.org/10.1016/S2215-0366(15)00082-6">insure psychotherapy</a>, while B.C. and Ontario are expanding access. Early intervention for youth with psychosis can prevent disability and <a href="https://doi.org/10.1017/S0033291703001119">improve recovery</a>, yet youth at risk are often <a href="https://www.sfu.ca/content/dam/sfu/carmha/resources/2017-toward-quality-mh/CARMHA%20REPORT_29%20Aug_Final.pdf">turned away</a> from emergency departments, waiting months for assessment, only to increase the likelihood of committal. </p>
<figure class="align-center ">
<img alt="A police officer in full uniform walks with a dark-haired woman in a park with trees in the background." src="https://images.theconversation.com/files/349923/original/file-20200728-17-11k9gb6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/349923/original/file-20200728-17-11k9gb6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=411&fit=crop&dpr=1 600w, https://images.theconversation.com/files/349923/original/file-20200728-17-11k9gb6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=411&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/349923/original/file-20200728-17-11k9gb6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=411&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/349923/original/file-20200728-17-11k9gb6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=517&fit=crop&dpr=1 754w, https://images.theconversation.com/files/349923/original/file-20200728-17-11k9gb6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=517&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/349923/original/file-20200728-17-11k9gb6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=517&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">An RCMP officer in charge of the Surrey RCMP mental health outreach team talks with a registered psychiatric nurse in Surrey, B.C., in June 2020. They are part of a mobile crisis response unit partnership between the Surrey RCMP and Fraser Health Authority that attend calls in Surrey involving mental health issues.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
</figcaption>
</figure>
<p>Most psychiatric hospitalizations are <a href="https://doi.org/10.1192/bjo.2017.4">indeed involuntary</a>. Would delays that increase the risk of youth death and disability be accepted for an illness like diabetes?</p>
<p>Enhanced funding for community supports — crisis teams and supportive housing — would reduce the direct and indirect costs of mental illness that represent <a href="https://read.oecd-ilibrary.org/social-issues-migration-health/making-mental-health-count/the-cost-of-mental-illness_9789264208445-5-en#page12">4.4 per cent of GDP</a>; investment of $85 per capita pales in comparison to the $7,068 in health-care expenditures <a href="https://www.statista.com/statistics/436378/total-health-spending-per-capita-canada/#:%7E:text=As%20of%202019%2C%20the%20per,the%201984%20Canadian%20Health%20Act">per Canadian</a>. </p>
<p>Mobilizing greater commitment, however, entails immense political will.</p>
<h2>Why health is a political issue</h2>
<p>Mental health policy is politicized by the federal and provincial governments and contested among professionals and advocates.</p>
<p>Although jurisdiction for health care lies with provinces, Ottawa used its spending power to encourage the provinces to launch medicare. Of the five conditions provinces must meet to secure federal health transfers, <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3662667">comprehensive care</a> was defined as medically necessary <a href="http://accessh.org/wp-content/uploads/2015/02/1802_Mossialos_intl_profiles_2014_v6.pdf#page=21">hospital and physician services</a>. </p>
<p><a href="https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/science-research-data/canada-health-act-infographic/cha-infographic-eng.pdf">The Canada Health Act</a> followed the path of the 1957 <a href="http://uregina.ca/%7Erasmussk/publications/can_pscyhol_article.pdf">Hospital Insurance and Diagnostic Services Act</a> that excluded psychiatric hospitals, non-physician community care and limited psychiatric general hospital beds to 10 per cent, foreshadowing our <a href="https://doi.org/10.1503/cmaj.170738">current dilemma</a>.</p>
<p>While provinces that fail to insure hospital and physician services risk forfeiting federal transfers, they can exclude community care with impunity. Mental health care has therefore focused on clinical, hospital-based services instead of helping people regain their health by insuring community supports that would <a href="https://doi.org/10.1016/j.socscimed.2020.113007">reduce institutional system costs</a>.</p>
<figure class="align-center ">
<img alt="A woman bows her head." src="https://images.theconversation.com/files/349914/original/file-20200728-21-1pzmr8l.jpg?ixlib=rb-1.1.0&rect=454%2C696%2C3752%2C2059&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/349914/original/file-20200728-21-1pzmr8l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/349914/original/file-20200728-21-1pzmr8l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/349914/original/file-20200728-21-1pzmr8l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/349914/original/file-20200728-21-1pzmr8l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=425&fit=crop&dpr=1 754w, https://images.theconversation.com/files/349914/original/file-20200728-21-1pzmr8l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=425&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/349914/original/file-20200728-21-1pzmr8l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=425&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Mental illness needs to be treated with the same urgency and seriousness as physical diseases are.</span>
<span class="attribution"><span class="source">(Volkan Olmez/Unsplash)</span></span>
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</figure>
<p>Federal and provincial government relations and their accommodation of the medical profession further <a href="https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.18.3.114">guide health policy</a>. Given competing demands on provincial budgets, political and professional concerns may overshadow patient needs. Physician strikes that occurred when medicare and the Canada Health Act <a href="https://www.jstor.org/stable/pdf/3228491.pdf">were enacted</a> reflect the contentious nature of policy negotiations. </p>
<p>Exclusion of community-based mental health care from the terms of the Canada Health Act, and the absence of targeted federal funds to address the omission, resulted in fragmented accountability, revealing misaligned strategy as politics ascended policy. </p>
<h2>Addressing structural discrimination</h2>
<p>Canada’s federal structure and intergovernmental dynamics profoundly shaped health policy. The Canada Health Act set the terms for federal health transfers, establishing financial incentives for provincial governments, which have reinforced regressive patterns of medical care.</p>
<p>Although the <a href="https://www.theglobeandmail.com/news/politics/ontario-quebec-alberta-reach-health-deals-with-ottawa/article34264300/">2017 federal health accords</a> targeted funds for mental health, they fell short of the $3.1 billion annual investment required to meet health spending targets recommended by the <a href="https://www.mentalhealthcommission.ca/English/focus-areas/mental-health-strategy-canada">Mental Health Commission of Canada</a>. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/349927/original/file-20200728-17-mr8dv5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man gestures while speaking with a report entitled Shape the Future in the foreground." src="https://images.theconversation.com/files/349927/original/file-20200728-17-mr8dv5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/349927/original/file-20200728-17-mr8dv5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=427&fit=crop&dpr=1 600w, https://images.theconversation.com/files/349927/original/file-20200728-17-mr8dv5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=427&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/349927/original/file-20200728-17-mr8dv5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=427&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/349927/original/file-20200728-17-mr8dv5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=536&fit=crop&dpr=1 754w, https://images.theconversation.com/files/349927/original/file-20200728-17-mr8dv5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=536&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/349927/original/file-20200728-17-mr8dv5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=536&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Roy Romanow, head of the commission on health care, speaks during a news conference in Ottawa in February 2002 after releasing his interim report.</span>
<span class="attribution"><span class="source">CP PHOTO/Jonathan Hayward</span></span>
</figcaption>
</figure>
<p>The 2002 <a href="http://publications.gc.ca/collections/Collection/CP32-85-2002E.pdf">Romanow Commission on the Future of Health Care</a> emphasized federal and provincial co-operation and recommended funding follow patients rather than be tied to institutions. </p>
<p>Enhanced mental health supports would reduce public expenditures and employer productivity loss by <a href="https://doi.org/10.1503/cmaj.170738">$255 billion over 30 years</a>. Failure of governments to adequately fund mental health will only raise societal costs and increase the <a href="https://www.cbc.ca/news/canada/toronto/police-mental-crisis-1.5623907">30,000 mental health crisis calls</a> that Toronto police alone receive annually, and so the time for action is upon us. Were it not for federal incentives, after all, Canadians might not have universal health care today.</p><img src="https://counter.theconversation.com/content/142264/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mary Wiktorowicz receives funding from the Canadian Institutes of Health Research and York University; her research was previously funded by the Canadian Foundation for Healthcare Improvement. She is affiliated with the Dahdaleh Institute for Global Health Research.
