25 February 1994 - 27 February 1994

Substance Abuse: The Need and Scope for International as well as National Strategies

Chair: The Hon Joseph A Califano Jr

Our topic was scarcely a new one at Ditchley; memories of our conferences among the participants stretched back twenty-five years. But we recognised that the scale and pattern of substance abuse, and awareness of the menace it posed, were constantly developing. There were elements of the hydra about the problems; as preventive action curtailed one form others sprang up, like the proliferating use of solvents - especially perhaps among the disadvantaged young - and the growth of addiction to new pharmaceutical products, where unwise prescription often compounded the general risk that disadvantage might emerge to view more slowly than benefit

Public perception, it was argued, tended to misunderstand the true relative weight of different elements; by most measures illicit drugs took far fewer lives than alcohol, and alcohol than tobacco, though it was fairly pointed out that the ranking in terms of violent disruption to social order might well be the reverse. In most Western developed countries there was, however, encouraging movement in popular thinking towards general disapproval of all these categories; the incidence of smoking, for example, had fallen away markedly, save in limited groups like young females, throughout the United States, Canada and Britain, and in these countries the stigmatising of illicit drugs too was mostly stronger than a decade ago even in severely-disadvantaged inner-city areas.

There was spirited debate about how far there was any real link between drug abuse and poverty - certainly no compelling causation upon individuals existed, but statistical correlations were hard to ignore, even when allowance was made for uneven reporting. The discussion brought home however that patterns of substance abuse differed very widely from one country to another - in social attitudes, in stages reached in the cycle of addiction propensity, and as between one substance and another. In Australia, for example, illicit drug use seemed to have little relationship with poverty; in some ex-Communist countries of Central Europe it presented amounting challenge linked with wider perceptions of free-market break-out; in less developed areas of Asia it was still sometimes accepted as a solace to poverty. Correlations between different classes of abuse also differed strikingly - among Russians alcohol over-use and illicit drug use rarely overlapped, whereas one Western study showed smokers as eighteen times more likely than non-smokers to have problems in other categories as well.

Our recognition of very different patterns around the world brought home to us the strength and significance of interactions across frontiers. US tax policies could impact severely upon Canadian strategy against smoking (and generate big smuggling risks); more notably still, the developed countries which sometimes condemned others for the production and passage of materials for heroin and cocaine were often themselves gravely culpable in their lack of controls over the export of drug-precursor chemicals, and still more in the tolerance - indeed, the positive support and promotion, as in aspects of Europe’s Common Agricultural Policy - of cigarette and alcohol export. Economic motivations seemed to be simply transferring Western smoking problems to the developing world.

But we knew that, however keen the disapproval, economic motivations could not simply be wished away; they concerned the jobs of workers, not just the profits of plutocrats. Coca-growing areas of Latin America needed advice, financial aid and time if agricultural diversification was to have any chance of success, and in Western countries both tobacco and alcohol were the basis of major industries. International action, and international conventions to focus it, had to recognise these realities.

There were, we recalled, a number of such conventions, though their emphasis at present lay more towards illicit drugs than tobacco or alcohol. Even with drugs their impact was uneven; not all relevant countries had ratified, there were mostly no enforcement mechanisms or sanctions, and even monitoring and evaluation were at best unsystematic. Politically-driven effort at improvement seemed needed in all these respects.

Should there be comprehensive strategies, both nationally and beyond, to deal with all categories of substance abuse? We were pulled several ways. There were clearly common elements running through policies for each category; there were interactions and overspills, for example as the underlying problem of addiction simply turned the addict to new directions when old ones were closed off; there were valuably transferable lessons between categories; there was a case too that the force of social attitudes should not seem to tolerate one category while assailing others. Against all this, there were genuine and often deep differences between the problems posed, in both nature and severity; and it was unrealistic to expect that social and economic problems could be overridden, or political support be mustered for the overriding, with uniform ease across the entire spectrum of substances. To demand a single common strategy might condemn action on the whole spectrum to proceed at the pace set by the most intractable. Modest practical steps, not grand designs - so it was strongly urged - were the true way forward. Perhaps the need was for a shared strategic analysis and understanding of interactions and of transferable instruments, to serve as coherent background to more purpose-built and differentiated policies both within and among countries?

Our discussion of what might be the character of such policies agreed that they must certainly be multi-faceted as to both particular instruments - education, prohibition, taxation, therapies, advertising constraints and the like - and general angles of approach; simple either/or dichotomies between prevention and treatment, or between supply-side and demand-side attack, were out of place. But there was a strong strand of judgment that some Western countries could with advantage re-balance their effort and their resource allocation to give greater weight to remedial elements - with a public-health orientation, and using the model of combating disease rather than crime - and less, proportionately, to the aspects apt for the criminal-justice approach. The latter remained nevertheless unavoidable; and it could itself contribute on the prevention side by making compulsory treatment part of its armoury. Many useful treatment techniques, including some exploiting the commitment and persuasive power of ex-addicts, were becoming recognised.

