case study on alcohol and drug abuse

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• v.9(8); 2015 Aug

A 16-Year-old Boy with Combined Volatile and Alcohol Dependence: A Case Report

Soumya sachdeva.

1 Graduate, Department of Psychiatry, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India.

Raghu Gandhi

2 Resident, Department of Psychiatry, University of Minnesota, Minneapolis.

Pankaj Verma

3 Assistant Professor, Department of Psychiatry, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi, India.

Arshdeep Kaur

4 Graduate, Department of Psychiatry, SSR Medical College, Mauritius.

Rohit Kapoor

5 Resident, Department of Pediatrics, St John Providence Children’s Hospital Detroit, Michigan United States.

Substance abuse has been defined as the use of chemical substances for non medical purposes in order to achieve alterations in psychological functioning. The substances commonly abused in India include nicotine, alcohol, cannabis and opioids. However, the use of solvents and propellants is also on the rise as these are inexpensive, legally available household, industrial, office and automobile products; which are more commonly available to children and adolescents. We hereby describe a 16-year-old boy with combined volatile and alcohol abuse; who presented with increasing ataxia, visual and hearing disturbances.

Case Report

A 16-year-old adolescent male with a normal birth history and developmental milestones and belonging to low socioeconomic status; was brought to the outpatient department by his mother who permitted and consented along with the child in writing the report, complained that the child was smelling a rubber based adhesive using a handkerchief since the last 3 years. There was significant family history of alcohol dependence in father. There was no history of fever, head injury, seizure or attention deficit hyperactive disorder. There was no history of stress, tension or depressive thoughts. The toluene based substance abuse began gradually from 5ml/day and picked up to 20 ml each per day gradually over a span of 1 year which remained relatively stable during the presentation to the outpatient. After acute ingestion of Polychloroprene based solvent; the adolescent complained of tinnitus, slurring of speech, restlessness tremors, dizziness and ataxia. During the phase of withdrawal, there was coprolalia with assaultive and abusive behaviour, increasing fights, maladaptive behaviour and headache. These symptoms increased in severity; which compelled the parent to seek help. In addition, excessive tearing in the morning, headaches, decreased cognitive ability were the prominent symptoms in the morning; due to withdrawal. After obtaining detailed history, it was found that there was no confusion, visual hallucinations and/or seizure. Alcohol abuse began approximately 6 months after the volatile substance abuse, on detailed questioning child was asked whether he needed to cut down on the drinking behaviour, his annoyance, guilty and use of alcohol eye opener in the morning the response was positive for ¾ of the questions. He further added that the alcohol abuse began when the patient’s friends circle changed to include more people of higher age group. The patient used to steal money from his house in order to fetch the abused substance. The child was a school drop out as he faced inability to concentrate and low scores at school. Moreover, he often was involved in assaultive behaviour at school. The alcohol consumption increased from initially 20-40 ml of local alcohol (42.6% w/v) average per day to approx 60-120 ml per day (42.6%w/v); later during the span of last 2 months before presentation to the outpatient department. The child abused glue more than the alcohol due to its easy availability. During times of the day when no glue was consumed; alcohol abuse was noted along with the peers of elder age. During the phase of acute alcohol intoxication alone; the adolescent complained of nausea, headache, dizziness and excessive somnolence however when combined with glue sniffing; disorientation and ataxia, restless, diaphoresis and nystagmus were complained of, in addition. The child also developed blurring of vision and inability to perceive numbers and letters in the central visual field and fixed hearing deficits to increased frequency sound was noted; more prominent during the last 2 months, during which period combined abuse was done and dose of alcohol was increased to about 60-120 ml of (42.8% w/v) alcohol per day. A progressively increasing tendency of violence, disorientation, restlessness was noticed by the mother and his family in the form of anger outbursts, abusive and assaultive behaviour in the last two months during which alcohol intake was accelerated. The child presented to the clinic in a state of withdrawal since the mother had not let the child consume any substances since the last 2 days. The child tried to abstain from glue and alcohol a few times; but each episode of abstinence was followed by increase in the use. During the phase of abstinence; the child complained of increasing slurring of speech, difficulty hearing voices and sleep disturbances. General physical examination revealed a rash over the nostrils and nasolabial folds; a low BMI for age and a debilitated adolescent, with conjunctival pallor and a resting pulse of 92/min, and blood pressure of 110/80 mmHg. The central nervous examination exhibited symptoms of withdrawal including combativeness, irritability, aggressiveness, an impaired long term recall on minimental status examination with a score of 20. The psychometric tests scored low on aptitude and skills. IQ assessment was done using Seguin Form board, Malin’s intelligence scale for Indian child. The test score indicated to a below average intelligence in the child. On the Family Environmental Scale; there was a low score in all subgroups like personal, relationship, and system maintenance. The areas of behaviour control, problem solving, communication, affective response scored low. Cranial nerve examination showed normal pupillary reflexes and mild pallor of both optic discs on fundus examination, hearing loss of sensorineural type on both sides of moderate type. The child had a normal motor examination and sensory examination and flexor plantar response. Cerebellar examination revealed ataxic gait with a wide base and a moderate dyssmetria was observed on finger nose test; abdominal examination revealed hepatomegaly with liver margin 2 cm below costal margin and a span of 12 cm chest and cardiovascular examination was normal. The haematological workup revealed mild anaemia with Hb of 8gm% with MCV of 104 fl/cell, hypersegmented polymorphs and macrocytosis and were noted on the peripheral smear. The vitamin B12 levels were low 12pg/dl (nl200-900pg/dl) and liver function tests had transaminases 3 times the upper limit. (ALT-152U/l, ASt-200U/L, ALP-160U/L). A grade I fatty liver was noticed on abdominal sonogram. Audiometery results demonstrated moderate sensorineural hearing loss. Urine drug screen for alcohol was found to be negative. Urine for heavy metal screen was found to be negative. Renal Function tests, serum electrolyte, glucose, serologic tests for syphilis, urinalysis and chest radiograph were normal. Urine EEG, electromyogram, nerve conduction studies and electro retinogram was found to be normal. The contrast study of the head sequential sections showed cerebellar atropy and cortical atropy and generalized attenuation of white matter [ Table/Fig-1 ]. The patient was admitted for the treatment of alcohol withdrawal and management of withdrawal due to volatile substance abuse; pharmacological therapy was begun using thiamine, Lorazepam, were given to decrease agitation and maintenance fluids were begun as well. Buspirone was begun at 5 mg/day and increased to 30mg/day. When the condition of the child stabilized; a short term course of supportive psychotherapy which included cognitive behavioural therapy was employed. This involved exploring and addressing problems which co-occurred with the abuse as well as the positive and negative consequences of drug use. A family based approach and person centered general counselling was adopted to help in recognizing and reducing craving and avoiding high risk situations. With the management of the patient; there was a subsequent decrease in the frequency of volatile substance abuse as well as decreased craving for the volatile substances as well as the alcohol. The general debilitation of the adolescent was improved during the process of detoxification and high energy feeds were instituted after correcting the vitamin and metabolic disturbances. Social workers were also involved in the process. They took detailed histories, delivered brief interventions to help the child for a behavioural change, and assessed the progress and provided encouragement and assistance to rebuild the child’s life. It also included the development of drug logs (when the child took the drug and when he was abstinent) and progress reviews to avoid the risky situations. Engagement in healthy was promoted and periodic rewards for abstaining were offered to the child. Alcohol dependence in father was also addressed and was included in the treatment. The child was discharged from the hospital uneventfully. The alcohol intake decreased during the subsequent follow-up visits. The child had a regular follow up with the clinic for a span of 1 year during which general condition of the child showed improvement however then subsequently dropped out.

