Drug addiction has also changed from a social standpoint, and is now viewed as a «normal» situation removed from marginality and delinquency. The view of the junkie as a jobless outlaw living in poverty and suffering from associated infectious diseases has been superseded, although not entirely forgotten. In its place has emerged a new type of addict: the younger, weekend user who consumes multiple drugs and is socially well adapted (at least initially), and who has fewer associated infectious diseases. However, because of variations in the types of substance consumed, their affordability, and the duration of drug use, these persons form a heterogeneous group in which social stereotypes have blurred. Some dependent persons are extremely marginalized, increasingly ostracized and condemned to social euthanasia, whereas others are part of a distinguished crowd living the superficial life of a socialite addict.
With regard to health care, we are facing a situation marked by transition in which the epidemic spread of hepatitis C, hepatitis B, HIV infection and tuberculosis in persons dependent on opiate drugs has largely been contained. Current alarm originates not from the health service, but from rising AIDS-associated morbidity and mortality, which has triggered the search for «clean» drugs that avoid needle sharing and intravenous injection. The study in this issue by Navarro Cañada et al reports alarming figures for the prevalence of HIV and hepatitis C infection, the consequences of which will be felt in the middle and long term. The recurrent but largely neglected tuberculosis problem merits particular attention. In addition, we should realize that prevalence studies always miss the most severely marginalized group of opiate dependent persons who constitute an «unassailable stronghold» that social and health services fail to reach.
As in other levels of health care, the involvement of primary care in providing help for drug dependence has been inadequate, and it is only in recent times that there has been a firm commitment on the part of regional health systems to do their part in caring for these patients. The response to this problem has historically been to outsource care for drug dependent persons. The causes of this neglect have included:
– Non-appreciation of drug dependent individuals as patients
– Inadequate involvement of the health system in care for drug dependent persons until they come to be considered infectious disease patients. This has favored the appearance of poorly coordinated parallel systems.
– Lack of flexibility (based on a cure-oriented mentality) in considering detoxification and quitting the only possible treatment for drug dependence.
In the near future we may hope to see health professionals commit to three specific goals: accepting heterogeneity among drug dependent individuals, diversifying therapeutic strategies, and devoting greater resources to health care and coordination between programs.
Drug dependent persons differ in the number of substances they use (one or more than one), the type of consumption, and their attitude toward drug use. Users of illegal drugs are always one step ahead of health care professionals in terms of knowledge about the substances they consume, and this obliges us to constantly update our own knowledge. Although we have traditionally associated drug dependence with opiates and their derivatives, the use of (for example) synthetic drugs is a reality, and their consumption is increasing as reflected in the changing patterns of drug use in the last decade. These drugs are associated with other substances, a feature that increases the risk of acute intoxication and makes treatment difficult. Antidotes are not available for some synthetic drugs, and there is already evidence of irreversible neurotoxic damage whose middle and long term effects remain unknown. Therapeutic options need to be diversified in accordance with the health needs and the wishes of drug dependent patients. As the article by Navarro Cañada et al points out, activities aimed at damage reduction (e.g., needle exchange and heroin prescriptions) are just as legitimate as high-commitment, drug-free programs. Three degrees of intervention have been established depending on the level of commitment required from the drug dependent patient:
– Low: administration of opioid agonists and medical supervision.
– Moderate: As in low-commitment programs but with social and educational support in the form of workshops and resources for economic and judicial rehabilitation.
– High: As above but with psychotherapeutic support in the form of educational therapy and treatment for psychological disorders.
Another issue centers on cost effectiveness evaluations for each type of intervention. Any option that leads to improvements in the health, social situation or social cohesion and integration of drug dependent persons and their families is acceptable.
Increased efforts on the part of the health care system, and particularly primary care services, are indispensable. Drug dependent persons should be considered persons who are ill, and therefore as patients who can benefit from preventive interventions or specific treatments. In addition, they should be considered as persons who have asked for help. No other type of user has the potential to benefit more from the features intrinsic to primary care: access, integral care, continuity and a biopsychosocial approach to care. Thus the commitment of primary care teams needs to go beyond mere gestures.
Naturally there will be situations for which there is no appropriate treatment. Such patients should receive care that maximizes their chances of staying alive and enjoying an acceptable quality of life. This, in fact, is the same approach as is desirable for patients with any chronic illness.
When this approach is used for all patients with chronic health problems, we will have achieved the standardization that Navarro Cañadas and colleagues urge us to aspire to, and that is surely within our reach.
General references
Barrio G, Bravo MJ, De la Fuente L. Consumo de drogas en España: hacia una diversificación de los patrones de consumo y los problemas asociados. Enf Emergencias 2000;2:88-102.
Cabrera J. Ante un cambio, una respuesta: drogas de síntesis en España. FMC 2002;9:514-23.
Claramonte X, Nogué S, Monsalve C. ¿Nuevas drogas de diseño?, ¿nuevas drogas de síntesis? FMC 2002;9:323-34.
Puigdolers E, Cots F, Brugal MT,Torralba L, Domingo-Salvany A. Programas de mantenimiento de metadona con servicios auxiliares: un estudio de coste efectividad. Gaceta Sanitaria 2003; 17:123-30.