Steve Lurie is Executive Director of the Canadian Mental Health Association, Toronto and Adjunct Professor, Factor-Inwentash Faculty of Social Work, University of Toronto
</span></em></p>Federal incentives would enhance community support for those with mental illness and would avert police engagement.Mary E. Wiktorowicz, Professor of Global Health Governance and Policy, Dahdaleh Institute for Global Health Research, York University, CanadaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1386722020-05-26T12:18:15Z2020-05-26T12:18:15ZI’ve been following families in open adoptions for 15 years, observing adoptive parents’ struggles to share painful origin stories with kids<figure><img src="https://images.theconversation.com/files/336591/original/file-20200520-194978-ryxmfx.jpg?ixlib=rb-1.1.0&rect=5%2C5%2C3828%2C2149&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Knowing the truth about one's origins is crucial to identity formation, according to adoption experts.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/parents-talking-with-son-on-bench-in-park-royalty-free-image/1130374456">Motortion/iStock via Getty Images Plus</a></span></figcaption></figure><p>Adoption has changed dramatically in recent years. <a href="https://theconversation.com/international-adoptions-have-dropped-72-percent-since-2005-heres-why-91809">International adoptions have dropped dramatically</a> since 2005. Today, most adoptions are domestic, with the <a href="http://www.kinshipcenter.org/resources/blog/open-adoptions-are-a-national-trend-study-finds-that-95-of-us-infant-adoptions-have-openness.html">vast majority</a> being open adoptions, meaning there is some type of contact or exchange of information between birth families and adoptive families, before and sometimes after the adoption. </p>
<p>Research has shown that openness benefits all parties involved. <a href="https://www.childwelfare.gov/pubPDFs/bulletins_maintainrelationships.pdf">Birth parents</a> are reassured the child they placed is alive and well, <a href="https://doi.org/10.1097/NMC.0000000000000370">alleviating anxiety and guilt</a>. Adoptive parents are able to answer their children’s inevitable questions, and also experience <a href="https://doi.org/10.1177/0265407515611494">comfort and reassurance</a> knowing they were chosen by the birth family and can be in touch with them <a href="https://www.childwelfare.gov/pubPDF/bulletins_maintainrelationships.pdf">if genetic questions arise</a>. For children, openness eliminates the need to search for their birth parents. Access to birth parents <a href="https://global.oup.com/academic/product/open-adoption-and-diverse-families-9780190692032">allows children to gain insight</a> and ask questions about their identity and roots. </p>
<p>I am a <a href="https://www.abbiegoldberg.com">psychologist</a> who studies open adoption. One topic <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1111/famp.12491">I research</a> is how adoptive parents grapple with the decision of whether and when to share difficult origin stories with their children.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/336571/original/file-20200520-152327-k7mb6a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/336571/original/file-20200520-152327-k7mb6a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/336571/original/file-20200520-152327-k7mb6a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/336571/original/file-20200520-152327-k7mb6a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/336571/original/file-20200520-152327-k7mb6a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/336571/original/file-20200520-152327-k7mb6a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/336571/original/file-20200520-152327-k7mb6a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/336571/original/file-20200520-152327-k7mb6a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Most babies adopted in the United States today were born here.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/loving-male-same-sex-couple-cuddling-baby-daughter-royalty-free-image/1177240987">monkeybusinessimages/iStock via Getty Images</a></span>
</figcaption>
</figure>
<h2>What psychologists recommend</h2>
<p>Adoption experts advise a <a href="https://bpar.org/telling-truth-adopted-foster-child-book/">full, honest disclosure</a> of a child’s origin story. This recommendation is based on years of research documenting the <a href="https://doi.org/10.1111/1469-7610.00014">negative effects of secrecy</a> on adopted individuals. Psychologists emphasize the long-term benefits trust builds between parents and their children, as well as the need adopted individuals have to know the truth about their origins in order to <a href="https://www.nacac.org/resource/seven-core-issues-in-adoption-and-permanency/">fully understand themselves and have healthy and meaningful relationships</a>. This recommendation is firm, even in situations of rape or incest, birth parent substance abuse, incarceration or physical abuse.</p>
<p>Such discussions should be <a href="https://global.oup.com/academic/product/open-adoption-and-diverse-families-9780190692032">developmentally staged</a>, meaning they should vary depending on the child’s age. For example, to a preschooler, parents might explain their birth mother was not healthy enough to care for them; to a teen, they might share their birth mother struggled with alcoholism.</p>
<p>All information should be shared with the child by the time they reach adolescence. Identity development begins in childhood but takes center stage in adolescence, when youth begin to ask key questions like “Who am I?” and “Who am I in relation to others?” For adopted teens, <a href="https://doi.org/10.1300/J145v01n01_02">identity development can be more complete</a> if it involves coming to terms with their conception. If adopted youth are lied to about their origins, the discovery of such lies can prompt feelings of betrayal and <a href="https://www.nacac.org/resource/seven-core-issues-in-adoption-and-permanency/">amplify the shame and guilt</a> that often result from secrecy about adoption in the first place. </p>
<h2>Easier said than done</h2>
<p>While the theory of how and when to tell difficult origin stories to adopted children is clear, my research has found the practice more murky. </p>
<p>Since 2005, I’ve been conducting a long-term study of adoptive families. I first interviewed the parents prior to adoptive placement and have interviewed them every few years since – most recently, when their children were between the ages of eight and 12. Eleven couples in my study adopted children who were reportedly conceived via rape or incest.</p>
<p>From the time they agreed to the adoptive placement, all of these 22 parents carefully considered how their children’s conception circumstances would affect their children and what, if anything, they would need to tell them. Parents worried about the stigmatizing aspects of their child’s origin story, with several emphasizing they would keep the circumstances of their children’s conception private, within their immediate family.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/336573/original/file-20200520-152344-wfwkwe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/336573/original/file-20200520-152344-wfwkwe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/336573/original/file-20200520-152344-wfwkwe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/336573/original/file-20200520-152344-wfwkwe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/336573/original/file-20200520-152344-wfwkwe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/336573/original/file-20200520-152344-wfwkwe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/336573/original/file-20200520-152344-wfwkwe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/336573/original/file-20200520-152344-wfwkwe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Honesty leads to trust.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/perfect-family-holding-hands-adopted-child-being-royalty-free-image/1004735032">Motortion/iStock via Getty Images Plus</a></span>
</figcaption>
</figure>
<p>When I last interviewed them, none of the parents had shared explicit information about their children’s conception details. A few had tentatively raised the topic, by saying things like, “I don’t think that your birth parents were in love.” Two-thirds said they had not shared because they had incomplete or questionable information. </p>
<p>For example, they said they had been told by the adoption agency their child was conceived through rape, but not by the birth mother herself – so how did they know? Some wondered if the birth mother had said it was stranger rape to protect an older boyfriend from being accused of statutory rape. While parents said they wanted to believe birth mothers, the possibility of an alternative narrative gave them pause to consider the potential risks of telling a story to their children that might not be true. It’s possible, also, some were questioning birth mothers’ stories because they wish to believe a less stigmatizing version, enabling them to not have to tell it. </p>