Contrast study of the head: Sequential section associated with cerebeller atrophy and generalized attenuaton of white matter

Substance abuse is on the rise in India particularly among the adolescents. The last several decades have noticed a growing prevalence of inhalant use in India; most notably volatile petroleum products, correcting fluids and adhesives [ 1 – 3 ]. There are very few reported studies from India on inhalant abuse. Between 1978- 2003; a study carried out showed that 4.7% of the adolescents used inhalants as the primary drug and 1.2% of them consumed inhalants as the secondary drug [ 1 ]. Another study done over a course of 2 years demonstrated that among majority of adolescents; the first use was attributed to curiosity and a desire to experiment [ 4 ]. The reason for growing use of inhalants among adolescents may be attributed to the low cost, easy availability and faster action [ 3 , 5 ]. Few studies document higher use of inhalants by adolescents of low to middle socio economic status [ 3 , 5 , 6 ]. There is also high prevalence of school dropouts and unemployed status [ 1 , 3 , 6 ].

There are several consequence of inhalant abuse. The patient may suffer from asphyxia, accidental injury, cardiac arrhythmias, respiratory depression; and in most severe cases; it may lead to death [ 6 , 7 ]. Continuous use can lead to the development of withdrawal syndrome on abrupt discontinuation of use. The symptoms observed upon withdrawal include sweating, nausea, vomiting, lack of sleep, craving, lack of concentration, jitteriness, irritability, rise in heart rate, headache, body aches, tingling sensations; and in some of the cases, can even lead to delusions, altered perceptions and hallucinations inhalants produce vapours, these can be sniffed or taken in deep breaths. The effect appears within minutes. The duration of the high can last from minutes to hours [ 8 ]. Inhalant abuse in small doses produces a pleasing sensation and a sense of euphoria [ 7 ]. However with increasing doses; illusions, auditory and/or visual hallucinations, fearfulness and impaired perception of size and shape may be noticed in the patient. Studies looking at white matter changes demonstrate that inhalant abuse is associated with a lower IQ; affecting both verbal and performance IQ; however the former is affected more [ 9 , 10 ].

Alcohol abuse in India too is rising rapidly. In 1980s, the first age of alcohol use was reported to be 28 years; but this has now fallen to 17 years in 2007 [ 11 ]. Alcohol intoxication also has several dire consequences. These include poor judgement, impaired coordination, ataxia, nausea, vomiting, euphoria and slurring of speech. Withdrawal from alcohol consumption can lead to development of anxiety, difficulty with sleep, autonomic instability, hallucinations –visual, tactile or auditory and seizures; called delirium tremens. Alcohol abuse in children manifests as difficult behaviour in school, social impairment, inability to learn and the development of conduct disorder can also occur. A consumption of 40 g of pure alcohol in a day by men and 20 g of pure alcohol in day by women falls under the criteria for heavy drinking; causing harm to health [ 12 ].

The child also suffered from anaemia as seen in case. Anaemia in alcoholics has a complex and multifactorial aetiology and can be microcytic or macrocytic. Poor nutrition, liver dysfunction and a state of chronic inflammation all contribute to it [ 13 ].

