Salud mental 2020;

ISSN: 0185-3325

DOI: 10.17711/SM.0185-3325.2020.020

Alcohol and drugs

Guillermina Natera Rey1

1 Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz.

Correspondence: Guillermina Natera Rey Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz. Calzada México Xochimilco 101, Col. San Lorenzo Huipulco, 14370, Tlalpan, Mexico City, Mexico. Email:

In 2018, the WHO released the SAFER initiative, designed to reinforce alcohol availability restrictions, advance and expand measures to regulate driving while under the influence, facilitate prevention through the timely detection of alcohol abuse, have health professionals available to support brief interventions that have proven beneficial for prevention, offer affordable, appropriate treatment, enforce comprehensive bans or restrictions on alcohol advertising, sponsorship and promotion and lastly increase alcohol prices through excise duties and pricing policies. If governments and civil society implement this global, intersectoral, integral initiative, they will reduce alcohol-abuse related problems. Achievements in each area will benefit the entire community.

Progress has been made in the overall treatment of this issue, and despite the limited knowledge available on its diagnosis, treatment, and prevention, this does not mean that the problem is insoluble. The health sector must assign sufficient resources, however, acknowledging that this is an inexorable health problem.

Reliable information must be distributed on the risks of alcohol and drug abuse in a wide range of communities and its impact on users, their families, society and work. These processes are associated with social determinants, such as economic, educational, and health, precariousness, and the cultural that force individuals to a humdrum violent life in which they take out their frustrations with those closest to them.

Every year, there are three million deaths worldwide due to harmful alcohol use, accounting for 5.3% of all deaths. Approximately 35 million substance users have a substance use disorder. Harmful alcohol consumption is a causal factor in over 200 diseases and disorders, with 5.1% percent of the global burden of disease and injury being attributable to alcohol consumption, calculated in terms of disability-adjusted life expectancy (DALE) (WHO, 2018). Among those aged between 20 and 39, 13.5% of deaths are attributable to alcohol use, due, among other things to traffic accidents, physical and mental comorbidities, suicide and interpersonal violence. In the Region of the Americas, per capita consumption in liters of pure alcohol in people over the age of 15 was 7.1 liters for women and 20 liters for men, equivalent to 32.8 gr/day (WHO, 2019).

In Mexico (Villatoro et al., 2017), 19.8% (16.8 million) of people drink excessively, corresponding to five or more drinks for men and four or more for women on one occasion in the past year. Alcohol dependence criteria are met by 2.2% of the population (3.9% of men and 0.6% of women). Among junior and senior high school students (Villatoro et al., 2015), 14.5% reported excess alcohol use in the past month (15.7% of men and 13.3% of women).

One of the requirements of the rehabilitation process is the ability to stop drinking, yet deteriorating use is a reflection of the severity of the problem that prevents a person from being in control of their drinking, as documented in one of the articles included in this issue. The study of adolescents and their impulsiveness, which is also included in this issue, although it does not refer to substance use, highlights an important aspect to consider, namely that adolescents with these characteristics have impaired cognition and affectivity, making them susceptible to substance use, which they cannot possibly control.

Regarding drugs, UNODC (2019) reports that the number of people who use drugs increased by 30% from 2009 to 2017. In 2017, 5.5% (271 million) of the world population aged between 15 and 64 had taken drugs in the past year. Marijuana is the most popular illegal drug worldwide, with 188 million people using it in 2017, while 53.4 million people used opioids in the past year, 56% more than in 2016. Overall, North America is the subregion with the highest annual prevalence of opioid use (4.0%).

Between 1991 and 2014 in Mexico, lifetime drug use among junior and senior high school students doubled from 8.2% to 17.2%. Marijuana use increased sevenfold and cocaine use fivefold from 0.7% to 3.3%. Elementary school students reported an average age of onset of drug use of 13.6 years. The main illegal drug they have tried is marijuana (106,065 students - 2.3%), followed by inhalants (83,008 - 1.8%). In the case of high school students, the most commonly used drug is marijuana 10.6%), followed by inhalants (5.8%), cocaine (3.3%), methamphetamines (2%) and heroin (0.9%). (Villatoro et al., 2015). Drug use has a significant impact on the economy, families, communities, and society, regarding the future opportunities of young people.

As for treatment, according to Harris et al. (2019), heavy drug users are also extremely likely to display psychiatric comorbidity. A recent publication mentions that seeking treatment for this condition doubled the likelihood of also receiving treatment for substance use. Internationally, a comparison of prevalence of use and the diagnosis of substance use disorder in 25 countries found that lifetime use is 24.8%, while lifetime prevalence of substance use disorders according to DSM-IV criteria is 3.5% (2.2% for substance abuse and 1.2% for substance dependence). This prevalence increases proportionally in higher income countries (Degenhardt et al., 2019). It is essential to reinforce addiction treatment systems to prevent dependents from only seeking treatment after they have a psychiatric comorbidity.