<p>The desire to preserve children’s innocence, combined with uncertainty about birth mothers’ accounts, were described as key reasons for ongoing silence around their children’s origins. All study parents said they were uncertain about how they would share this information down the road. One-third had consulted or intended to consult with adoption therapists to plan the telling. Parents with ongoing birth mother contact described their intention to verify the story and plan its telling with her. </p>
<p>Adoptive parents in my study describe a commitment to openness, while also struggling with a lack of guidance around how and when to disclose difficult conception details. Indeed, adoptive parents generally get a lot of information and guidance before they adopt, but do not get a lot of post-adoption counseling <a href="https://doi.org/10.1016/j.childyouth.2018.06.017">unless they seek it out</a>. </p>
<p>The parents in my study are hesitating to disclose, but are also worried about waiting too long and risking feelings of betrayal, such as, “Why did you lie to me?” Adoptive parents in this situation should consult with therapists <a href="https://adoptionsupport.org/member-types/adoption-competent-professionals/">who have training in adoption issues</a> as they navigate these uncertain waters, with the knowledge that children deserve the truth about their own stories – even when that truth is difficult.</p><img src="https://counter.theconversation.com/content/138672/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Abbie E. Goldberg does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Experts recommend adopted children be told about their origins, no matter how difficult the circumstances, but doing so is tricky for adoptive parents.Abbie E. Goldberg, Professor of Psychology, Clark UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1327322020-03-09T19:01:05Z2020-03-09T19:01:05ZOpioid marketing to Canadian doctors hyped benefits, downplayed harms<figure><img src="https://images.theconversation.com/files/317913/original/file-20200301-166503-ukpk31.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C5447%2C3628&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The way opioid drugs were marketed to doctors may have contributed to the opioid crisis. </span> <span class="attribution"><span class="source">AP Photo/Mark Lennihan</span></span></figcaption></figure><p>Between January 2016 and June 2019 there were over <a href="https://health-infobase.canada.ca/datalab/national-surveillance-opioid-mortality.html">13,900 deaths from opioid overdoses</a> in Canada, 4,500 of which occurred in 2018. Based on information to date, 2019 is likely to have a similar mortality rate. Most deaths these days are from street drugs laced with fentanyl, carfentanil and other similar products. </p>
<p>But most <a href="https://www.nature.com/articles/d41586-019-02686-2">experts agree that aggressive marketing of prescription opioids has been one of the major triggers for what we are seeing today</a>. In 2000, OxyContin (long-acting oxycodone), made by Purdue Pharma, was added to Ontario’s drug formulary, a list of all medications covered under the Ontario Drug Benefit program. By 2004, all opioid-related <a href="https://doi.org/10.1503/cmaj.090784">deaths had gone up by 50 per cent and deaths specifically from long-acting oxycodone had increased more than five-fold</a>.</p>
<p>At one point, Purdue was paying <a href="https://nationalpost.com/news/canada/the-selling-of-oxycontin">100 doctors per year up to $2,000 per talk</a> to go across Canada and talk about pain management to other physicians. One of those doctors was CBC radio’s Brian Goldman, host of <em>White Coat, Black Art</em>. In his 2010 book, <em>Night Shift</em>, <a href="https://nationalpost.com/news/canada/the-selling-of-oxycontin">Goldman recounts how he was treated by the companies who paid him</a>: </p>
<blockquote>
<p>“… I was put up in five-star hotels and taken to nice restaurants. When I travelled across the continent, I was invariably given a ticket in business class.”</p>
</blockquote>
<p>The most effective method companies have to promote their products, the one that they put the most money into, is visits to doctors by sales representatives. These men and women are paid to go from office to office touting the products made by their companies. In the United States, <a href="https://doi.org/10.1001/jama.2018.19320">over $5.5 billion </a>is spent on drug marketing by sales representatives.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/317866/original/file-20200228-24676-1ows5r3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/317866/original/file-20200228-24676-1ows5r3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/317866/original/file-20200228-24676-1ows5r3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/317866/original/file-20200228-24676-1ows5r3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/317866/original/file-20200228-24676-1ows5r3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/317866/original/file-20200228-24676-1ows5r3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/317866/original/file-20200228-24676-1ows5r3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">OxyContin, a long-acting oxycodone, was added to the Ontario drug formulary in January 2000.</span>
<span class="attribution"><span class="source">AP Photo/Toby Talbot, File</span></span>
</figcaption>
</figure>
<p>Here in Canada, sales representatives are regulated through the <a href="http://innovativemedicines.ca/wp-content/uploads/2018/06/Code-Formatted_Regular_EN-2.pdf">Code of Ethical Practices</a> of Innovative Medicines Canada (IMC), the lobby group representing the major pharmaceutical companies operating in Canada. The code states: </p>
<blockquote>
<p>“Members must provide full and factual information on products, without misrepresentation or exaggeration. Statements must be accurate and complete. They should not be misleading, either directly or by implication.”</p>
</blockquote>
<h2>Claims about benefits</h2>
<p>As researchers of pharmaceutical policy, we were interested in the extent to which these standards are upheld in practice. In 2009-10, we carried out a <a href="https://doi.org/10.1007/s11606-019-05584-5">research project with an international team</a>. In the Canadian side of this study, we asked general practitioners in Vancouver and Montréal who saw sales representatives, to fill out questionnaires after each visit to record what they had been told. In total this study included nearly 1,700 reports by doctors, around half in Canada and the rest in the U.S. and France. Claims about benefits of drugs were made twice as often as statements about harms. Contraindications — information on who should not use a medicine — were mentioned about 15 per cent of the time, and serious harmful effects only five to six per cent of the time.</p>
<p>This study was carried out at the height of opioid prescribing. We therefore went back to see what doctors reported about what sales representatives had said when they were promoting the opioids. There were 69 sales visits with opioid promotions, reported on by 54 doctors. We called this the “nuts and bolts” of opioid promotion as doctors reported on the specific messages sales representatives used to promote prescription opioids.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/317915/original/file-20200301-166509-y9ouzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/317915/original/file-20200301-166509-y9ouzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/317915/original/file-20200301-166509-y9ouzr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/317915/original/file-20200301-166509-y9ouzr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/317915/original/file-20200301-166509-y9ouzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/317915/original/file-20200301-166509-y9ouzr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/317915/original/file-20200301-166509-y9ouzr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In more than half of opioid promotions, pharmaceutical representatives did not mention any harmful effects.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Graeme Roy</span></span>
</figcaption>
</figure>
<p>In over half of these opioid promotions, no harmful effects were mentioned, although health benefits were discussed nearly 80 per cent of the time. These benefits were often vague, broad claims, such as a promise of “better quality of life” with oxycodone use. Serious harms, such as respiratory depression or arrest, were mentioned in just 12 per cent of promotions.</p>
<p>Even when information on harm was provided, often the aim was to reassure. For example, when one doctor raised the risk of a potentially fatal interaction between an opioid and an antidepressant, the representative answered that “the drug label does not refer to this situation as dangerous and therefore the drug is not contraindicated.”</p>
<p>In nine per cent of promotions, doctors said that the sales representatives had mentioned addiction or abuse. However, the only information doctors reported hearing was claims of a low addiction or abuse potential. For example, statements included: “good drug if [you are] concerned about abuse, cannot get abused” and “safer than codeine and other opiates and non-addictive,” or for “elderly patients not wanting any strong narcotics.”</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/317916/original/file-20200301-166503-tpxt7l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/317916/original/file-20200301-166503-tpxt7l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/317916/original/file-20200301-166503-tpxt7l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/317916/original/file-20200301-166503-tpxt7l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/317916/original/file-20200301-166503-tpxt7l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/317916/original/file-20200301-166503-tpxt7l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/317916/original/file-20200301-166503-tpxt7l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Oxycodone 5 milligram tablets.</span>