There are many factors which may be contributory to the development of substance abuse in the patient in this case report which can be explained on the basis of bio-psycho-social model. These include family history of substance use, peer pressure, easy availability of drugs, lower social strata, family with conflicts and lack of proper parenting. The patient’s intellectual decline can be explained by the presence of cerebral atrophy findings; similar findings have been reported by the author of various other studies too [ 14 – 16 ]. As seen in our case as well, the loss of vision was progressive and the patient’s visual acuity decrease maybe because of toluene induced optic neuritis and; also the fundic examination in our patient revealed pale optic discs [ 17 ]. There are no studies currently in literature featuring combined abuse of glue and alcohol. In our case; when the child was suffering from combined glue and alcohol intoxication; disorientation, ataxia, restless, diaphoresis and nystagmus were noted. In the phase of combined withdrawal; the child complained of increasing slurring of speech and difficulty hearing voices and sleep disturbances.

This case is first of the kind depicting clinical features as well as withdrawal of combined volatile and moderate alcohol abuse. The feature of combined intoxication of the two abused substances makes it difficult for the clinician to reach a diagnosis. Our case report thus puts forward the scenario of increasing combined alcohol and volatile substance abuse and growing problem of the same. Also, this case sensitizes physicians to think of substance abuse to be a complex presentation in the child. However, more exploration, case studies for assessing symptoms of intoxication and withdrawal in case of combined volatile and alcohol abuse are needed.

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Module 9: Substance-Related and Addictive Disorders

Case studies: substance-abuse disorders, learning objectives.

• Identify substance abuse disorders in case studies

Case Study: Benny

The following story comes from Benny, a 28-year-old living in the Metro Detroit area, USA. Read through the interview as he recounts his experiences dealing with addiction and recovery.

Q : How long have you been in recovery?

Benny : I have been in recovery for nine years. My sobriety date is April 21, 2010.

Q: What can you tell us about the last months/years of your drinking before you gave up?

Benny : To sum it up, it was a living hell. Every day I would wake up and promise myself I would not drink that day and by the evening I was intoxicated once again. I was a hardcore drug user and excessively taking ADHD medication such as Adderall, Vyvance, and Ritalin. I would abuse pills throughout the day and take sedatives at night, whether it was alcohol or a benzodiazepine. During the last month of my drinking, I was detached from reality, friends, and family, but also myself. I was isolated in my dark, cold, dorm room and suffered from extreme paranoia for weeks. I gave up going to school and the only person I was in contact with was my drug dealer.

Q : What was the final straw that led you to get sober?

Benny : I had been to drug rehab before and always relapsed afterwards. There were many situations that I can consider the final straw that led me to sobriety. However, the most notable was on an overcast, chilly October day. I was on an Adderall bender. I didn’t rest or sleep for five days. One morning I took a handful of Adderall in an effort to take the pain of addiction away. I knew it wouldn’t, but I was seeking any sort of relief. The damage this dosage caused to my brain led to a drug-induced psychosis. I was having small hallucinations here and there from the chemicals and a lack of sleep, but this time was different. I was in my own reality and my heart was racing. I had an awful reaction. The hallucinations got so real and my heart rate was beyond thumping. That day I ended up in the psych ward with very little recollection of how I ended up there. I had never been so afraid in my life. I could have died and that was enough for me to want to change.

Q : How was it for you in the early days? What was most difficult?

Benny : I had a different experience than most do in early sobriety. I was stuck in a drug-induced psychosis for the first four months of sobriety. My life was consumed by Alcoholics Anonymous meetings every day and sometimes two a day. I found guidance, friendship, and strength through these meetings. To say early sobriety was fun and easy would be a lie. However, I did learn it was possible to live a life without the use of drugs and alcohol. I also learned how to have fun once again. The most difficult part about early sobriety was dealing with my emotions. Since I started using drugs and alcohol that is what I used to deal with my emotions. If I was happy I used, if I was sad I used, if I was anxious I used, and if I couldn’t handle a situation I used. Now that the drinking and drugs were out of my life, I had to find new ways to cope with my emotions. It was also very hard leaving my old friends in the past.

Q : What reaction did you get from family and friends when you started getting sober?

Benny : My family and close friends were very supportive of me while getting sober. Everyone close to me knew I had a problem and were more than grateful when I started recovery. At first they were very skeptical because of my history of relapsing after treatment. But once they realized I was serious this time around, I received nothing but loving support from everyone close to me. My mother was especially helpful as she stopped enabling my behavior and sought help through Alcoholics Anonymous. I have amazing relationships with everyone close to me in my life today.

Q : Have you ever experienced a relapse?

Benny : I experienced many relapses before actually surrendering. I was constantly in trouble as a teenager and tried quitting many times on my own. This always resulted in me going back to the drugs or alcohol. My first experience with trying to become sober, I was 15 years old. I failed and did not get sober until I was 19. Each time I relapsed my addiction got worse and worse. Each time I gave away my sobriety, the alcohol refunded my misery.

Q : How long did it take for things to start to calm down for you emotionally and physically?

Benny : Getting over the physical pain was less of a challenge. It only lasted a few weeks. The emotional pain took a long time to heal from. It wasn’t until at least six months into my sobriety that my emotions calmed down. I was so used to being numb all the time that when I was confronted by my emotions, I often freaked out and didn’t know how to handle it. However, after working through the 12 steps of AA, I quickly learned how to deal with my emotions without the aid of drugs or alcohol.

