Applying a Public Health Approach to Drug Abuse ... - SAGE Journals

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APPLYING A PUBLIC HEALTH APPROACH ABUSE RESEARCH

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WILSON M. COMPTON Applying a public health perspective to drug abuse research has far-reaching implications. First, the health of the entire community is of concern, not just the individual patient. Because of the social impact of drug abuse, these problems become the responsibility of all citizens to address. Second, the perspective requires treating drug abuse as a health issue, not as a criminal justice, moral, or social issue. Third, as in other branches of medicine, applying this perspective to drug abuse research will encourage development of the most effective ways to enhance drug abuse prevention and treatment interventions through cross-disciplinary approaches. The public health approach requires studies that (1) determine need for intervention; (2) provide clues about etiology; (3) determine effective approaches, systems, and financing strategies; and (4) measure the impact of interventions and services on the health of a population. Overall, attending to the public health implications of research will help to assure the maximum impact of scientific findings.

INTRODUCTION

What is meant by “public health research”? Public health research is defined as an approach to improving health that focuses on population-based measures. Applying this rubric to drug abuse research means that the tools of epidemiology are used to help determine need, provide clues about etiology, plan services, and determine effectiveness of interventions through measures of the impact on the health of a population. As seen in Figure 1, epidemiology is seen as linked in a reciprocal manner with basic research to elucidate answers to questions about etiology and with interventions research to inform the need for and outcomes of prevention and treatment services. __________ Wilson M. Compton, M.D., M.P.E., is the director of the Division of Epidemiology, Services and Prevention Research at the National Institute on Drug Abuse (NIDA). At NIDA, Dr. Compton has been emphasizing the importance of public health drug abuse research, building on his previous work on HIV prevention and co-occurring disorders in treatment and community settings.

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FIGURE 1

PUBLIC HEALTH DRUG ABUSE RESEARCH

So what is the purpose of writing an article about a public health approach to drug abuse research? In this era of burgeoning neuroscience, it may be useful to review how the techniques and focus of public health care research can continue to contribute to productive avenues of research. It is quite obvious how such an approach is important to drug abuse prevention and treatment service delivery planners. In these cases, it is imperative to understand the changing patterns of drug abuse in one’s community whether that is a town, county, state, region, or nation. But how does a public health approach help us in the research arena where the goals are quite different than policy and treatment planning? In the research area, we look to the ways that a public health perspective allows us to move the field forward in terms of elucidating possible causes and outcomes of drug abuse so that more effective interventions can be developed for prevention and treatment. Therefore, this article provides a brief review of the ways in which a public health perspective has informed the study of drug abuse in the recent past and how researchers can build on these foundations. From a practical perspective, this outline will also serve as a guiding document for the Division of Epidemiology, Services and Prevention Research at the National Institute on Drug Abuse (NIDA) of the U.S. National Institutes of Health. Within NIDA, it is in this division where a public health focus is most generally disseminated. DISCUSSION

What are the implications of a public health focus in drug abuse research? The implications of this focus are that researchers can move the field forward by applying 462

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PUBLIC HEALTH APPROACH TO DRUG ABUSE RESEARCH

tried and true methods of epidemiology. This means determining the web of causation for specific drug abuse epidemics based on careful detective work. How does this perspective inform the larger scientific field? The model includes a focus on population groups so that results can be generalized to well-defined groups. Using this public heath perspective, sampling frames are always carefully considered. Therefore, the public health approach explicitly acknowledges the limitations of sampling design so that policy-relevant conclusions are more likely than in other areas of research in which the lack of representative samples often makes results of uncertain relevance. Linkages with developmental sciences (both biological and psychological), neuroscience, and cognitive sciences are promoted by a public health focus. Public health researchers bring attention to burgeoning problems and provide clues to potentially fruitful lines of research, which can then be followed up by basic science and treatment researchers. The situation of co-occurring psychiatric disorders may be used to illustrate how the principles of public health research can guide the process of scientific inquiry. The first finding is based on a series of epidemiological studies in which rates of psychiatric disorders have been shown to be much more common than expected among substance abusers (Compton, Cottler, Ben-Abdallah, et al., 2000; Regier et al., 1990; Kessler et al., 1994; Warner, Kessler, Hughes, Anthony, & Nelson, 1995). Because many psychiatric symptoms lack specificity, this overlap could be due to at least four different pathways: (1) substance use could cause (or exacerbate) psychiatric disorders; (2) psychiatric symptoms could lead to substance use; (3) some other factor could cause both substance use and psychiatric symptoms; (4) psychiatric symptoms could be a temporary phenomenon due to the direct toxic effects of substances (Lehman, Myers, & Corty, 1989; Compton, Cottler, Phelps, Abdallah, & Spitznagel, 2000). Testing the plausibility of each of these pathways is the business of science. Both cross-sectional and longitudinal studies can be used and sampling from treatment settings and the general population will allow consideration of whether these associations are related to treatment-seeking per se or due to some other cause (Grant, 1997). One implication of this overlap of substance-related and non-substance-related psychiatric disorders is that treatment services need to be structured to address the overlap (US Department of Health and Human Services, 1995). In addition, prevention programs may help to inform us as to the temporal association of the two sets of conditions (i.e., if we reduce the severity of psychiatric disorders, does the rate of substance abuse diminish as well, or vice versa) (Glantz, 2002). Taking these epidemiological findings further, other areas of scientific inquiry are asked to address this public health need. In the neurosciences realm, what are SUMMER 2005