<span class="attribution"><span class="source">AP Photo/Keith Srakocic, File</span></span>
</figcaption>
</figure>
<p>Despite the inadequate safety information and the lack of warnings about the need for caution reported by the doctors, most said that they were somewhat or very likely to increase prescribing of the drug compared with before the sales visit. In nearly 60 per cent of promotions, doctors judged the quality of scientific information to be good or excellent.</p>
<p>Given the serious harm from overprescribing of opioids, this study highlights the need for doctors to seek out information on medicines from sources that are independent of the pharmaceutical industry, and to avoid relying on sales representatives.</p>
<h2>The fox guarding the henhouse</h2>
<p>Health Canada has largely turned over regulation of sales representatives’ activities to IMC, which waits for complaints before it acts. Complaints are adjudicated by representatives of member companies. Even if companies are found guilty of violating the Code, the <a href="http://innovativemedicines.ca/wp-content/uploads/2018/06/Code-Formatted_Regular_EN-2.pdf">maximum penalty is $100,000</a>, small change for a multinational company.</p>
<p>Relying on the pharmaceutical industry to regulate its own marketing of medicines is a classic case of the fox guarding the henhouse. We know from the experience with opioids that there are serious consequences for public health when doctors rely on misleading information about the benefits and harms of medicines.</p>
<p>If we want to stop the next round of deaths from misleading promotion, Health Canada needs to start actively regulating drug promotion, including imposing meaningful sanctions.</p><img src="https://counter.theconversation.com/content/132732/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>In 2016-2019, Joel Lexchin was a paid consultant on two projects: one looking at developing principles for conservative diagnosis (Gordon and Betty Moore Foundation) and a second deciding what drugs should be provided free of charge by general practitioners (Government of Canada, Ontario Supporting Patient Oriented Research Support Unit and the St Michael’s Hospital Foundation). He also received payment for being on a panel at the American Diabetes Association, for a talks at the Toronto Reference Library, for writing a brief in an action for side effects of a drug for Michael F. Smith, Lawyer and a second brief on the role of promotion in generating prescriptions for Goodmans LLP and from the Canadian Institutes of Health Research for presenting at a workshop on conflict-of-interest in clinical practice guidelines. He is currently a member of research groups that are receiving money from the Canadian Institutes of Health Research and the Australian National Health and Medical Research Council. He is member of the Foundation Board of Health Action International and the Board of Canadian Doctors for Medicare. He receives royalties from University of Toronto Press and James Lorimer & Co. Ltd. for books he has written. </span></em></p><p class="fine-print"><em><span>Barbara Mintzes is a member of Health Action International (HAI-Europe Association), a non-profit organization that supports public interests in pharmaceutical policy. She was a member of Health Canada’s Expert Advisory Group on the Marketing of Opioids in 2018 and 2019. She has no other interests to declare and receives no funding from pharmaceutical companies. </span></em></p>Aggressive marketing of prescription opioids by pharmaceutical companies provided doctors with scant information about potential harmful effects.Joel Lexchin, Professor Emeritus of Health Policy and Management, York University, Emergency Physician at University Health Network, Associate Professor of Family and Community Medicine, University of TorontoBarbara Mintzes, Senior Lecturer, Faculty of Pharmacy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1203652019-08-08T09:35:31Z2019-08-08T09:35:31ZParents’ drug, alcohol and tobacco use negatively impacts all areas of child well-being – new study<figure><img src="https://images.theconversation.com/files/287172/original/file-20190807-144883-12vgm33.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/little-boy-holding-toy-bunny-while-772471801?src=ZJXFFaTj9xmepOaoL0nnvg-1-2">Africa Studio/Shutterstock</a></span></figcaption></figure><p>We all know that the use of tobacco, alcohol and drugs harms our own health. But many people are not aware that their use of these substances can sometimes also affect the health and well-being of others – including their own children. </p>
<p>Take secondhand smoking for example. Its effect on child well-being is so well evidenced that smoking in cars with under 18s was <a href="https://www.gov.uk/government/news/smoking-in-vehicles">banned in Wales in 2015</a>. For good reason, too – the NHS estimates that every year <a href="https://www.nhs.uk/smokefree/why-quit/secondhand-smoke">300,000 GP visits and 9,500 hospital admissions</a> in the UK are due to children’s exposure to others’ tobacco smoke. </p>
<p>While less is known about the secondary harms that come from parents’ alcohol and drug use, we do know that up to <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-9-377">30% of children in the UK</a> live with at least one parent or carer who binge drinks alcohol, and that 6% live with a parent who is dependent on alcohol. 8% of children also live with at least one parent or carer who uses drugs up to once a month, and 3% live with a parent who is drug dependent. These numbers might seem small, but as there are nearly <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/bulletins/annualmidyearpopulationestimates/mid2018">15m people aged 18 years and under in the UK</a>, this means that nearly 500,000 children could be living with a drug dependent adult.</p>
<p>But families are complicated. While it seems straightforward to suggest children exposed to tobacco smoke, for example, may grow up to have problems breathing, researchers are becoming aware of the many other ways in which parental behaviour and the environment can affect children. For example, smoking, drinking and drug use all cost money which can put financial strain on the family. In addition, activities that involve substances can take parents away from their children, which may cause stress and conflict at home. </p>
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<p>For our <a href="https://www.cambridge.org/core/journals/development-and-psychopathology/article/enduring-effects-of-parental-alcohol-tobacco-and-drug-use-on-child-wellbeing-a-multilevel-metaanalysis/CBDF7A2308D3F37B2AE20079C4834B7A">newly published study</a>, we decided to look into the effects of substance use on child well-being. This included physical, psychological (mental health), cognitive (measured through things like school achievement), social (including whether they had positive relationships or antisocial behaviour) and economic (for example, whether the family requires financial support) well-being. </p>
<p>Instead of following the more typical approach of looking at use of just one substance, we analysed how parents’ combined use of alcohol, drugs and tobacco impacts on children. One of the reasons we did this is because very often those who use drugs also smoke and drink. We were also interested in how children are affected and whether any effects endure over time. </p>
<h2>Secondary well-being effects</h2>
<p>We used multiple sources to identify studies that have investigated the relationship between parental drug, alcohol or tobacco use and its effect on children in these five areas of well-being. We ultimately used 56 studies, noted any relationship between parental substance use and child well-being that had been found in them, and then analysed the data.</p>
<p>We found that, overall, parental substance use was associated with a reduction in child well-being in all five areas. What was particularly stark was that this effect endured over time, meaning that the relationship was still present even if there was a gap between when the parent and child’s information was collected. </p>
<p>We also saw that parents’ non-dependent substance use (where an individual is not clinically dependent on a substance) also affected child well-being. And that parental alcohol use had similar risks for child well-being as tobacco use, which suggests that just the use of a substance could be harmful for child well-being.</p>
<p>Our study of the research also showed that parental drug use had the greatest effect on child well-being, compared to alcohol and/or tobacco. We believe this may be because of the illegal nature of its use, which puts parents at risk of being fined as well as arrested, which can promote poverty, placing additional strains on family life.</p>