Q : How hard was it getting used to socializing sober?

Benny : It was very hard in the beginning. I had very low self-esteem and had an extremely hard time looking anyone in the eyes. But after practice, building up my self-esteem and going to AA meetings, I quickly learned how to socialize. I have always been a social person, so after building some confidence I had no issue at all. I went back to school right after I left drug rehab and got a degree in communications. Upon taking many communication classes, I became very comfortable socializing in any situation.

Q : Was there anything surprising that you learned about yourself when you stopped drinking?

Benny : There are surprises all the time. At first it was simple things, such as the ability to make people smile. Simple gifts in life such as cracking a joke to make someone laugh when they are having a bad day. I was surprised at the fact that people actually liked me when I wasn’t intoxicated. I used to think people only liked being around me because I was the life of the party or someone they could go to and score drugs from. But after gaining experience in sobriety, I learned that people actually enjoyed my company and I wasn’t the “prick” I thought I was. The most surprising thing I learned about myself is that I can do anything as long as I am sober and I have sufficient reason to do it.

Q : How did your life change?

Benny : I could write a book to fully answer this question. My life is 100 times different than it was nine years ago. I went from being a lonely drug addict with virtually no goals, no aspirations, no friends, and no family to a productive member of society. When I was using drugs, I honestly didn’t think I would make it past the age of 21. Now, I am 28, working a dream job sharing my experience to inspire others, and constantly growing. Nine years ago I was a hopeless, miserable human being. Now, I consider myself an inspiration to others who are struggling with addiction.

Q : What are the main benefits that emerged for you from getting sober?

Benny : There are so many benefits of being sober. The most important one is the fact that no matter what happens, I am experiencing everything with a clear mind. I live every day to the fullest and understand that every day I am sober is a miracle. The benefits of sobriety are endless. People respect me today and can count on me today. I grew up in sobriety and learned a level of maturity that I would have never experienced while using. I don’t have to rely on anyone or anything to make me happy. One of the greatest benefits from sobriety is that I no longer live in fear.

Case Study: Lorrie

Figure 1. Lorrie.

Lorrie Wiley grew up in a neighborhood on the west side of Baltimore, surrounded by family and friends struggling with drug issues. She started using marijuana and “popping pills” at the age of 13, and within the following decade, someone introduced her to cocaine and heroin. She lived with family and occasional boyfriends, and as she puts it, “I had no real home or belongings of my own.”

Before the age of 30, she was trying to survive as a heroin addict. She roamed from job to job, using whatever money she made to buy drugs. She occasionally tried support groups, but they did not work for her. By the time she was in her mid-forties, she was severely depressed and felt trapped and hopeless. “I was really tired.” About that time, she fell in love with a man who also struggled with drugs.

They both knew they needed help, but weren’t sure what to do. Her boyfriend was a military veteran so he courageously sought help with the VA. It was a stroke of luck that then connected Lorrie to friends who showed her an ad in the city paper, highlighting a research study at the National Institute of Drug Abuse (NIDA), part of the National Institutes of Health (NIH.) Lorrie made the call, visited the treatment intake center adjacent to the Johns Hopkins Bayview Medical Center, and qualified for the study.

“On the first day, they gave me some medication. I went home and did what addicts do—I tried to find a bag of heroin. I took it, but felt no effect.” The medication had stopped her from feeling it. “I thought—well that was a waste of money.” Lorrie says she has never taken another drug since. Drug treatment, of course is not quite that simple, but for Lorrie, the medication helped her resist drugs during a nine-month treatment cycle that included weekly counseling as well as small cash incentives for clean urine samples.

To help with heroin cravings, every day Lorrie was given the medication buprenorphine in addition to a new drug. The experimental part of the study was to test if a medication called clonidine, sometimes prescribed to help withdrawal symptoms, would also help prevent stress-induced relapse. Half of the patients received daily buprenorphine plus daily clonidine, and half received daily buprenorphine plus a daily placebo. To this day, Lorrie does not know which one she received, but she is deeply grateful that her involvement in the study worked for her.

The study results? Clonidine worked as the NIDA investigators had hoped.

“Before I was clean, I was so uncertain of myself and I was always depressed about things. Now I am confident in life, I speak my opinion, and I am productive. I cry tears of joy, not tears of sadness,” she says. Lorrie is now eight years drug free. And her boyfriend? His treatment at the VA was also effective, and they are now married. “I now feel joy at little things, like spending time with my husband or my niece, or I look around and see that I have my own apartment, my own car, even my own pots and pans. Sounds silly, but I never thought that would be possible. I feel so happy and so blessed, thanks to the wonderful research team at NIDA.”

• Liquor store. Authored by : Fletcher6. Located at : https://commons.wikimedia.org/wiki/File:The_Bunghole_Liquor_Store.jpg . License : CC BY-SA: Attribution-ShareAlike
• Benny Story. Provided by : Living Sober. Located at : https://livingsober.org.nz/sober-story-benny/ . License : CC BY: Attribution
• One patientu2019s story: NIDA clinical trials bring a new life to a woman struggling with opioid addiction. Provided by : NIH. Located at : https://www.drugabuse.gov/drug-topics/treatment/one-patients-story-nida-clinical-trials-bring-new-life-to-woman-struggling-opioid-addiction . License : Public Domain: No Known Copyright

Alcohol Abuse in Society: Case Studies

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• Adrian Bonner 3 &
• James Waterhouse 4  

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The last three chapters have demonstrated how routine data may be collected from the health service and forensic medicine. These data present a view of the occurrence of alcohol and drug abuse in society which is generated from a ‘medical model’. As useful as this approach is, it does not take into account the nature and needs of specific groups. To do this a more ‘socially appropriate perspective’ can be used. The following case studies illustrate some of the problems resulting from methodological issues in this area of investigation and, in particular, from studies undertaken in short-term projects undertaken by graduate students. Important discussions relating to: ‘what level of consumption constitutes abuse ’ ‘alcohol usage by the elderly’, and ‘the effectiveness of health education’ will be introduced.

