Substance Use, Substance Abuse and Injuries: An Overview

Robert Mann, PhD, Senior Scientist, Social Prevention and Health Policy Research, Centre for Addiction and Mental Health Director, Collaborative Program in Addiction Studies and Associate Professor, Dalla Lana School of Public Health, University of Toronto 1

Overview of this presentation

• Injury as a major health problem in Canada • Epidemiology of alcohol and drug use • Contribution of alcohol and drugs to injury risk • Prevention paradox • Prevention approaches: evidence 2

Injury as a major health problem in Canada

• Injuries are the leading cause of death up to age 44 in Ontario • In 1989, injuries were the second leading cause of Potential Years of Life Lost in Canada • Motor vehicle collisions by themselves are the leading cause of death for children and adolescents 3

The Economic Burden of Unintentional Injury in Canada, 1998 Source: Smartrisk, 1999 The Economic Burden of Unintentional Injury in Ontario, 1999 Source: Smartrisk, 2006 4

Epidemiology of alcohol and drug use in Canada

• Alcohol and drugs are widely used in Canada • Use differs substantially by type of substance, region/province, age group and other demographic factors 5

Source: Canadian Addiction Survey, 2005 6

Source: Canadian Addiction Survey, 2005 7

Percentage Reporting Lifetime and Past Year Drug Use, 2007 OSDUHS (Grades 7-12) Alcohol Cannabis Opioid Pain Relievers Cigarettes Solvents Stimulants Other Hallucinogens OTC Sleeping Medication Ecstasy Cocaine Jimson Weed Glue Tranquillizers OxyContin LSD Methamphetamine Ketamine ADHD Drugs Crack Heroin Ice (Crystal Meth) PCP Rohypnol GHB 64.7% 29.9% 23.1% 28.3% 9.4% 7.0% 7.0% 12.2% 4.5% 4.3% 3.4% 5.3% 2.2% 2.2% 2.2% 2.0% 1.9% 1.7% 1.5% 1.2% 1.1% 1.2% 0.6% 0.6% 80 60 40 20 0 20 40 60 % Lifetime Use % Past Year Use 80 61.2% 25.6% 20.6% 11.9% 5.8% 5.7% 5.5% 4.0% 3.5% 3.4% 2.6% 2.5% 1.8% 1.8% 1.6% 1.4% 1.1% 1.0% 1.0% 0.9% 0.8% 0.7% 0.6% 0.5% 8

Contribution of alcohol and drug use to injury risk

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How do you measure the effects of a substance on injury risk?

Relative Risk (RR) =

Incidence of substance in those with injury outcome Incidence in those without outcome

-or, it is the risk of an outcome or event (e.g., an injury) relative to exposure to a risk factor (e.g., substance use, or a specific amount of substance use) 10

• Measuring alcohol and drugs in those with an injury outcome is relatively simple • Measuring drugs, and to a lesser extent alcohol, in those without an injury outcome, i.e., the control sample, is typically much more difficult 11

Survey…

• If someone stopped you by the side of the road and asked you for a blood sample, would you provide one?

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Relative Risk of Fatal Collision Involvement Relative to Blood Alcohol Content (BAC) 13

Effects of alcohol, cannabis and cocaine on fatal collision risk – Quebec data, Dussault et al, 2002.

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Prevention Paradox

• Alcohol and drug abuse and dependence, although serious, are relatively rare in the population • It is clear that those suffering from abuse and dependence are at increased risk of injury • However, most of the problems caused by alcohol (and possibly illicit drugs too) are caused by those of us who are ‘social’ or occasional users • One simple example comes from drinking driving – the large majority of impaired drivers who are caught by police, or involved in collisions, do not meet the criteria for alcohol dependence or abuse 17

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Comparison of injury fatality rates, current drinkers vs. nondrinkers, Chen, Baker and Li, AAP, 2005 19

Prevention Approaches

• How can we prevent injuries related to alcohol and drug use?

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Some prevention approaches are popular but aren’t very effective...

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Some prevention approaches are effective but may not be popular… 22

The role of education 23

Factors influencing drinking driving fatalities in Ontario: 1962-1995. From Asbridge et al, Journal of Studies on Alcohol, 65, 450-459.

Drinking Driver Fatalities and Per Capita Alcohol Consumption in Ontario, 1962-96

12 10 8 2 0 6 4

Year

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Factors influencing alcohol-related driver fatalities: • Alcohol consumption – 1 litre increase in per capita consumption increases drinking driver fatalities between 8 –14% 25

Factors influencing alcohol-related driver fatalities: • Breathalyser law – introduction of the original legal limit reduced drinking driver fatality rates by 18% 26

Factors influencing alcohol-related driver fatalities: • Formation of MADD Canada – reduces drinking driver fatality rates between 19 – 23% 27

Factors influencing alcohol-related driver fatality rates: Summary

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Alcohol availability and consumption

– 1 litre increase in per capita consumption increases drinking driver fatalities between 8 –14%

Legal initiatives

– introduction of the original breathalyzer law reduced drinking driver fatality rates by 18%

Social action

- Formation of MADD Canada reduces drinking driver fatality rates between 19 – 23% 28

Policies can have negative effects!

• We saw that alcohol policies can affect drinking driving rates, and they also can affect rates of other alcohol-related problems too • Suicide is very strongly related to alcohol consumption at the individual and the population level 29

Policies can have negative effects!

• There has been a lot of pressure on governments by the private sector to deregulate alcohol retailing over the past several decades • The Province of Alberta, in a series of events, turned the retail sale of alcohol over to the private sector in the 1970’s-80s • We evaluated the effects of this deregulation on male and female suicide mortality rates in the province with time series analyses 30

The effects of privatization in Alberta

30 25 20 15 10 35 40 45 50 55 60 65 70 75 80 85 90 95 male suicide mortality rates in Alberta male suicide mortality rates in Ontario 31

The effects of privatization of alcohol sales in Alberta

30 25 20 15 10 5 0 76 78 80 82 84 86 88 90 92 94 96 98 Male suicide mortality rates in Ontario Female suicide mortality rates in Ontario Male suicide mortality rates in Alberta Female suicide mortality rates in Alberta 32

Concluding Comments

• Alcohol and illicit drugs are leading contributors to the burden of injury in Ontario and Canada • The contribution of alcohol is substantially greater than any illicit drug • The majority of these injuries may involve individuals who would not be considered as having a clinically defined substance dependence or substance abuse problem 33

Concluding Comments (cont’d)

• With regard to alcohol-related injuries, policies on the economic, legal and physical availability of alcohol are the most powerful determinants of population injury rates • As well, other legal and societal factors can exert important influences on these rates • Thus, while alcohol and drug injury rates are unacceptably high, research identifies effective means to reduce those problems 34