<p>Given that large numbers of children may be affected by parental substance use, this is an important public health challenge. Particularly given that we know that poor well-being in childhood can <a href="https://www.sciencedirect.com/science/article/pii/S1054139X11001613">impact later life</a> too. Clearly the challenges that families face over substance use must be addressed for the future well-being of children. That’s easier said than done, however, and our study shows that it is not as simple as addressing a dependent substance use problem in isolation. </p>
<p>The family environment is a space that encapsulates most interactions between the parent and the child, and quite often interventions that address these interactions along with parental substance use and child well-being do lead to improved outcomes. Further work that supports the challenges of family life and addresses family interactions, strain in the family, and considers structural challenges, such as poverty, is a good place to start to address this problem.</p><img src="https://counter.theconversation.com/content/120365/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emily Lowthian works for DECIPHer, Cardiff University. She receives funding from the Economic Social Research Council.</span></em></p><p class="fine-print"><em><span>Simon C Moore receives funding from ESRC, MRC, NIHR. </span></em></p>Parents’ substance use affects children’s physical, psychological, cognitive, social and economic well-being, a new review of the research has found.Emily Lowthian, PhD Researcher in Parental Behaviours, Cardiff UniversitySimon C Moore, Professor of Public Health Research, Co-Director of Crime and Security Research Institute and Director of Alcohol & Violence Research Group, Cardiff UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1061632018-11-25T19:06:01Z2018-11-25T19:06:01ZAmbulance call-outs for pregabalin have spiked – here’s why<figure><img src="https://images.theconversation.com/files/246806/original/file-20181122-182071-2lpqex.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">At higher-than-prescribed doses, pregabalin causes sedation and euphoria.</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/i4rOpdj444c">Bruno van der Kraan</a></span></figcaption></figure><p>Pregabalin (sold under the brand name Lyrica) is prescribed as an anti-epileptic and a painkiller for nerve pain. Australian prescriptions of pregabalin have risen significantly in the past five years. It’s now in the <a href="https://www.nps.org.au/australian-prescriber/articles/top-10-drugs-2015-16">top ten most expensive medications for the Pharmaceutical Benefits Scheme</a> (PBS). </p>
<p>We’ve also seen a rise in “off-label” prescription of pregabalin. This means it’s being prescribed for conditions for which there is limited evidence of effectiveness. Pregabalin is <a href="https://www.nejm.org/doi/full/10.1056/NEJMp1704633">often prescribed</a> for chronic or persisting pain, for example, even when there is no clear nerve-related cause. </p>
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<p>Pregabalin is thought to have effects in the brain similar to those of benzodiazepines such as diazepam (Valium) by indirectly increasing levels of the neurotransmitter GABA. </p>
<p>Until recently, researchers and doctors <a href="https://europepmc.org/abstract/med/24849194">did not think pregabalin was addictive</a>. But now studies suggest pregabalin may also have an indirect effect on the brain’s reward chemical, dopamine. </p>
<p>Our research, published today in the <a href="https://www.mja.com.au/">Medical Journal of Australia</a>, shows ambulance call-outs associated with the misuse of pregabalin have increased tenfold in Victoria since 2012. This mirrors an increase in prescription rates.</p>
<h2>Growing evidence of misuse</h2>
<p>In 2010, the <a href="https://link.springer.com/article/10.1007/s00228-010-0853-y">first study</a> was published that reported on a trend of pregabalin misuse. </p>
<p>Since then, several <a href="https://link.springer.com/article/10.1007/s40263-014-0164-4">international research articles</a> have documented misuse, including <a href="https://link.springer.com/article/10.1007/s40265-017-0700-x">using higher doses than are recommended</a>. At higher-than-prescribed doses, pregabalin causes sedation and euphoria.</p>
<p>People who use opioids – painkillers like oxycodone, or illicit opioids such as heroin – have a particularly <a href="https://link.springer.com/article/10.1007/s40263-014-0164-4">high risk</a> of misusing pregabalin. So do those with a history of substance use problems. </p>
<p>People who use illicit drugs report often using pregabalin in combination with other drugs. Pregabalin <a href="https://link.springer.com/article/10.1007/s40263-014-0164-4">has been implicated</a> in drug-related deaths in individuals who weren’t prescribed the medication, and often in combination with other sedative medications or illicit drugs. </p>
<p>High rates of pregabalin use are also reported in secure environments, such as prisons, in both <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4657313/pdf/austprescr-38-160.pdf">Australia</a> and <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/385791/PHE-NHS_England_pregabalin_and_gabapentin_advice_Dec_2014.pdf">the United Kingdom</a>. </p>
<h2>What did we find?</h2>
<p>We analysed a unique database (<a href="https://www.turningpoint.org.au/research/population-health">the Ambo Project</a>) that documents all ambulance attendances related to alcohol and drug use and mental health in Victoria. </p>
<p>We found pregabalin-related ambulance attendances increased tenfold between 2012 and 2017, from 0.28 cases per 100,000 population to 3.32 cases per 100,000. Pregabalin misuse contributed significantly to 1,201 call-outs from 2012 to 2017. </p>
<p>Pregabalin has a sedative effect, which can be compounded when used with other drugs that cause sedation, including alcohol, or other prescribed medications such as benzodiazepines and sleeping tablets (such as Valium). </p>
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Read more:
<a href="https://theconversation.com/despite-escalating-prescriptions-nerve-pain-drug-offers-no-relief-for-sciatica-74699">Despite escalating prescriptions, nerve pain drug offers no relief for sciatica</a>
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<p>More than two-thirds of pregabalin-related ambulance call-outs were for people who also used other sedatives. Almost 90% required transport to hospital. In some situations, such sedation could be life-threatening.</p>
<p>Our findings of rising harms, especially from co-use with other drugs, echo findings from a <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/add.14412">New South Wales</a> research group that used data from poisons hotline calls, hospital admissions, and coronial reports from drug-related deaths. </p>
<h2>How to reduce the harms</h2>
<p>Doctors need to ensure patients are provided with the opportunity for careful and considered informed consent.</p>
<p>Pregabalin is a high-risk medication, especially when used with other sedatives. Although some doctors are aware of the side effects and harms associated with pregabalin, many are not. </p>
<p>The <a href="https://www.racgp.org.au/yourracgp/faculties/queensland/newsletter/september-2018/">Royal College of General Practitioners recently warned doctors</a> to carefully assess the risks when prescribing these medications, particularly for people who are also prescribed opioids or benzodiazepines. <a href="https://www.nps.org.au/news/gabapentinoid-misuse-an-emerging-problem">NPS MedicineWise</a> also recently highlighted the need for prescribers to exercise caution.</p>
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Read more:
<a href="https://theconversation.com/health-check-why-can-you-feel-groggy-days-after-an-operation-74989">Health Check: why can you feel groggy days after an operation?</a>
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<p>Better regulation is also needed. </p>
<p>Some Australian states including Victoria plan to implement <a href="https://www2.health.vic.gov.au/public-health/drugs-and-poisons/safescript">real-time prescription monitoring (RTPM)</a>. This would allow authorities to monitor and regulate access to high-risk medications such as opioid painkillers (oxycodone or similar) or benzodiazepines. </p>
<p>But pregabalin is not on the list of medications that will be captured by real-time prescription monitoring. To reduce the high risk of harm from pregabalin misuse, we should consider adding this drug to the list.</p>
<p>In the United Kingdom, pregabalin will become a “scheduled” or <a href="https://www.bmj.com/content/363/bmj.k4364">controlled medication</a> from April 2019. This means doctors will need to apply for a permit before prescribing it. </p>
<p>If this is found to be successful, Australia should consider following suit.</p><img src="https://counter.theconversation.com/content/106163/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>We would like to acknowledge the contribution of our co-authors Karen Smith, Debbie Scott and Paul Dietze. Thanks to Ambulance Victoria for providing the data and the Population Health team at Turning Point who code it to create this unique data set.