• Alcohol Consumption
• Alcohol Abuse
• Royal College
• Student Nurse
• Addictive Behaviour

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Bonner, A., Waterhouse, J. (1996). Alcohol Abuse in Society: Case Studies. In: Bonner, A., Waterhouse, J. (eds) Addictive Behaviour: Molecules to Mankind. Palgrave Macmillan, London. https://doi.org/10.1007/978-1-349-24657-1_17

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A Research Strategy Case Study of Alcohol and Drug Prevention by Non-Governmental Organizations in Sweden 2003-2009

• Charli Eriksson 1 ,
• Susanna Geidne 1 ,
• Madelene Larsson 1 &
• Camilla Pettersson 1  

Substance Abuse Treatment, Prevention, and Policy volume  6 , Article number:  8 ( 2011 ) Cite this article

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Alcohol and drug prevention is high on the public health agenda in many countries. An increasing trend is the call for evidence-based practice. In Sweden in 2002 an innovative project portfolio including an integrated research and competence-building strategy for non-governmental organisations (NGOs) was designed by the National Board of Health and Welfare (NBHW). This research strategy case study is based on this initiative.

The embedded case study includes 135 projects in 69 organisations and 14 in-depth process or effect studies. The data in the case study has been compiled using multiple methods - administrative data; interviews and questionnaires to project leaders; focus group discussions and seminars; direct and participatory observations, interviews, and documentation of implementation; consultations with the NBHW and the NGOs; and a literature review. Annual reports have been submitted each year and three bi-national conferences Reflections on preventions have been held.

A broad range of organisations have been included in the NBHW project portfolio. A minority of the project were run by Alcohol or drug organisations, while a majority has children or adolescents as target groups. In order to develop a trustful partnership between practitioners, national agencies and researchers a series of measures were developed and implemented: meeting with project leaders, project dialogues and consultations, competence strengthening, support to documentation, in-depth studies and national conferences. A common element was that the projects were program-driven and not research-driven interventions. The role of researchers-as-technical advisors was suitable for the fostering of a trustful partnership for research and development. The independence of the NGOs was regarded as important for the momentum in the project implementation. The research strategy also includes elements of participatory research.

Conclusions

This research strategy case study shows that it is possible to integrate research into alcohol and drug prevention programs run by NGOs, and thereby contribute to a more evidence-based practice. A core element is developing a trustful partnership between the researchers and the organisations. Moreover, the funding agency must acknowledge the importance of knowledge development and allocating resources to research groups that is capable of cooperating with practitioners and NGOs.

Introduction

Alcohol and drug prevention is high on the public health agenda in most countries. The national initiatives differ, although action plans have been proposed by international organizations such as WHO [ 1 ]. Moreover, there is an increasing demand for evidence-based alcohol and drug prevention, causing an increased emphasis on research for prevention, an emphasis that this field shares with health promotion, prevention in general, and social work [ 2 – 8 ]. This means that prevention research needs to move "from basic to more and more applied research; from descriptive hypothesis-generating pilot studies to full-fledged, methodologically sophisticated, hypothesis-testing studies; from smaller to larger samples for testing; from greater to lesser control of experimental conditions; from more artificial 'laboratory' environments to real-world geographically defined communities; from testing the effects of single intervention strategies into more complex studies of multiple strategies integrated into intervention systems; and from research-driven outcome studies to 'demonstration' projects that evaluate the capacity of various types of communities to implement prevention programs based on prior evaluations" [[ 9 ], p 183]. It has also been more than 10 years since Nutbeam [ 10 , 11 ] noted the gap between the need for knowledge and the priorities among researchers.

Many years have passed since these recommendations, but still the gap between evidence and practice has not been bridged despite important achievements in implementation research [ 12 ], designs for effectiveness and translation research [ 13 ], and a series of initiatives regarding the evidence-practice gaps [ 14 – 22 ]. The call for more practice-based evidence is a challenge for policy-makers, practitioners, researchers, and funding agencies [ 17 , 23 ]. In several countries research on alcohol and drug issues has been incorporated into addiction research centres [ 24 – 28 ]. For many years much addiction research has been the product of specialized research centres rather than the contribution of standalone scientists. Moreover it is the specialist centres, in collaboration with the national funding agencies, which today assert leadership, set agendas, and help determine standards [ 24 ]. However, a common element in the missions of these centres is monitoring the substance use in the population, its causes, and courses, while prevention research is not high on the agendas. Furthermore, the establishment of national centres demonstrates the political administration's emphasis on scientific, evidence-based policies, but at the same time demonstrates the view that credible research is best performed within independent scientific bodies [ 26 ].

In Sweden in 2002 an innovative project portfolio for non-governmental organisations (NGOs) was designed by the National Board of Health and Welfare (NBHW). This included an integrated research and competence-building strategy to strengthen alcohol and drug prevention. This case study aims to describe and analyse this initiative.

