Zdrav Var 2006; 45: 7-8
7
SLOVENIA, PUBLIC HEALTH AND THE PROBLEMS OF ADDICTION
Thomas F. Babor1
Slovenia is a small country that is moving rapidly toward full integration with the European Union and the global economy. With a long tradition of familiarity with alcohol and tobacco, Slovenia is no stranger to the public health problems associated with the use of dependence-producing substances. As the papers published in this issue of the Slovenian Public Health Journal show, the economic and political changes taking place in your country are creating new challenges for public health practitioners and policymakers. In this brief introduction, I would like to offer several observations on the role of public health in the development of an organized national response to the problems of addiction, and suggest some new opportunities for public health research and prevention policy.
First, what can we learn from these papers about the problems of addiction in contemporary Slovenia? One lesson is that Slovenia is experiencing the same kinds of problems as other countries undergoing rapid economic development. This is in part a result of applying new epidemiological tools, such as school surveys and the monitoring of admissions to alcohol and drug treatment programs. School surveys are one of the most useful ways to describe the extent of substance use. As indicated by survey research in the Gorenjska region, the prevalence of alcohol intoxication, tobacco use and cannabis smoking is comparable to that found in other European countries. This is a cause for concern and speaks to the need for systematic planning of prevention measures. Other papers in this issue identify the potential risks of the hallucinogen Ecstasy, which is especially popular with young adults who frequent dance clubs in urban areas, and the recognition among Slovenian psychiatrists that pathological gambling is a growing problem. It is clear from these papers that there is an important need in Slovenia to expand epidemiological surveillance programs so that an organized response can be formulated to the problems of substance use and addiction.
A second reflection is prompted by the following question: What are the most appropriate responses to the problems of addiction in Slovenia? As the emerging economies of Europe struggle to find ways to deal with the crime, psychiatric disorders, medical conditions,
Editorial
and social problems associated with psychoactive substances, the first response is often to expand treatment programs, as suggested by several of the papers in this volume dealing with methadone maintenance, gambling, and alcoholism. Another response is to develop school-based prevention programs. A third response is to increase penalties for the use and distribution of drugs such as Ecstasy, heroin and cannabis. Based on what has been learned from research on alcohol (1) and the illegal psychoactive substances (2), these responses, while important, should only be considered an initial step in the development of a more comprehensive public health approach to the problems of substance use and addiction. Such an approach would begin with the consideration of more effective, evidence-based measures that focus on populations as well as individuals. In the area of alcohol abuse, for example, the most effective measures are higher alcohol taxes, procedures to deter drunk driving, such as random breath tests, and restrictions on the availability of alcohol (1, 3). Availability restrictions include higher age limits on the purchase of alcohol and controls on the times, locations and days of sale. My final observation concerns the role of research in the development of an effective public health response. Perhaps the most encouraging thing about the papers written for this volume is the extent to which empirical research is starting to focus on the problems of addiction in Slovenia. When addictive substances begin to be recognized as a health issue, the first approach is often to use the methods of clinical epidemiology to describe the populations affected and the problems they are experiencing. Articles in this volume dealing with clients in alcoholism and methadone maintenance provide valuable information about the effectiveness of treatment and predictors of treatment response. This research is also useful in the development of a cadre of clinical scientists who are able to serve as experts when questions about public policy inevitably arise. But clinical research is just the beginning of an organized public health approach. Interdisciplinary collaboration is often required among social, behavioral and medical researchers in order to set up surveillance systems, health services research, prevention planning and policy
ąDepartment of Community Medicine, University of Connecticut, School of Medicine, Farmington, CT, USA Correspondence to: e-mail: Babor@nso.uchc.edu
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analysis. The papers in this volume represent an important first step in building the necessary expertise, data bases, research findings and program evaluations that will prepare Slovenia for the public health challenges ahead.
References
1.   Babor T, Caetano R, Casswell S, Edwards G, Giesbrecht N, Graham K et al. Alcohol: No Ordinary Commodity: Research and Public Policy. Oxford, UK: Oxford University Press, 2003.
2.   MacCoun RJ, Reuter P. Drug War Heresies. Learning from other vices, times and places. New York: Cambridge University Press, 2001.
3.   World Health Organization. Global Status Report: Alcohol Policy. Geneva: World Health Organization, 2004.
Zdrav Var 2006; 45: 9-10
9
SLOVENIJA, JAVNO ZDRAVJE IN PROBLEMI ODVISNOSTI
Thomas F. Babor1
Uvodnik
Slovenija je majhna dr‘ava, ki hitro napreduje na poti k polni integraciji v Evropsko unijo in svetovno gospodarstvo. Zaradi dolge tradicije uporabe tobaka in alkohola Sloveniji niso neznani zdravstveni problemi, povezani z u‘ivanjem substanc, ki vodijo v odvisnost. Prispevki, objavljeni v tej {tevilki revije, govorijo o tem, da dru‘bene in politi~ne spremembe v dr‘avi prina{ajo nove izzive zaposlenim in politikom na podro~ju javnega zdravstva. V tem kratkem uvodu bi rad podal nekaj misli o vlogi, ki jo ima javno zdravstvo pri oblikovanju organiziranih nacionalnih ukrepov za re{evanje vpra{anj zasvojenosti. Nakazal bi tudi rad nekatere nove mo‘nosti za javnozdravstvene raziskave in preventivno dejavnost.