Shalini Arunogiri has previously received a scholarship from the National Health and Medical Research Council (NHMRC), and the Society for Mental Health Research (SMHR).
</span></em></p><p class="fine-print"><em><span>Dan Lubman has received funding from the National Health and Medical Research Council, the Australian Research Council, beyondblue, Movember, Victorian Department of Health and Human Services, Commonwealth Department of Health, Victorian Gambling Research Foundation and the Victorian Health Promotion Foundation. He has also received speaking honoraria from AstraZeneca, Indivior, Janssen, Servier, Shire and Lundbeck and has provided consultancy advice to Lundbeck and Indivior. </span></em></p><p class="fine-print"><em><span>Rose Crossin has previously received an RTP scholarship from the Australian Department of Education and Training. </span></em></p>Ambulance call-outs associated with the misuse of pregabalin (Lyrica) have increased tenfold in Victoria since 2012, mirroring an increase in prescription rates.Shalini Arunogiri, Addiction Psychiatrist, Lecturer, Monash UniversityDan Lubman, Director, Turning Point Alcohol and Drug Centre & Professor of Addiction Studies, Monash UniversityRose Crossin, Research Officer in Addiction Studies , Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1012152018-08-08T10:22:17Z2018-08-08T10:22:17ZVolatile substance abuse – a problem that never went away<figure><img src="https://images.theconversation.com/files/231063/original/file-20180808-191044-15p42gg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/drop-glue-on-tube-squeezed-hand-1044832498?src=vHYomBTWmolwcuSSVg4cGg-1-24">Shutterstock/Butus</a></span></figcaption></figure><p><a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2017registrations">Drug related deaths</a> are now at their <a href="https://theconversation.com/record-level-of-drug-deaths-in-england-and-wales-latest-official-figures-99710">highest levels</a> since records began in England and Wales. In 2017, there were 56 ecstasy deaths, each new tragedy generating headlines and leading to calls for action, such as the introduction of <a href="https://ndarc.med.unsw.edu.au/resource/bulletin-no-24-global-review-drug-checking-services-operating-2017">drug checking in nightclubs</a> and <a href="https://www.independent.co.uk/news/uk/home-news/uk-festivals-drug-testing-the-loop-deaths-mutiny-a8374126.html">festivals</a>. But others are abusing a different range of substances, a problem that many people think largely disappeared in the 1980s and has been ignored in all the headlines. </p>
<p>Volatile substance abuse (VSA) comprises inhalation of <a href="http://www.emcdda.europa.eu/publications/drug-profiles/volatile">volatile compounds</a> in chemical products – such as glues, paints, spray deodorants and fuels – for <a href="https://www.talktofrank.com/drug/glues-gases-and-aerosols">their psychoactive effects</a>. These substances are derided as a cheap high and use is <a href="https://www.ncbi.nlm.nih.gov/pubmed/17900889">stigmatised</a> in comparison to other drugs. But users report that it can be <a href="https://www.ncbi.nlm.nih.gov/pubmed/17900889">pleasurable</a>, as well as an effective means of self-medicating pain and low mood. </p>
<p>As volatile substances are marked for household or industrial purposes, they are readily available. Misuse is covered by the <a href="https://www.gov.uk/government/publications/psychoactive-substances-act-guidance-for-retailers/psychoactive-substances-act-2016-guidance-for-retailers">same laws</a> designed to prevent supply of new psychoactive substances. </p>
<p>VSA use peaks in early adolescence and declines with age. In England in 2016, 11% of <a href="https://digital.nhs.uk/data-and-information/publications/statistical/smoking-drinking-and-drug-use-among-young-people-in-england/2016">11- to 15-year-olds</a> reported having been offered volatile substances and 4.4% of respondents reported they had used them at least once in the 12 months prior to the survey – more than any other drug apart from cannabis. Furthermore, 61% of pupils who first tried a substance at the age of 11 or younger reported that this was a volatile substance. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/231064/original/file-20180808-1652-1j5okg0.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/231064/original/file-20180808-1652-1j5okg0.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/231064/original/file-20180808-1652-1j5okg0.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/231064/original/file-20180808-1652-1j5okg0.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/231064/original/file-20180808-1652-1j5okg0.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/231064/original/file-20180808-1652-1j5okg0.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/231064/original/file-20180808-1652-1j5okg0.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The SACKI warning logo.</span>
<span class="attribution"><a class="source" href="https://www.bama.co.uk/abuse">The British Aerosol Manufacturers' Association (BAMA)</a></span>
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<p>Since 2001 there have been 834 <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/deathsrelatedtovolatilesubstanceabuseandheliumgreatbritain">deaths related to these substances</a> in Britain and 64 in 2016 alone – on a par with the number associated with ecstasy use. But VSA deaths do not simply affect young people. In terms of mortality, deaths of young people have declined and almost half of all VSA deaths are now of adults between the ages of 20 and 39.</p>
<p>The response to VSA in the UK is fragmented and a more coordinated approach to data collection, prevention, treatment and supply reduction is needed. First, we need better data on use and associated harms.</p>
<p>England, for example, <a href="https://digital.nhs.uk/data-and-information/publications/statistical/adult-psychiatric-morbidity-survey/adult-psychiatric-morbidity-survey-survey-of-mental-health-and-wellbeing-england-2014">no longer collects</a> data on use of most products in adults. Public Health England <a href="https://www.gov.uk/government/statistics/substance-misuse-and-treatment-in-adults-statistics-2016-to-2017">reports</a> that 359 individuals presenting to drug treatment services in 2016/17 declared use of “solvents”. </p>
<h2>‘Not real drugs’</h2>
<p>But this is likely to be an underestimate because charities and treatment providers tell us that pathways into treatment are hampered by stigma and therefore users are often unwilling to seek help. There is a perception from some users and providers that these substances are not considered “real drugs” and a lack of routine assessment by treatment workers and healthcare professionals means that a history of VSA is often missed by drug treatment and other health services.</p>
<p>Little is known about how to effectively prevent VSA and treat users. Although there is some <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1360-0443.2011.03650.x">tentative evidence</a> to <a href="https://www.ncbi.nlm.nih.gov/pubmed/26969125">support the use</a> of individual counselling, family therapies and residential activity and engagement programmes, few providers have the skills or resources to offer these solutions. </p>
<h2>Industry’s key role</h2>
<p>The solvents industry has a key role to play in risk reduction. In the UK – and in keeping with cigarette labelling – this has led to the introduction of the <a href="https://www.bama.co.uk/abuse">SACKI logo</a> (Solvent Abuse Can Kill Instantly) carried on almost all aerosol products. Manufacturers should be encouraged to continue looking for ways to make their products harder to misuse.</p>
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<img alt="" src="https://images.theconversation.com/files/231069/original/file-20180808-160647-6rwz2h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/231069/original/file-20180808-160647-6rwz2h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/231069/original/file-20180808-160647-6rwz2h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/231069/original/file-20180808-160647-6rwz2h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/231069/original/file-20180808-160647-6rwz2h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/231069/original/file-20180808-160647-6rwz2h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/231069/original/file-20180808-160647-6rwz2h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Deodorants and aerosols are also categorised as volatile substances which can be abused.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hand-holds-deodorant-can-on-blue-1025523079">Shutterstock/Butus</a></span>