AD prevention in Sweden - legislation, national action plans, resources, and actors

Sweden has a long tradition of a restrictive alcohol policy [ 29 ]. The temperance movement became a powerful actor in the Swedish alcoholic beverage policy [ 30 ]. Moreover, Sweden is one of the few countries in Europe with a narcotics policy that aims to create a society entirely free of illicit drugs [ 31 ].

The overall goal of the Swedish action plan on alcohol and narcotics is to promote public health by reducing the medical and social harm caused by alcohol and to create a drug-free society. The strategy for achieving this goal with regard to alcohol is to reduce the total consumption and prevent harmful drinking, taking into account differences in living conditions among boys, girls, men, and women. Six priority sub-goals have been adopted: alcohol should not be consumed in transport contexts, at workplaces, or during pregnancy; children should grow up in an alcohol-free environment; the age of alcohol debut should be postponed; drinking to point of intoxication should be reduced; there should be more alcohol-free environments; and illicit alcohol should be eliminated. The sub-goals in the action plan on narcotics are to reduce recruitment to drug abuse, induce people with substance abuse problems to give up their abuse, and to reduce the supply of drugs. Interventions targeting children, adolescents, and parents are of high priority [ 32 ].

Swedish alcohol policy is based on a combination of taxed-based price controls and the alcohol retail monopoly in order to limit the availability and accessibility of alcohol [ 32 ]. There is strong evidence for the preventive effects of an alcohol retail monopoly [ 33 , 34 ] and high prices on alcohol are regarded as one of the most effective ways of reducing total alcohol consumption and alcohol-related problems [ 35 ]. When Sweden entered the EU in 1995, the conditions changed and Sweden could no longer have an independent alcohol policy. For example, the availability of alcohol increased as a result of changed rules for private import, and alcohol taxes had to be adjusted. The numbers of alcohol shops as well as their opening hours have also increased remarkably since 1995 [ 29 ]. The increased movements across borders have also had an influence on the illicit drugs market. Almost all narcotics that are consumed in Sweden have been produced outside the country. A well-developed international collaboration is therefore of high importance for the limitation of illicit drugs in Sweden [ 32 ].

An effective alcohol and drug policy also requires national coordination. The Swedish government has established a national council for alcohol, narcotics, doping, and tobacco. The council consists of members of public authorities, civil society, and researchers, and is led by the State Secretary of the Ministry of Health and Social Affairs. The council is commissioned to advise the government on issues about alcohol, drugs, doping, and tobacco and to present information about research results [ 36 ].

There is a need for the different sectors in society to increase and deepen their cooperation for an effective prevention of the use of alcohol, tobacco, and drugs. In the Swedish action plan on alcohol and illicit drugs as well as in the government bill for public health the importance of the voluntary sector is emphasized [ 36 , 37 ]. In the latter document, A renewed public health policy , it is stated that cooperation between the state and the voluntary sector should be expanded and that the conditions for the voluntary sector's work should improve [ 37 ]. An agreement about the relations between the government, the voluntary sector in the social setting, and the Swedish Association of Local Authorities and Regions has recently been developed through a dialogue between the parties. The dialogue is another way for the government to call attention to the voluntary sector and to its ambition to strengthen the sector and improve its conditions. The goal of the agreement was to strengthen the independence of the voluntary sector as moulders of public opinion and to support the development of public medical service carried out by the voluntary sector [ 38 ]. The Swedish voluntary sector has a long tradition of alcohol prevention, especially the temperance movements [ 39 ].

NGOs in Sweden

The Swedish voluntary sector is both different and similar to those in other countries. A major difference lies in its history in that, for instance, as early as in the 16th century the responsibility for health and care was organized under the state instead of in the regime of the church. In parts of Europe the church still is an active actor in health and care [ 40 , 41 ]. Also, popular mass movements have played an important role in the development of Swedish society [ 41 , 42 ]. The Swedish voluntary sector is as large as in other industrialized countries, although quite different in character. It is dominated by organizations in the cultural and recreational field, mainly sports organizations. Since the early 1990s the Swedish voluntary sector has expanded, particularly in the two areas of culture and recreation, as well as in the area of social care [ 43 ]. It can also be called membership-based; almost everyone in Sweden is a member of some organization. Because of these differences in history and structure in different societies, the voluntary sector plays different roles. In Sweden, NGOs are more of a complement then a substitute for state programs, and have an important role as forerunners and innovators [ 44 ].

Previous research has shown that the Swedish voluntary sector was highly dependent on public financing, which is partly correct. Looking at the entire sector together, about 30 percent of its financing comes from government funding. However, within the health care and social service sector, public financing stands for more than 70 percent. That is quite high in comparison with other European countries, but not the highest [ 45 ].

Support to NGOs today

Organizational grants.

The National Board of Health and Welfare (NBHW) has a government commission to administer the grants to national organizations for the disabled, the elderly, and relatives of elderly persons; to national organizations in the social setting; and to national and local organizations. For the moment this amounts to about 300 million SEK to about 100 organizations. Also the Swedish National Institute of Public Health has funds to distribute to NGOs or to other organizations working together with NGOs. The Swedish State Inheritance Fund is also a possible source of funding for NGOs. They administer over 300 million SEK a year to provide grants to NGOs working with children, youth, and the disabled. In addition other governmental agencies such as the Swedish National Board for Youth Affairs also support NGOs.