Tobacco use is a public health problem associated with an array of diseases that become fatal, such as various cancers. The age of onset of cigarette smoking is 16.9 years (16.4 for men and 18.1 for women). The average number of cigarettes smoked per day increased from 6.5 in 2011 to 7.3 in 2015 (from 6.8 to 7.7 cigarettes per day in men and from 5.6 to 6.3 cigarettes per day in women). A total of 56.1% of current smokers have attempted to quit in the past 12 months (60.7% of women and 54.3% of men). A statistically significant decrease in household exposure to tobacco smoke was observed from 18% (7.4 million) in 2011 to 13.3% (5.5 million) in 2016 (Reynales-Shigematsu et al., 2017), which has been attributed to smoking restrictions in closed public places. Most of the time, this policy is respected, with non-smokers tending to enforce the rule of not allowing smoking at home. Adolescence is considered a risky age for the onset of use of substances such as tobacco, since many cognitive and affective areas are still developing. This is also true, however, of the elderly population with nicotine dependence, which is associated with cognitive impairment in the executive domain. This knowledge should be used to warn this population that their situation may deteriorate since the brain, like the rest of the body, changes as a person grows older. Mild cognitive impairment may increase, as borne out by the text by Aguiar Assis in this issue.

Other methodologies inform us of the dynamics and the role played by use in the lives of users not included in these statistics because they have no fixed abode or are in prison, who belong to the world of the marginalized. They experience social suffering caused by adversity to the detriment of a sense of purpose in their lives. This is a field that requires specialized treatment and support centers that meet their needs and deal with their precariousness, as can be seen in the review of inhalants (Medina-Mora et al., 2014) and in recent studies on crack (Natera et al., 2019). In these populations, research shows that no treatment has been fully successful. Those who have sought it and found it useful have temporarily stopped using, which is beneficial for their health. However, they are continuously exposed to various alternatives, which shows just how difficult it is to stop using crack and inhalants. It is essential to engage in a conversation with other disciplines such as economics, sociology and anthropology, for example, on the concept of the body, for which metaphors are often used. However, little has been done on the scientific construction of this area.

Many issues remain to be addressed in terms of populations such as migrants, indigenous populations where excessive alcohol use, amounting to 10.1% in 2008, is regarded as natural and part of the culture. This has consequences for the family, particularly women and children, for whom the lack of care is particularly severe. In these settings, violent acts against women and children are common, the suffering of victims is tolerated and the victimizer is justified because of the belief that because he is a man he has to drink “as if they followed rules that tell them what to do and how to do it,” relieving them of any responsibility of having to limit their use, or teaching their children to delay the age of onset. They feel that the latter is not an activity that concerns them (Natera-Rey, 2017).

Given the harm alcohol use causes others, treatment is required since alcohol use negatively impacts mental and physical health, the family economy and interpersonal relationships, encouraging violence. It is essential to help families cope with this situation, for which they are not necessarily responsible (Natera et al., 2009).

I do not wish to overlook the fact that there are still fuzzy moral concepts, by which I do not mean the beliefs of users but of rather those who serve them and of the general population, who judge them. This prevents those who need it from seeking treatment or means that the latter is unsuccessful due to the lack of legitimate empathy from the health professional, who also stigmatizes them. Heavy alcohol or drug users, especially those with limited resources, are people who have been extremely vulnerable and attacked due to the context. They experience a loss of identity and social inequality and are unemployed or underemployed, with no chance of escaping from this situation.

It is impossible during the period we are all experiencing to avoid reflecting on the effect of worldwide confinement due to COVID 19, and substance use. Fortunately, now as never before, the health sector has emphasized and developed care for mental health and substance use, which may involve confinement, restrictions on physical and social distancing and the unfortunate possibility of family violence. Affecting human ties causes frustrations, feelings of anxiety, depression and anguish, which could have an impact on the increase in alcohol and drug use. Accordingly, some states declared prohibition while others restricted the sale of alcohol. Beer production was suspended during the most critical period of the epidemic for being an unnecessary activity. Due to the lack of available alcohol and the reduction of people’s purchasing power, methanol began to circulate with deadly consequences, which have not yet been fully quantified yet which, according to the news, claimed 300 victims. Bootleg alcohol, which has always existed, particularly during periods of scarcity, is an issue that has rarely been studied yet must be explored due to the amount of adulterated drinks that are continuously created.

A team of researchers from the Institute undertook a timely survey to measure variations in alcohol use before and during confinement (Tiburcio-Sainz et al., 2020). Preliminary analyses show that 23.3% of respondents began using substances, while 5.5% started using alcohol. Men doubled their daily alcohol use, from 8.6% to 16.6%, while women tripled it from 4.1% to 15%. This does not refer to the amount used, the reasons for which we will know later, but the stress caused by uncertainty, anxiety and frustration undoubtedly played a role. Restricting use in the private sphere necessarily affects the public sphere, raising the question of whether alcohol-related accidents and street violence declined.

Is there an answer to the problem alcohol and drug use that claims so many lives? Are primary relationships and upbringing part of the solution? Does having emotionally close parents or at least a mother from birth help? What can be done if the mother has experienced vulnerability? Does school provide a second chance? Does this require understanding the psychosocial and cultural context? This is not an easy issue to solve. The state must commit to controlling availability and addressing social determinants, so that the lack of state intervention does not prevent the population from envisaging alternatives.

Finally, figures yield valuable information but still fail to provide an in-depth understanding of drug related societal problems. As Han (2015) says “They can lull us into a false sense of security and believe that we grasp the situation; it is a form of atomization of life that leads to the atomization of identity”. His apt remarks underline the fact that there is an enormous need to expand integrated research in the vast field of health.


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