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the potential biological causes of the increased rates of psychiatric disorders among substance abusers? Are there common brain mechanisms that help to explain the overlap (Jacobsen, Southwick, & Kosten, 2001)? Does the common age of onset of substance use disorders and many psychiatric conditions provide any clues as to a shared etiology? Do distinct gender patterns provide clues? Are there common genetic pathways for these disparate but interrelated conditions? For the treatment area, the needs are clear (US DHHS, 1995). The fundamental question is whether effective treatments can be designed for co-occurring disorders that account for the synergistic and complex interactions of the multiple conditions. Once potentially fruitful interventions are designed, how can these treatments best be implemented in real-life settings? As the building blocks of a research agenda are accumulated in the area of cooccurring psychiatric disorders, some of the research questions are answered. For example, not all psychiatric disorders are increased in the presence of substance use. Certain psychiatric disorders antedate the onset of substance use disorders (Compton, Cottler, Phelps et al., 2000). The inheritance pattern for co-occurring disorders is generally distinct from that of substance use disorders. One condition in particular overlaps particularly strongly with substance use disorders: conduct disorder in children/adolescents (and the closely related antisocial personality disorder in adults). For the issue of the overlap of co-occurring psychiatric disorders, these are just a few of the examples of ways that science has started with a public health perspective and has followed up with a series of studies to explain and address the problems. As seen in these examples, the public health focus provides a useful framework for understanding and organizing drug abuse research so that the most relevant questions can be addressed and the lines of research with the greatest potential pursued. What are the major alternatives to a public health approach? For example, one might consider biological and bio-psycho-social approaches to drug abuse research. These alternative approaches have strengths, but a public health perspective allows for the broadest approach that will lead to the most likely enhancements of treatment and prevention in the long run. Taking each approach separately, first consider a biological approach. Certainly, the biological underpinnings of drug abuse have generated a great deal of excitement among drug abuse researchers. Both the major brain pathways of reinforcement and promising models of major clinical components of addiction have been elucidated (e.g., mechanisms of withdrawal and tolerance for several substances) (Herman & Stimmel, 1996). Despite these major advances, applying these findings without assessment of the extent and outcomes of addiction would mean that very little relevance of findings would be demonstrated. The strength of the biological findings lies in their application to major questions of health. Only 464



with a public health overview can we understand whether particular questions have broad implications. Another alternative to the public health approach is the bio-psycho-social approach. While this approach attempts to provide an all-encompassing theoretical structure by simultaneously examining biological, psychological, and social factors in drug abuse, this approach lacks a coherent view of the problems. By providing a consolidated view of potential causes and correlates of drug abuse, the bio-psychosocial approach has appeal. The problem is that this approach lacks the understanding of how extensive particular drug problems are. The bio-psycho-social approach links multiple domains but does not address the extent of drug abuse in any explicit way. In this way, a public health perspective can be linked with biological, psychological, and social approaches to understanding drug abuse while remaining a foundation for these particular approaches. CONCLUSIONS