Project grants

In the late 1990s a new system of awarding grants to NGOs in the arenas of alcohol and narcotics, vulnerable children and their families, and violence against women was prepared. The previous systems were from the late 1970s and early 1980s, and during the 1990s many investigations recommended a better, more structured follow-up and evaluation of the NGOs' work. One new idea that emerged during the 1990s was increased performance management, that is, the need to point out achieved results and effects of different activities. It was emphasized that the government should not interfere with the running of the organizations but does have the duty to monitor the use of the grants. There was also a desire that renewal efforts and collaborations should be encouraged and supported.

In the late 20th century grants were awarded through the Swedish National Institute of Public Health (with money from the Swedish State Inheritance Fund) to a number of alcohol and drug prevention projects. A final report and an internal evaluation were required from the applicants. There was also an external evaluator, who conducted an evaluation of 11 projects focusing on their working processes [ 46 ]. Among the lessons learned from this evaluation were that the way of working should be characterized by frequent contacts and dialogue between the funding agency and the project, and also by supervision. The evaluation report also suggested that the support to the project leaders should be reviewed with regard to the possibility of different types of need-based support. Moreover, the short-term thinking in the funding of these kinds of projects was not in line with the needed time-frame.

Setting the Scene: NGO strategy for alcohol and drug prevention

Non-governmental organizations have received grants from the NBHW to conduct alcohol and drug preventive work in a special venture since 2003 [ 47 ]. This initiative is part of the national plan of action to prevent alcohol-related harm and the national plan of action against narcotics and comes from the Ministry of Health and Social Affairs. The working committee, which decides who will get funding, consists of members of the NBHW, the Swedish National Institute of Public Health, and the Swedish National Board for Youth Affairs (previously members of the Swedish Alcohol Committee and the Swedish National Drug Policy Coordinator were included). The working committee, after consulting the research team at Örebro University, also decides which projects will be studied in-depth. NBHW's initiative represented a new way of thinking. One point of departure was to create a project portfolio with a broad combination of organizations to mobilize many forces in the alcohol and drug preventive work. The initiative also contains supervision for the project leaders, competence support through regular meetings for project leaders, and an integrated Research & Development (R&D) investment (Figure 1 ).

Integrated research and development for NGO alcohol and drug prevention .

Need for knowledge building and learning

There is an increasing trend towards promoting evidence-based public health initiatives. International expert committees have presented the state of science with regard to alcohol prevention: Alcohol Control Policies in Public Health Perspectives [ 48 ]; Alcohol Policy and the Public Good [ 49 ]; and Alcohol: No Ordinary Commodity -Research and Public Policy [ 33 , 50 ]. National authorities have presented reviews presenting evidence for practitioners and politicians [ 51 – 53 ]. However, there are important knowledge gaps to be filled. Among these is the lack of effectiveness studies where the external validity is high. If we want to see more evidence-based practice we need more practice-based evidence [ 54 ]. This means an improved emphasis on cooperation between researchers and practitioners [ 10 ].

A comprehensive perspective on the concept of knowledge, including scientific and practical knowledge as well as practical wisdom, is needed. Scientific knowledge about alcohol and drug issues needs to be complemented with knowledge about methods for alcohol and drug prevention. As in other public health fields, ethical issues and practical wisdom are important [ 55 ]. Moreover, the science, craft, and art of implementation are of utmost importance. There are many reasons besides practicalities that are significant for the implementation of programs [ 7 , 56 ]. In a recent review, 23 different factors were found that were of importance for the degree of the implementation [ 12 ] and that also have a great impact on the program effects.

Research on alcohol and drugs has often been organized in special research institutes, which often focus on basic research on alcohol and drugs [ 24 – 28 ]. This basic research is related both to basic biomedicine as well as social and behavioural studies. Another activity, which has been accorded great prominence, is the monitoring of alcohol and drug use in the population in general as well in different groups. Intervention research has been given less prominence in these often national research institutes. However, the national agencies, such as the Swedish Institute of Public Health, have been involved in the evaluation of different intervention projects. So far research on NGO-driven alcohol and drug prevention has been almost completely lacking. Research has been a more or less exclusive activity for the university. However, this has been based on the trust in the impartiality and objectivity of the university-based researchers. The downside of this position is that this type of research may lack the necessary cultural awareness and insights necessary for a proper understanding of basic factors for successfully planning intervention programs as well as evaluating research efforts. In other words the roles of the researcher in intervention studies need to be addressed. In a recent study, Holmila et al. [ 57 ] outlined three different positions for researchers in community intervention studies. The researcher can be an external observer, not taking part in the preventive activities - acting as an unobtrusive observer . The researcher assumes no responsibility for the design or implementation of the projects but acts as an independent conductor of process evaluation and observer of project outcomes. Another position is to be a researcher-as-technical advisor . In this role the researcher has responsibility for evaluation but also takes the responsibility for providing scientific advice on effective preventive strategies if asked for [ 58 – 60 ]. This could include training and technical assistance to the projects. Progress reports on findings as well as results from different on-going studies can be presented to the practitioners, which may use this information as they desire. A third type is researcher-as-designer , where the project is designed by the research team in partnership with the practitioner. The researcher is an active participant in project planning as well as the process of carrying it out and evaluating the effects. This approach is particularly useful when the goal is to test one or more designed prevention strategies under as close to optimal conditions as possible. Examples of such in Sweden are the STAD Project in Stockholm [ 61 ] and the Trelleborg Project [ 62 ]. The Örebro Prevention Program is an example of a program where all parts of the process were in the hands of the researchers [ 63 ].