Much stress was laid upon the scope for, and value of, more systematic exchanges of information - an international data-bank, even - about the experience various countries had in methods of coping with substance ­abuse issues. The range of experiment-tested knowledge now capable of being transferred was increasingly wide, and with all due allowance for differences of situation and culture the possibilities of cross-learning must be very considerable. (At the same time, the spiritedly-inconclusive debates we had about the arguments for legalising or at least decriminalising “soft” drugs illustrated the problems of automatic read-across; so did our uncertainties over the right balance to strike between the particular merits of harm-reducing devices like the publicly-funded supply of fresh hypodermic needles to intravenous drug-abusers, and the general risks of appearing thus to condone law-breaking.) But we did all acknowledge the merit of pragmatic concentration upon what proves actually to do good or reduce harm in concrete situations. We saw, too, the value of wide intelligence­ exchange and warning to speed responses as new fields of abuse emerged.

The engine of action, as always, had however to be political will to change matters, to override reluctant special interests, to cut through filibusters hiding behind false perfectionism in the demand for proof of what was needed. It was here that the choice of priorities posed the sharpest dilemmas; and we did not succeed in making any clear cut choice - perhaps legitimately, given wide differences in national situations. But most of us stressed the special case for focusing upon the need to prevent young people from starting upon substance abuse, and to rescue them urgently if they did start. This imperative applied at least as powerfully to smoking and alcohol over-use as to the high- profile dangers of illicit drugs.

Were we down-hearted? Inevitably, the themes of danger and damage and death were a constant refrain in our discussions. But we did recognise that there were real successes to applaud, and that in some countries some sorts of abuse had plainly fallen away from peak levels. The basic message was one of concern and urgency, not of despair.

This Note reflects the Director's personal impressions of the conference. No participant is in any way committed to its content or expression.

Chairman: The Hon Joseph A Califano Jr
Chairman, Center on Addiction and Substance Abuse, Columbia University


Dr Gabriele Bammer     
Australian National University: Research Fellow

Professor Griffith Edwards CBE 
Professor of Addiction Behaviour, Institute of Psychiatry, University of London

Dr Michael Farrell
Senior Lecturer and Consultant Psychiatrist, National Addiction Centre and Maudsley Hospital

Dr Jane Greenoak
Director, Health Education Authority, with responsibilities for alcohol, mental health, workplace health and accidents.              

Commander John Grieve
Commander in charge of Criminal Intelligence, New Scotland Yard            

Ms Tessa Jowell MP
Member of Parliament (Labour), Dulwich

Mr Herbert Laming CBE
Chief Inspector, Social Services Inspectorate, Department of Health

Mr William Parker
Assistant Secretary, Drugs Policy Division, HM Customs and Excise, London           

Mr Geoffrey Podger      
Under Secretary for Health Promotion (Administrative), International Relations Unit, Department of Health.

Mr Tim Rathbone MP   
Member of Parliament (Conservative), Lewes

Dr Eileen Rubery            
Senior Principal Medical Officer, Head of Health Promotion (Medical) Division, Department of Health

Mrs Sue Street 
Director, Central Drugs Co-ordination Unit, London

Mr Jacques G LeCavalier             
Chief Executive Officer, Canadian Centre on Substance Abuse

Mr I (Ziggie) Malyniwsky             
Executive Director, Canada’s Drug Strategy Secretariat, Department of Health

Assistant Commissioner J Terry C Ryan 
Director of Drug Enforcement, Royal Canadian Mounted Police

Colonel Teodoro Campo Gomez              
Director, Anti-Narcotics Police, Bogota, Colombia

CZECH REPUBLIC            
Dr Kamil Kalina
Formerly Executive Director and Vice Chairman, National Drug Commission, Czech Republic

Professor Hansfried H Helmchen
Director, Psychiatric Clinic, Free University of Berlin

Frau Michaela Schreiber
Head of Division (Substance Abuse), Federal Ministry of Health, Bonn

Professor Dr V Navaratnam

Centre for Drug Research, Universiti Sians Malaysia, Pulau Pinang

Professor Andrey Vrublevsky
Director-General, State Research Centre on Addictions, Moscow

Ambassador Cresencio s Arcos Jr
Principal Deputy Assistant Secretary, Bureau of International Narcotics Matters, Department of State

Professor Peter Edelman
Counselor to the Secretary of Health and Human Services (on leave from Georgetown University Law Center)

Dr Enoch Gordis
Director, National Institute on Alcohol Abuse and Alcoholism

The Hon Sterling Johnson Jr
United States District Judge, Eastern District of New York

Dr Herbert D Kleber
Executive Vice President and Medical Director, Center on Addiction and Substance Abuse, Columbia University

Mr John W Lee
Attaché (Drug Enforcement Agency), United States Embassy, London

Mr Jeffrey Merrill
Vice President and Director, Division of Policy Research and Analysis, Center on Addiction and Substance Abuse (CASA), Columbia

Dr Mitchell S Rosenthal
President, Phoenix House (the largest US private, non-profit substance abuse service agency)

Mr Jerry Sanders
San Diego Police Department: Chief of Police

Dr Steven A Schroeder
President, Robert Wood Johnson Foundation, Princeton, NJ

Ms Abigail Trafford
Health Editor and Editor, weekly Health section, The Washington Post

Dr Sidney M Wolfe
Director, Public Citizen Health Research Group Washington DC

Dr Neil Collishaw
Member, Tobacco or Health Programme, World Health Organisation