Global public health objectives need to address substance abuse in developing countries

Substance addiction is a large and growing problem for developing societies. A new study that surveyed reports on modalities for treating addiction and their effectiveness in the developing world calls on policymakers to use this information to support the design of programs that meet known population needs. The study also encourages looking at ways to adapt the Alcoholics Anonymous (AA) model to fit different cultural norms. The findings are published in the Annals of Global Health.

The World Health Organization has indicated that alcohol and illicit drugs pose multifaceted dangers to millions of people, from the psychological damage of addiction to a range of physical health problems. A recent report highlights the need to address a broad spectrum of mental health issues, including substance use disorder (SUD), in order to achieve global public health objectives. This led to a call by policymakers to improve access to treatment for SUD in developing nations. Resources to address SUD in the developing world are severely limited, however, and some 34% of low- and middle-income nations have not yet developed a substance use policy.

"It is difficult to assess the extent of SUD. This is, in part, because of the limited capacity of these countries' governments to conduct national surveys, but it is also due to underinvestment in mental health care in these countries and to underutilization of mental health services in resource-poor settings," says Craig L. Katz, MD, of the Departments of Psychiatry and Medical Education, Icahn School of Medicine at Mount Sinai, New York. "The poorest nations allocate the smallest portion of their already strained public budgets to mental health."

These challenges provided the impetus for a review of the current literature on SUD treatment in the developing world, with the aim of informing future program development and research. Investigator Jasleen Salwan, MD-MPH Candidate, Icahn School of Medicine at Mount Sinai, identified 30 relevant studies published in 1994 or later. The treatment methods included pharmacological approaches, intervention studies to prevent, detect, and reduce harm, the AA-style or Minnesota/Therapeutic Community Model, and multimodal approaches. Two studies compared treatment approaches between two different countries: China with Germany, and El Salvador with Puerto Rico. Other studies looked at access to treatment and resources for providers.

"An important finding is that what works well in one setting may not work well in another," notes Salwan. "Existing research highlights the need to provide secular alternatives to the dominant faith-based treatment approach in El Salvador, to improve access to harm reduction programs for crack cocaine users in Brazil, and to ensure the availability of safe havens for recovering addicts in China to avoid being treated as criminals."

Although comprehensive overviews of treatment models were markedly absent from the literature surveyed, the studies highlight specific areas of need within developing countries, building on existing awareness of general barriers to treatment in those countries. "Policymakers can use this information to design programs that meet known population needs and avoid providing extraneous services," adds Katz.

The investigators recommend that future research should blend inquiry with practice. "Although further investigation is clearly needed in order to better understand the specific needs of developing world populations, assisting those populations should be a primary goal of all endeavors. Conversely, service-oriented planning for addressing SUD in the developing world should be done with a mandate to study the effect of interventions in order to establish program efficacy," comments Katz.

Finally, the authors suggest further evaluation of the AA model. There were mixed results in the literature regarding implementation of the AA model in developing countries that invite further exploration, ideally in more systematic and comprehensive ways.

"Although there is reason to question whether a model that relies so heavily on self-revelation and sharing will work in all places due to cultural and privacy concerns, the AA model has great appeal for developing countries that lack financial resources to create more comprehensive substance use treatment programs. Finding successful ways to adapt the AA model in different settings therefore may not only be a cost-effective way to scale up services, but also help foster a culture of awareness of substance use issues that can in turn spark greater investment in medicalized resources beyond what AA can offer," Katz concludes.