Addiction, health and treatment interventions J. Rehm Social and Epidemiological Research (SER) Department, Centre for Addiction and Mental Health, Toronto, Canada Dalla Lana School of Public Health, University of Toronto (UofT), Canada Dept. of Psychiatry, Faculty of Medicine, UofT, Canada PAHO/WHO Collaborating Centre for Mental Health & Addiction (G. Gmel, M. Roerecke, M. Rylett, K.D. Shield) Epidemiological Research Unit, Technische Universität Dresden, Klinische Psychologie & Psychotherapie, Dresden, Germany
Addictions covered Alcohol Drugs and non-medical use of prescription drugs Not covered: Gambling Gaming/internet
Topics covered Prevalence Burden of SUD as a disease Burden associated with alcohol and drugs as risk factors Treatment What would happen if (the example of alcohol)?
Prevalence of substance use disorders PREVALENCE
Global prevalence for different drug use disorders Age standardized prevalence of illicit dependence, 2010 (GBD, Degenhardt et al., 2014) Cannabis Amphetamines Cocaine Opioids % 95% CI % 95% CI % 95% CI % 95% CI Females 0.14 (0.12-0.16) 0.18 (0.16-0.22) 0.06 (0.05-0.07) 0.14 (0.12-0.16) Males 0.23 (0.20-0.27) 0.31 (0.27-0.37) 0.14 (0.12-0.16) 0.31 (0.27-0.35) Overall 0.19 (0.17-0.21) 0.25 (0.22-0.28) 0.10 (0.09-0.11) 0.22 (0.20-0.25)
GBD numbers for alcohol are an underestimate -> WHO Global status report 2014
Distribution of AUD around the world (GSRAH) 0.0% 2.0% 4.6% 7.4% 11.4% 18.9% 30.1% 0.003 0.02 0.05 0.07 0.1 0.2 0.3
Burden of AUD as disease and risk factor BURDEN
Alcohol use disorders DALYs per 100,000 people, Age standardized, Both sexes, 2010 <71.4 71.4 93.8 93.8 118.6 118.6 184.4 184.4 239.2 239.2 290.9 290.9 339 339 389.8 389.8 525.6 >525.6 ATG VCT BRB COM W Africa DMA Caribbean LCA GRD TTO MDV TLS MUS SYC MHL KIR SLB FSM VUT WSM FJI TON E Med. MLT Persian Gulf SGP Balkan Peninsula
Drug use disorders DALYs per 100,000 people, Age standardized, Both sexes, 2010 <189.1 189.1 231.3 231.3 251.8 251.8 275.5 275.5 303.2 303.2 330.7 330.7 374 374 428.2 428.2 528.7 >528.7 ATG VCT BRB COM W Africa DMA Caribbean LCA GRD TTO MDV TLS MUS SYC MHL KIR SLB FSM VUT WSM FJI TON E Med. MLT Persian Gulf SGP Balkan Peninsula
What is the health burden of illicit drug disorders? Illicit drug dependence directly accounted for 20 0 million DALYs (95% UI 15 3 25 4 million) in 2010, accounting for 0 8% (0 6 1 0) of global all-cause DALYs. Opioid dependence was the largest contributor to the direct burden of DALYs (9 2 million, 95% UI 7 1 11 4). The proportion of all-cause DALYs attributed to drug dependence was 20 times higher in some regions than others, with an increased proportion of burden in countries with the highest incomes. Countries with the highest rate of burden (>650 DALYs per 100 000 population) included the USA, UK, Russia and Australia. Main diseases associated: - overdose - injecting drug use as a risk factor for HIV or hepatitis C - suicide
2010 GBD in % of all DALYs
GBD Men 2010
GBD women
Percentage of deaths How many deaths are attributable to alcohol dependence? 25 20 15 10 5 0 Alcohol-attributable Alcohol-attributable (net) Heavy drinking Alcohol dependence Men 16,1% 13,9% 11,1% 10,7% Women 8,5% 7,7% 5,3% 3,7% Total 13,6% 11,8% Men Women Total 9,2% 8,4% Rehm et al Eur Neuropsychopharm 2013
While burden is high, treatment rates are low TREATMENT
Treatment of mental disorders globally Kohn et al., 2004
Treatment in Europe ESEMED study Alonso et al., 2004
Treatment in the US (NSDUH 2012) Treatment received: pain relievers (973 k), marihuana (958 k), cocaine (658 k), heroin (450 k), mainly in self-help groups! Estimated dependence/abuse of illicit drugs: 7.3 million Specifically: marihuana (4,304 k), pain relievers (2,056 k), cocaine (1,119 k), heroin (467 k) Relatively low treatment rate except for heroin, but much higher than for alcohol use disorders!
And what would happen if we started to treat.. The example of alcohol
Simulations: what burden could be prevented by increasing treatment rates in the EU? Most conservative estimate: mortality burden! Approach bottom up: estimates for each country and then aggregated Approach was selected as current treatment rates are lowest for all mental disorders: under 10% in the EU! Effectiveness of treatment was based on Cochrane reviews Five scenarios selected Rehm et al., 2012 Alcohol consumption, alcohol dependence, and attributable burden of disease
Number of deaths avoided over one year in men by treatment for AD in the EU in 2004 by five different treatment modalities (up to 13% of all alcohol-attributable deaths) Rehm et al., 2012 Alcohol consumption, alcohol dependence, and attributable burden of disease
Number of deaths avoided over one year in women by treatment for AD in the EU in 2004 by five different treatment modalities (up to 9% of all alcohol-attributable deaths) Rehm et al., 2012 Alcohol consumption, alcohol dependence, and attributable burden of disease
The link to heavy drinking Rehm et al., 2014 Alc Alc (rejoinder)
Another model But does it reflect reality? Roerecke et al., 2013, J. Clin. Psychiatry
Relative risk for mortality Relative risk for mortality How could alcohol dependence treatment be successful? It reduces level of consumption either to abstinence or by sizable reduction of heavy drinking Typical risk curve for alcohol (e.g., liver cirrhosis mortality) Relative gain in risk for mortality of reducing by three drinks/day for different levels of drinking Drinks per day Roerecke & Rehm, 2013 Alc.Alc Drinks per day
Reduced drinking including abstinence to continued heavy drinking (RR: 0.41 after 8.8 years on average) Risk of heavy drinkers in red
Other results of the meta-analyses Reduction of drinking without abstinence was also significantly better than continued heavy drinking Abstinence was associated with the lowest mortality rate Conclusion: reducing drinking helps in any case, the more you reduce, the better
SUD are prevalent, cause a lot of burden which could be reduced, if treatment is initiated which reduces consumption CONCLUSION