Changing the Addiction Field

Table of Contents

Introduction

In the following some of major changes that have taken place in the addiction field over the last decades will be listed. Many of these changes have resulted from the normal sequence of fact finding, through information and advocacy towards actual changes in policies and practices. At the time when Ambros Uchtenhagen is handing over the management of the ISF to Jürgen Rehm it is appropriate to review his role in science and policy in the addiction field.

Radical changes in paradigm

Over the past decades there have been many dramatic changes in the addiction field. We often take the current practice as obvious, while however only few years earlier we believed or acted in the exactly opposite manner. Many illustrations of these radical changes in paradigm can be found in the addiction field. From a situation e. g. some 30 years ago where it was almost impolite not to offer a cigarette to a visitor, whether it was at home or at the workplace (even if this workplace was an addiction clinic), to a situation like we have today, where it would make the visitor make uncomfortable if he or she would be offered a cigarette, spans indeed only some 30 years. Similarly the changes in the treatment of addiction to illegal drugs have undergone rather drastic changes. Who could have predicted 30 years ago that a therapist would prescribe heroin to the heroin-addict?

To a great extent these dramatic changes have resulted from a huge increase in scientific knowledge in the aetiology and epidemiology. There is no doubt that the past decades have yielded a significant gain in our understanding of the magnitude of the addiction problem and its causes. This applies in particular to the advances made in our understanding of the biological mechanisms of addiction. The discovery of the system of neuro-transmission and the role played therein by dopamine has shed a completely new light on the mechanisms of addiction. But also our understanding of the psychological, social and economic mechanisms around addiction has advanced very considerably. There is now a reasonably reliable estimate in our societies on the extent of the use of illegal drugs in most countries, which in Europe is to a great extent thanks to the leadership work of the epidemiology group of the Pompidou Group. And an assessment of the relative importance of the addictions in the overall pattern of determinants of the health of the public has become possible thanks to the studies on the global burden of disease (GBD).

Coming of age

Closely related to the development in science there has been a trend towards professionalisation and towards institutionalisation. Many universities in Europe now have a chair in addiction sciences. Slowly but surely the recognition is growing that preventing, treating and rehabilitating addiction problems requires special knowledge and skills. There are now professional associations of addiction scientists and addiction workers in most countries and even at an international level. Almost all countries in Europe today have some sort of national resource centre for addictions. At the level of the European Union there is an addiction resource centre: the EMCDDA. Although today its remit is still limited to illegal drugs this is a position which at the long run is untenable and it is therefore very likely that in the future this centre will expand its activities to cover also the other addictions. The number of addiction journals has grown continuously, even sometimes to an extent that one might wonder whether there should not be a bit more international pooling of the resources going into the production of all these national journals.

The public health perspective

The most important shift, it seems to me, that has taken place over the last decades is the growing attention for public health oriented action rather than in furthering efforts directed at the individual addict. The advance of tobacco control measures, in comparison with the attention for cessation, is only one illustration of this. In the field of alcohol too, the last decades have shown a rapid increase in the interest of public health oriented policies to control the harm done by alcohol consumption. Following the establishment and the promotion of the European Alcohol Action Plan (EAAP) by the Regional Office for Europe of WHO in the beginning of the nineties, almost all countries in the European Union have developed mechanisms towards better control of alcohol related harm. In this context it is relevant to refer to the work of the Alcohol Policy and the Public Good group, which with the publication of the report with the same title gave the necessary scientific support for the proposed policies. The public health actions proposed in the EAAP stand in some contrast to the earlier focus of WHO on treatment and rehabilitation. Another clear manifestation of the advance of the public health perspective in the addiction field is the concept of harm reduction in the drug abuse field. While there was very considerable resistance in all societies throughout Europe against the idea of not aiming all efforts towards abstinence, slowly but surely this has become official policy almost everywhere. The most recent example of this shift comes from the Russian Federation, where the Chief State Sanitary Doctor issued an ordinance on the 9^th of September which recommends to ‘provide support to and expand, jointly with the Interior Ministry of the Russian Federation, the harm reduction programmes while ensuring a comprehensive preventive approach to intravenous drug users’.