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<p>One way of doing this is to replace harmful chemicals in products, as has been done in the <a href="https://www.echa.europa.eu/documents/10162/f28ce048-676d-4d17-b939-0c08e9a0db9f">European Union</a>, for example with the removal of the liquid solvent toluene from consumer spray paints and glues. Technical advances might enable other manufacturers to reformulate their products, or to market consumer products in smaller sizes to make heavy consumption more difficult. </p>
<p>Retailers, including the online giants, also have an <a href="http://volatilesubstances.org.nz/retailers-guide/">important role to play</a>. In addition to complying with existing law, retailers should only allow single purchases of products such as lighter fluid. In-store and online signage and displays should not draw attention to products or offer promotions on products that might be misused. Staff and systems should also be trained to identify customers who might be misusing products and shop design and product location should be considered as a way to reduce thefts.</p>
<p>These substances are not “glamorous” and their use is not associated with fashionable clubs, festivals or modern <a href="https://theconversation.com/the-link-between-drugs-and-music-explained-by-science-89132">cultural movements</a>. Few in the media demand that government “does more” in response to the harm they do. Nevertheless, the health and social harms of VSA are significant.</p>
<p>The total societal cost to the public purse in England and Wales has been estimated to be <a href="https://www.bwbllp.com/file/resolv-impact-report-final-11-dec-2017-pdf">£346m every year</a>. Intensive and regular VSA is strongly associated with acute social and economic disadvantage. In the UK, 12% of those dying after use had at some time <a href="http://www.re-solv.org/wp-content/uploads/2016/02/25YearsofVSA.pdf">lived in care</a>. The relative lack of attention paid to volatile substances and the harm they can cause suggests that society may value the people who use them <a href="https://theconversation.com/record-level-of-drug-deaths-in-england-and-wales-latest-official-figures-99710">even less</a> than those who snort cocaine, inject heroin, smoke cannabis, or swallow prescription drugs.</p><img src="https://counter.theconversation.com/content/101215/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Harry Sumnall receives and has received funding from grant awarding bodies for drug and alcohol research. He is an unpaid member of the Advisory Council on the Misuse of Drugs (ACMD), an unpaid trustee of the drug and alcohol prevention charity Mentor UK, an unpaid Board Member of the European Society for Prevention Research (EUSPR), and an unpaid scientific adviser to the MIND Foundation
We would like to acknowledge the contribution of Re-Solv, a UK charity working to prevent volatile substance use, to our piece.</span></em></p><p class="fine-print"><em><span>Sarah J MacLean receives funding from The Australian Research Council and the Victorian Responsible Gambling Foundation. She is affiliated with the Australian Greens. </span></em></p>Glues, paints, spray deodorants and fuels are all abused for their psychoactive effects.Harry Sumnall, Professor in Substance Use, Liverpool John Moores UniversitySarah J MacLean, Senior lecturer, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/988132018-07-09T10:26:45Z2018-07-09T10:26:45ZAlcohol’s health benefits hard to prove, but harms are easy to document<figure><img src="https://images.theconversation.com/files/226042/original/file-20180703-116129-1n8dkyl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Alcohol is part of American life, but its health risks may be underplayed.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/clinking-glasses-alcohol-toasting-party-310311491?customer_ID=&campaign_ID=shutters.11154505&launch_ID=10580185&utm_source=sstkemail&utm_medium=email&utm_campaign=!Auto_API_Share_Module#">graphic.mooi/shutterstock.com</a></span></figcaption></figure><p>Alcohol is the most widely used drug in the <a href="https://www.globaldrugsurvey.com/">world</a>, including in the United States.</p>
<p>About 70 percent of adults in the United States report <a href="https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-facts-and-statistics">past-year alcohol consumption</a>, with over 37 million drinkers reporting binge drinking (defined for women as four or more drinks per occasion, and five or more drinks per occasion for men) <a href="https://www.sciencedirect.com/science/article/pii/S0749379717307535">at least once a week</a>. The prevalence of past-year drinking has increased in the past two decades, from 65.4 percent in 2001 to 2002 to <a href="https://www.sciencedirect.com/science/article/pii/S0376871614019966">72.7 percent in 2012 to 2013.</a> </p>
<p>Partially because it is such a commonly used substance, heavily marketed and glamorized in pop culture, Americans’ comfort with and acceptance of alcohol is high. </p>
<p>Should it be? </p>
<p>I research alcohol use and the associations between drinking and a wide range of problems. While the rising opioid epidemic has been receiving a lot of attention in the past five years, it is important to remember that alcohol is involved in a greater number of deaths and physical and social problems. Backed by a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4681589/">strong</a> <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0170366">industry</a>, alcohol’s dangers may be underplayed and its benefits exaggerated. A study to examine the health benefits of moderate alcohol consumption, jointly funded by the National Institutes of Health and the alcohol industry, was recently halted for reasons including possible conflicts of interests. Now is a good time to review some things we do know about alcohol.</p>
<h2>Is moderate drinking good for your health?</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/226312/original/file-20180705-122256-m2wuco.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/226312/original/file-20180705-122256-m2wuco.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/226312/original/file-20180705-122256-m2wuco.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/226312/original/file-20180705-122256-m2wuco.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/226312/original/file-20180705-122256-m2wuco.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/226312/original/file-20180705-122256-m2wuco.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/226312/original/file-20180705-122256-m2wuco.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Some studies have suggested that one glass of red wine a day can be good for health, leading some people to believe that benefits derive from all types of alcohol.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pouring-red-wine-into-glasses-vineyard-314750660?src=3agfYSCIfdUuqie8aH9eBg-1-7">Rostilav_Sedlacek/Shutterstock.com</a></span>
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<p>In the past two decades, the idea that moderate drinking may actually confer health benefits has taken hold, backed up by some <a href="https://www.ncbi.nlm.nih.gov/pubmed/10591709">preliminary</a> <a href="http://care.diabetesjournals.org/content/28/3/719/">evidence</a>. This led to the often-mentioned notion in the <a href="http://www.health.com/health/article/0,,20410287,00.html">popular</a> <a href="https://www.myhealthwire.com/news/breakthroughs/938">press</a> that a glass of red wine a day reduces the risk of cardiovascular disease and diabetes. </p>
<p>There was one major flaw in many of the studies used to back up the claim that a glass of red wine is good for health. They compared moderate drinkers to <a href="http://www.ave.ee/download/Fillmoreetalpaper2.pdf">non-drinkers</a> – rather than comparing lighter to heavier drinkers. There is a phenomenon called the <a href="https://academic.oup.com/aje/article/168/8/866/137699">“sick quitter paradox,”</a> however, that could affect study findings. “Sick quitter” means that non-drinkers tend to be less healthy than low-level drinkers, and that many people choose to not drink for health reasons. Therefore, some non-drinkers may be less healthy than moderate drinkers for reasons unrelated to alcohol.</p>
<p>The question as to whether moderate drinking is beneficial remains open. The National Institutes of Health recently sought to initiate a large randomized control trial, the gold standard for understanding causal relationships, to look into the <a href="https://www.nytimes.com/2017/07/03/well/eat/alcohol-national-institutes-of-health-clinical-trial.html">benefits of moderate drinking</a>.</p>