Kaj lahko izvemo iz tu objavljenih ~lankov o vpra{anjih zasvojenosti v dana{nji Sloveniji? Najprej to, da se Slovenija soo~a s prav takimi problemi kot vse druge dr‘ave v fazi hitrega gospodarskega razvoja. To je delno posledica uporabe novih epidemiolo{kih instrumentov, kot so to ankete v {olah in spremljanje vstopa alkoholikov in odvisnikov od drog v programe zdravljenja. Raziskave, ki so jih opravili na podro~ju Gorenjske, so pokazale, da so tam opijanje z alkoholom, kajenje cigaret in uporaba marihuane raz{irjeni v podobni meri kot v drugih evropskih dr‘avah. Ti izsledki so zaskrbljujo~i in ka‘ejo na potrebo po sistemati~nem na~rtovanju preventivnih ukrepov. ^lanki v reviji govore tudi o potencialni nevarnosti halucinogena ekstazija, ki je popularen predvsem med mladimi v plesnih klubih v mestnih sredi{~ih ter o zaskrbljenosti slovenskih psihiatrov zaradi nara{~ajo~ega {tevila zasvojenih z igrami na sre~o. Ti prispevki jasno ka‘ejo, da je treba v Sloveniji raz{iriti programe epidemiolo{kega nadzora, da bi na tej osnovi lahko organizirano ukrepali proti u‘ivanju drog in zasvojenosti. Odgovor pa zahteva tudi naslednje vpra{anje: Kako naj se Slovenija najbolj ustrezno loti vpra{anja zasvojenosti? Evropska gospodarstva v razvoju, ki si prizadevajo najti najbolj{e na~ine boja proti kriminalu, psihiatri~nim motnjam, boleznim in dru‘benim problemom, ki so povezani z uporabo psihoaktivnih substanc, najprej pomislijo na {iritev programov. To predlagajo tudi avtorji v nadaljevanju objavljenih prispevkov o vzdr‘evalnih metadonskih
programih, igranju na sre~o in alkoholizmu. Druga mo‘nost je uvajanje preventivnih dejavnosti v {ole, tretji pa uvedba stro‘je kazenske zakonodaje na podro~ju razpe~evanja drog, kot so to ekstazi, heroin in kanbis. Kot so pokazale raziskave o u‘ivanju alkohola (1) in nedovoljenih psihoaktivnih substanc (2), predstavljajo ti, sicer zelo pomembni pristopi, le prvo fazo v razvijanju celovitega javnozdravstvenega programa za prepre~evanje u‘ivanja in zlorabe drog.
V  okviru tak{nega programa bi najprej uvedli z znanstvenimi dokazi podkrepljen ukrepe, namenjene tako posameznikom kot skupinam prebivalstva. Kar se ti~e pitja alkohola, sodijo med najbolj u~inkovite ukrepe te vrste vi{ji davki na alkohol, ukrepi za prepre~evanje vo‘nje pod vplivom alkohola, npr. naklju~ni alko testi in omejitev dostopnosti alkoholnih pija~ (1, 3). Med zadnje ukrepe sodijo zvi{anje starostne meje za nakup alkoholnih pija~ in omejitev ~asa, krajev in dni za prodajo alkohola.
Moja zadnja pomisel pa velja vlogi raziskovanja pri oblikovanju u~inkovitih javnozdravstvenih programov.
V  prispevkih za to {tevilko je verjetno najbolj opogumljajo~e dejstvo to, da je v Sloveniji vedno ve~ empiri~nih raziskav, ki se ukvarjajo z vpra{anji zasvojenosti. Ko u‘ivanje drog, ki povzro~ajo zasvojenost, prepoznamo kot zdravstveni problem, je navadno prvi korak namenjen opredelitvi prizadetih skupin prebivalcev in njihovih problemov s klini~nimi epidemiolo{kimi metodami. ^lanki v tej {tevilki, ki so posve~eni uporabnikom programov za alkoholike in metadonskih programov, prina{ajo dragocene podatke o u~inkovitosti zdravljenja in napovednih dejavnikih izida. Te raziskave so v pomo~ tudi pri oblikovanju skupin klini~nih znanstvenikov, ki bi lahko ponudile strokovne odgovore na nova vpra{anja o javni politiki na tem podro~ju. Klini~ne raziskave pa so le za~etek organizirane javnozdravstvene akcije. Pogosto je za oblikovanje programov nadzora, zdravstvenovarstvenih raziskav, na~rtovanja preventivnih ukrepov in analizo teh dejavnosti, potrebno interdisciplinarno sodelovanje med raziskovalci na podro~ju dru‘benih, vedenjskih in medicinskih ved. Prispevki v tej {tevilki revije predstavljajo pomemben korak naprej pri oblikovanju potrebnega korpusa strokovnega znanja, podatkovnih
ąDepartment of Community Medicine, University of Connecticut, School of Medicine, Farmington, CT, USA Kontaktni naslov: e-po{ta: Babor@nso.uchc.edu
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baz, raziskovalnih izsledkov in evalvacij programov, ki bodo Slovenijo pripravili za soo~anje s prihajajo~imi izzivi na podro~ju javnega zdravstva.
Literatura
1. Babor T, Caetano R, Casswell S, Edwards G, Giesbrecht N, Graham K et al. Alcohol: No Ordinary Commodity: Research and Public Policy. Oxford, UK: Oxford University Press, 2003.
2.   MacCoun RJ, Reuter P. Drug War Heresies. Learning from other vices, times and places. New York: Cambridge University Press, 2001.
3.   World Health Organization. Global Status Report: Alcohol Policy. Geneva: World Health Organization, 2004.