The relation between science and policy

While we like to believe that changes in attitudes, or in policies for that matter, are rational and are thus related either to increased insight into damages caused by consumption or by changes in consumption patterns, this relation between science and policy response is not always that clear cut. It is in this tradition that habitually a report on the addiction problem starts with the almost obligatory claim of the growth of the problem. Policy responses, however, follow sometimes their own dynamics, whereby e. g. events in the close social environment of politicians or events widely covered in the media may be the ultimate determinant for the course of a national policy. On the other hand it is often also thanks to the personal investment and the personal determination of scientists that science does play the role it should.

The personal dimension

In this sense it is without any doubt that current public health oriented alcohol policies originate to a greater or lesser extent in the work by Kettil Bruun and the group that he worked with. The appearance of the so-called purple book [1] has determined much of the thinking and the research on alcohol policies later. Even today it is easy to detect a thread running from the purple book to Alcohol Policy and the Public Good (APPG), and from there to the European Alcohol Action Plan (EAAP). Likewise is the success of the European Alcohol Action Plan itself the result of the work by an numerous people, yet two people stand out there and it would not be exaggerating to say that, if they had not been there would not have been a EAAP: Dr Peter Anderson and Dr Ilona Kickbusch. They were initially the people who developed the plan and argued it through an uncountable number of forums.

Professor Uchtenhagen

My feeling is that in a likewise fashion much of what we see in Europe today in the drug abuse field is influenced by Ambros Uchtenhagen.

His significance for psychiatry, and particularly for social psychiatry in Switzerland, has been duly described by Fuchs in a laudatio published by European Addiction Research.

Uchtenhagen’s contributions in the addiction field are many and not easy to summarise.

If professionalisation and institutionalisation are major changes in the addiction field he certainly has contributed very substantially. In addition to the professional associations in the field of mental health which he established in Switzerland he founded the European Addiction Research Association. Together with Michael Krausz he established a new journal European Addiction Research which they together are still leading as chief editors and which together with Addictions forms the international top scientific forum in this field. At the time he was about to retire from his full time jobs at the university in Zürich he established in 1994 almost single-handed a new research institute: the Institut für Suchtforschung (ISF) in Zürich. In its short history the ISF has established itself as one of the leading research institutes in Europe. It has currently some 60 staff associated to it and is running an extensive research programme with commissioned researches from within the country but many also from other countries and international organisations.

The list of publications of which he is the only or the most important author is long and counts over 240 items. What is striking in this list is that his work covers a wide range of issues: from out-patient treatment of psychosis to the impact of marihuana, from the psycho-social aspects of HIV infection to the organisation of community mental health services, from non-voluntary treatment to psycho-geriatrics; the majority though dealing with substitution treatment. Another feature in this list is the relatively great number of articles and interviews for the popular press. He has never avoided the popular press or the media, on the contrary, it seems that he is keen to meet with them, and they are keen to meet with him. This obviously is of importance when it comes to make the public and politicians understand and accept why changes are needed or are to be pursued; without which any policy is doomed to fail.

Ambros Uchtenhagen’s main contribution in the addiction field is the developmental work and the evidence which he has provided for harm reduction practices, a term which by the way he himself uses only seldom. He was the main person behind the design and the development of the experiments which have led to the acceptance of substitution treatment. Critical in all this has been the studies which he carried out to evaluate the impact of the experiments. It is to a great extent thanks to Uchtenhagen that the Swiss drug abuse policy is the way it is: pioneering with new approaches, carefully studying the impact and subsequently persuading the population and the politicians. In its turn, many of the changes in other countries in Europe in this direction have been facilitated by what had been done earlier by the Swiss, building upon the direction indicated and the science assembled. In providing the right arguments for a harm reduction approach Uchtenhagen has been one of the main architects of current drug abuse policies in Europe which no doubt has saved many lives and has rendered European drug abuse policies a more humanistic face.

References

• 1 Bruun K, Edwards G, Lumio M. et al .Alcohol Control Policies in Public Health Perspective. Finnish Foundation for Alcohol Studies Helsinki; 1975
• 2 Fuchs WJ. On the Retirement of Prof. Dr. Dr. Ambros Uchtenhagen.  European Addiction Research. 1996;  2/1 68-69