South African Medical Journal
First published January 1884
October 2011, Vol. 101, No. 10 SAMJ
By addiction we usually mean continued involvement and dependence on drugs, including alcohol and tobacco. But addiction can also include an abnormal dependency on many other things, including pornography, gambling and food.
South Africa’s 2nd Biennial Anti-Substance Abuse Summit in Durban, with the theme ‘An Integrated Approach: Towards a Drug-free Society’, was recently hosted by the Department of Social Development and the Central Drug Authority (CDA) and was attended by many ministers and top politicians. However, Charles Parry and Bronwyn Myers in this issue1 argue persuasively that it is time to move away from the outdated political rhetoric of a ‘drug-free society’ and to engage in the work of formulating and implementing an evidence-based policy.
Problem gambling, another destructive form of addiction, also potentially has devastating effects on individuals and their families. Collins and colleagues,2 also in this issue, describe the effective management of this problem by the industry-supported National Responsible Gambling Programme (NRGP).
Substance abuse can be classified in terms of its potential harms. Nutt and colleagues3 ranked drugs on the basis of their potential for physical harm, dependence (addiction), and effects on families, communities and society, thereby offering a rational solution to a previously arbitrary classification. Tobacco is one of the most addictive substances, although its harmful effects are usually only apparent after long periods of time. Addiction to the more psychoactive drugs often poses more immediate and bigger problems to families and societies. It is in the management of these that supporters and opponents of the decriminalisation of drugs often share a common view, namely that such people require expert medical and other help and support and not stigmatisation or incarceration in jail.
A recent book Recovery RSA: A Resource Book for Those Affected by Addiction 4 has made a timely appearance. Compiled by Barbara Hutton, it draws on the experiences of many experts in the field and is aimed at addicts, families, significant others, professionals and support people. There is something of value for everyone with an interest in the field. The somewhat uneven length and quality of the chapters and the interspaced personal experiences of those with addictions strangely do not detract from the value of the book – professionals and lay people will return to the areas that most interest them.
The reasons for people becoming addicted to psychoactive substances are dealt with by Rodger Meyer. He describes the pathogenesis and the process of becoming addicted and notes that there is still very little agreement among authorities regarding the true nature of the condition. People commence drug or alcohol use for reasons that by and large are obvious: most people start using drugs or alcohol in the pursuit of intoxication, much like a primitive biological drive for needs like shelter, food, water and sex; curiosity initiates much alcohol and drug use; people commence drug or alcohol use as the cultural norm of celebration; some use drugs and alcohol as a deliberate form of deviation; others commence substance use as a form of medication; some use substances to blur the jagged edges of their confused lives (obfuscation); and finally, some use drugs or alcohol in an attempt to destroy themselves (annihilation).
Several chapters deal with different aspects of treatment of substance abuse and addiction. Most professionals acknowledge that addiction is an illness that affects the brain and that the addict needs treatment, like anyone suffering from a disease. There is also little doubt that environmental and social factors impact on the addict and have to be acknowledged and dealt with if treatment is to be successful. Katy Mennell describes the dramatic effects that addiction can have on families and ‘concerned others’, interspersed with personal tales of those who had such tough experiences. Family members may be helpful in the process of treatment, but may also be unwitting enablers of continuing the addiction. For all of them knowledge of the nature and effects of addiction is an important starting point. Medical and/or psychiatric illnesses can be caused by or associated with the addiction, or they can be present coincidentally, i.e. together with or alongside the addiction. This co-morbidity is dealt with in a chapter by Anthony Teggin.
The paper ‘Time to decriminalise drugs?’5 in South Africa evoked considerable comment, the majority favouring decriminalisation. Many who opposed such moves6 were people who had close experience with the harms of addiction. We all agree that the abuse of drugs is a scourge that is harmful to individuals, their families and society. However, because of the failure of the decades-long ‘war on drugs’, the need to reconsider drug policies and provide better solutions is gaining worldwide traction, e.g. the feature article of Time magazine of 11 July dealt with the tragedy of Mexico’s drug wars, which resulted in over 15 000 deaths due to violence in 2010; the New England Journal of Medicine 7 lamented the ‘epidemic of incarceration in the United States’, noting that the US has 5% of the world’s population but 25% of people incarcerated, much due to the war on drugs; and the ‘Report of the Global Commission on Drug Policy’8 concluded inter alia: ‘End the criminalization, marginalization and stigmatization of people who use drugs but who do no harm to others. Challenge rather than reinforce common misconceptions about drug markets, drug use and drug dependence.’
The government can provide leadership by re-evaluating the whole question of substance abuse based on the best evidence. But individuals and society must all contribute to this effort.
1. Parry C, Myers B. Beyond the rhetoric: Towards a more effective and humane drug policy framework in South Africa. S Afr Med J 2011;101:704-706.
2. Collins P, Stein DJ, Pretorius A, et al. Addressing problem gambling: South Africa’s National Responsible Gambling Programme. S Afr Med J 2011;101:722-723.
3. Nutt D, King LA, Saulsbury W, Blakemore C. Development of a rational scale to assess the harm of drugs of potential misuse. Lancet 2007;369:1047-1053.
4. Hutton B. Recovery RSA: A Resource Book for Those Affected by Addiction. Auckland Park: Stonebridge Books, 2011.
5. Van Niekerk JPdeV. Time to decriminalise drugs? S Afr Med J 2011;101:79-80.
6. Van Eeden A. Harm reduction – more than just side-effects. S Afr Med J 2011;101:358-359.
7. Rich JD, Wakeman SE, Dickman SL. Medicine and the epidemic of incarceration in the United States. N Engl J Med 2011;364:2081-2083.
8. Report of the Global Commission on Drug Policy June 2011. www.globalcommissionondrugs.org
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