The current major scientific questions for drug abuse public health research are many. From epidemiology and etiology research: What are the most effective frameworks to identify environmental risk factors and gene-environment interactions? What biological predictors of drug use/abuse can be used in field research? What are the major proximal influences to drug abuse (e.g. culture and social setting, stress, parenting style, peer associations, cognitive processes)? How do drug abuse trends differ between urban and rural areas and in underserved areas? From the drug abuse prevention research: What unexplored theories, models or empirical findings can be used to develop prevention strategies? How can escalation from initiation to regular use and to abuse/dependence be prevented? How can high-risk target groups for specific prevention interventions be identified? What community/population-specific factors ensure dissemination of effective prevention interventions? How can identification and intervention be achieved across a range of problems clusters, including multi-problem youth, using concepts from basic neuroscience, genetics, and cognitive sciences? From services research: How can laboratories be developed that blend research and practice in different settings (e.g., primary care)? How can drug abuse treatment and recovery models that account for the chronic illness concept be tested? What are the most effective service delivery models for criminal justice-involved drug abusers? Which components of the treatment delivery systems are effective for adolescent drug abusers? The implications of applying the public health approach are that scientific progress will develop through interdisciplinary linkages. There will be simultaneous movement of observations from epidemiological studies into research on practice and etiology. Furthermore, the public health model implies a constant process of SUMMER 2005

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rigorous evaluation. This includes the measurement of impact on clearly identified populations so that the extent of generalizability of findings is assessed. Overall, attending to the public health implications of research will help to assure the maximum impact of scientific findings. ACKNOWLEDGMENT

Please note that this paper represents the views of the author and does not necessarily represent the views of the National Institute on Drug Abuse, the National Institutes of Health or the Department of Health and Human Services. REFERENCES

Compton, W.M., Cottler, L.B., Ben-Abdallah, A., Phelps, D.L., Spitznagel, E.L., & Horton, J.C. 2000 Substance dependence and other psychiatric disorders among drug dependent subjects: Race and gender correlates. American Journal on Addictions, 9(2), 113-125. Compton, W.M., Cottler, L.B., Phelps, D.L., Ben-Abdallah, A., & Spitznagel, E.L. 2000 Psychiatric disorders among drug dependent subjects: Are they primary or secondary? American Journal on Addictions, 9(2), 126-134. Glantz, M.D. 2002 Introduction to the special issue on the impact of childhood psychopathology interventions on subsequent substance abuse: Pieces of the puzzle. Journal of Consulting and Clinical Psychology, 70(6), 1203-1206. Grant, B.F. 1997 The influence of comorbid major depression and substance use disorders on alcohol and drug treatment: Results of a national survey. In L.S. Onken, J.D. Blaine, S. Genser, and A.M. Horton. (Eds.), NIDA Research Monograph 172--Treatment of drug dependent individuals with comorbid mental disorders (pp. 4-15). Washington D.C.: NIH Publication No. 97-4172. Herman, J., & Stimmel, B. 1996 The neurobiology of cocaine addiction: From bench to bedside. New York: Haworth Medical Press. Jacobsen, L.K., Southwick, S.M., & Kosten, T.R. 2001 Substance use disorders in patients with posttraumatic stress disorder: A review of the literature. American Journal of Psychiatry, 158(8), 11841190.

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Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshleman, S., Wittchen, H.U., & Kendler, K.S. 1994 Lifetime and 12 month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the National Comorbidity Survey. Archives of General Psychiatry, 51(1), 8-19. Lehman, A.F., Myers, C.P., & Corty, E. 1989 Assessment and classification of patients with psychiatric and substance abuse syndromes. Hospital and Community Psychiatry, 400(10), 10191025. Regier, D.A., Farmer, M.E., Rae, D.S., Locke, B.Z., Keith, S.J., Judd, L.L., & Goodwin, F.K. 1990 Comorbidity of mental disorders with alcohol and other drug abuse, results from the epidemiologic catchment area (ECA) study. Journal of the American Medical Association, 264(19), 2511-2518. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration 1995 Assessment and treatment of patients with coexisting mental illness and alcohol and other drug abuse treatment improvement protocol (TIP) series 9. Rockville, MD: DHHS Publication No. (SMA) 95-3061. Warner, L.A., Kessler, R.C., Hughes, M., Anthony, J.C., & Nelson, C.B. 1995 Prevalence and correlates of drug use and dependence in the United States: Results from the National Comorbidity Survey. Archives of General Psychiatry, 52(3), 219-229.

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