<p>This trial was designed to pick up the heart benefits of consuming one drink a day, but it was not designed to be able to detect the negative consequences of moderate alcohol use, such as <a href="https://www.nytimes.com/2018/06/18/health/nih-alcohol-study.html">increases in breast cancer</a>. Many in the alcohol research community wondered what the recommendations from this study would be, since there are so many <a href="https://www.sciencedirect.com/science/article/pii/S0091743503003384">well-established problems with drinking even at moderate levels</a> that likely outweigh any potential benefits. </p>
<p>The study was recently canceled for a number of reasons, including <a href="https://www.statnews.com/2018/06/15/nih-report-controversial-alcohol-study/">inappropriate engagement between staff at the National Institute for Alcohol Abuse and Alcoholism (NIAAA) with both the study researchers and industry partners</a> and the subsequent <a href="https://www.the-scientist.com/the-nutshell/anheuser-busch-wont-fund-controversial-nih-alcohol-study-64326">removal of funding from the alcohol industry</a>. The now canceled study on the benefits of moderate drinking reminds us that it is important to remember all the physical and social consequences of alcohol consumption. </p>
<h2>What we do know: Impacts of alcohol on our health and well-being</h2>
<p>Alcohol is the <a href="https://jamanetwork.com/journals/jama/fullarticle/198357">third leading cause of premature mortality</a> in the United States, with an estimated 88,000 attributable deaths per year (<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4075492/">10 percent of all deaths among working-age adults</a>). Alcohol use disorder lifetime prevalence is 29.1 percent, with 13.9 percent of adults experiencing a <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2300494?version=meter%20at%20null&module=meter-Links&pgtype=article&contentId=&mediaId=&referrer=&priority=true&action=click&contentCollection=meter-links-click">past-year alcohol use disorder</a>. </p>
<p>Alcohol use, even at low levels, is linked to a number of cancers, including <a href="https://jamanetwork.com/journals/jama/fullarticle/1104580">breast</a>, <a href="https://academic.oup.com/annonc/article/24/2/301/223860">colorectal, liver and esophagus</a>. Alcohol causes a number of serious harms to others, many of them violence-related.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/226313/original/file-20180705-122271-1cdn9dp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/226313/original/file-20180705-122271-1cdn9dp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/226313/original/file-20180705-122271-1cdn9dp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/226313/original/file-20180705-122271-1cdn9dp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/226313/original/file-20180705-122271-1cdn9dp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/226313/original/file-20180705-122271-1cdn9dp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/226313/original/file-20180705-122271-1cdn9dp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Alcohol is involved in many instances of intimate partner violence.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/man-beating-his-wife-illustrating-domestic-261573011?src=5K6etMdTFqCaX5uUuGxVKw-1-5">sdecoret/Shutterstock.com</a></span>
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<p>A large proportion of all violent activities in the United States are associated with <a href="https://books.google.com/books?hl=en&lr=&id=ldQLhklj3m0C&oi=fnd&pg=PR3&dq=violence+alcohol&ots=ERasZ9bT2y&sig=BXfTUnwk7jSTWTNLKWVobMQUPWU#v=onepage&q=violence%20alcohol&f=false">alcohol</a>. These include increased risk of <a href="https://www.sciencedirect.com/science/article/pii/S0145213414001045">child maltreatment</a> – primarily physical abuse, intimate partner violence (with an estimated <a href="http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.216.6126&rep=rep1&type=pdf">6 to 57 percent of all cases involving drinking</a>), <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4484270/?_escaped_fragment_=po=11.1607">sexual assault</a>, assaults and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2831052/">gun violence</a>. While the rates of drinking after driving have fallen in the past two decades, it is still estimated that there were <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2682617?utm_campaign=articlePDF&utm_medium=articlePDFlink&utm_source=articlePDF&utm_content=jamainternmed.2018.1406">178,795 alcohol-related motor vehicle fatalities</a> between 2000 and 2015. Furthermore, the level of alcohol consumption considered “safe” has likely been overestimated for the majority of drinkers, with risks for a range of these outcomes associated with levels as low as three drinks a week and risks for many acute problems most common occasions consuming <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1111/add.12887">three drinks</a>. </p>
<h2>Disparities in alcohol-related consequences</h2>
<p>In addition, the impact of alcohol is not felt equally by all: The most vulnerable among us suffer the greatest consequences. In the U.S., African-American and Hispanic drinkers experience a greater number of social consequences of drinking, such as arguments or fights, accidents, and workplace, legal, and health problems, than white Americans, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2771773/">particularly among groups of low-level drinkers</a>. While we still do not fully understand the reasons for these disparities, they may be partially due to racial or ethnic stigma and stress, the unique <a href="https://www.jsad.com/doi/full/10.15288/jsad.2018.79.22">social and environmental contexts</a> of minority populations, or <a href="https://doi.org/10.15288/jsad.2018.79.7">decreased access to treatment and related support services</a>.</p>
<p>Sexual and gender minority adolescents <a href="https://jamanetwork.com/journals/jamapediatrics/fullarticle/380372">start drinking at younger ages</a> and continue to <a href="https://www.sciencedirect.com/science/article/pii/S0749379713006326">binge drink more frequently as adults</a>. These differences in alcohol-related problems at the same level of alcohol consumption contribute to disparities in many other health outcomes for these populations.</p>
<h2>Raising taxes, drinking age could offset harms</h2>
<p>There are a number of things we can do to reduce the burden of alcohol through public policy. The most effective policies include alcohol <a href="https://www.irs.gov/businesses/small-businesses-self-employed/excise-tax">excise taxes</a>, restrictions on the number of stores that sell alcohol, and restrictions on <a href="https://www.sciencedirect.com/science/article/pii/S0749379713002171">hours of sale</a>. A more restrictive alcohol policy environment is associated with fewer alcohol-related <a href="https://www.jsad.com/doi/abs/10.15288/jsad.2017.78.781">homicides</a>,<a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2682617?utm_campaign=articlePDF&utm_medium=articlePDFlink&utm_source=articlePDF&utm_content=jamainternmed.2018.1406"> motor vehicle crash fatalities</a>, and <a href="https://www.sciencedirect.com/science/article/pii/S0140673616324205">consumption by underage drinkers</a>. Raising the minimum drinking age has been shown time and again to be an effective way to curb alcohol-related mortality and <a href="https://www.mitpressjournals.org/doi/pdfplus/10.1162/REST_a_00615">morbidity</a>. While the alcohol industry often stands against many of these policies and regulations, these policies are relatively easy to implement. Also, they have been shown to be <a href="https://www.ncbi.nlm.nih.gov/books/NBK216412/">effective</a> to reduce the negative consequences of alcohol use in the United States.</p>
<p>Alcohol plays a pivotal role in American culture, but it is important to remember that there are more alcohol-attributable deaths and a myriad of physical and social problems related to drinking, even at low levels, than any other substance. Even if moderate alcohol consumption is linked to a slight reduction in cardiovascular disease - a question that remains open - the myriad other consequences of drinking make it unwise to recommend alcohol as a path to better health and well-being.</p><img src="https://counter.theconversation.com/content/98813/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christina F. Mair receives funding from the National Institutes of Health.</span></em></p>A recent study to assess the health benefits of alcohol was halted after investigators were found to have ties to the alcohol industry. Are health benefits overstated and risks underplayed?Christina Mair, Associate Professor of Behavioral and Community Health Sciences, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.