The present paper aims to describe and analyse alcohol and drug prevention supported by the NBHW and implemented by NGOs in Sweden during 2003-2009 with a special emphasis on research and development for an evidence-based practice. The case study analyses also the integrated research strategy and its main components.

Three research questions will be addressed:

Which types of organizations and projects have received grants from the NBHW for AD prevention?

What types of research and development activities for an evidence-based practice have been included?

How can a trustful partnership develop between practitioners, national agencies, and researchers?

Methods and materials, case study approach.

A case study method was chosen as the intention was to understand a real-life phenomenon in depth and the contextual factors were highly pertinent to the study [ 64 ]. This method investigates according to Yin contemporary phenomenon in depth and within its real-life context, especially when the boundary between the phenomenon and context are not clearly evident. Moreover, the case study approach copes with the situation such as in this case in which there will be more variables of interest than data, which leads to the need for multiple sources of evidence, with data needing to converge in a triangulating fashion. Furthermore, benefits from the prior development of theoretical propositions to guide data collection and analysis [ 64 ]. The present research strategy case study is on an organisational level. It studies a social process in a situation in which we have little knowledge of the phenomenon, integration of research in alcohol and drug prevention run by NGOs. Case studies as a main research strategy are selected as this is a unique case in Sweden, the impossibility to isolate the process and the intention is to combine research and action [ 65 ].

An embedded single-case design was chosen for the study. All the projects run by the NGOs are seen as embedded units of analysis in the study with special emphasis on the fourteen in-depth studies.

Participants

The embedded case study includes 135 projects in 69 organisations and 14 in-depth process or effect studies. The participants in this research strategy case study are the NGOs applying for funding to the NBHW and especially those NGOs that have received funding during 2003-2009. The project leaders and managers in the NGOs as well as the members of the different target groups are also participants in this study. Moreover, staff at the NBHW as well as other stakeholders is included.

Case study questions

When the research program started a set of overall research questions were developed. In this paper the focus is in one of these, how can a trustful partnership for practice-based research be developed? Additional questions concerns: the role as a project leader in NGOs, the impact of competence development, methods for documentation of project development, and the added value of running projects in NGOs.

Case study protocol

A plan for the research and development activities was developed the first year and amended each year after the completion of the annual report to the NBHW. This plan consisted of several parts relating to the overall activities as well as the different in-depth studies. Notes were taken at meetings and as part of the strategy a series of presentations as progress reports were given to, project leaders, NGOs and the NBHW.

Development of a Case Study Database

In the present study a broad range of methods was used in the data collection. This includes six types of data.

Administrative data

The applications from the NGOs to the NBHW as well as the funding decisions were the initial data, which was complemented by bi-annual as well as annual progress reports from all funded projects. These reports, which were submitted following a format developed by the research team, gave information on implementation and goal achievement as well as reflections on barriers and facilitating factors. The research team introduced this approach at a meeting with the project leaders, and this reporting resulted in an annual report to the NBHW on the progress of the alcohol and drug prevention projects run by the NGOs.

Interviews and questionnaires to project leaders

Data was collected from project leaders and their organizations in the years when funding was received from the NBHW. In 2003, 2005, 2007, and 2009 all project leaders were invited to respond to a questionnaire containing questions on being a project leader in a non-governmental organization. If the same project leaders were responsible for a project for more than one year they responded to more than one questionnaire. Most of those who answered the 2003 questionnaire also answered the 2005 questionnaire, due to the fact that many of those projects receiving funding in 2003 also were being funded in 2005. In total, 84 persons participated in the questionnaire study over the years. Of these, 38 project leaders answered the questions more than one year.

Focus group discussions and seminars

Thematic discussions were held as a part of the meetings with the project leaders. These highlighted special issues related to the practice of alcohol and drug prevention. Moreover, a series of joint seminars with NGOs and the research team have been held at national and organizational conferences focusing on different projects.

Direct observations, participatory observations, interviews, and documentation of implementation of the in-depth studies

The research team collected information by a variety of methods during the planning, implementation, and evaluation of the in-depth studies. Part of this data has been used in the analysis, resulting in separate reports and scientific publications. However, in this context more process-related data will be used to give insights into the development of the partnerships between researchers and practitioners.

Consultation with the NBHW and the NGOs

In the present paper information retrieved during the management of the NBHW support to the NGOs will be an additional source of information. Regular meetings have taken place with the steering committee and the senior administrative officer, who have been the same persons during all years. The consultations with the NGOs were more intense for those organizations selected for in-depth studies, but several meetings have also taken place with other organizations. Apart of the in-depth studies was feedback on preliminary results from different studies; this never radically changed the interpretation of results but did add valuable information.

Literature review

A systematic review of the research strategies for alcohol and drug prevention has been carried out as an integral part of the research program. A number of publications related to collaboration between researchers and practitioners were found. Special thematic sections and series have been looked for. Among the key words are addiction research centre, alcohol and drug research, preventive research, practice-based research, and evidence-practice gaps.

Analytical methods

The analytical approach in this case study follows a common strategy used in research programs: to start with the ordinary preventive activities and then study what is happening [ 66 , 67 ]. Using a naturalistic approach, which is always practice-based, it has been important to let different actors and stakeholders into the knowledge-building program. This also has implications for the selection of research and evaluation methods, given a need for mixed-method approaches [ 68 – 70 ]. In studies of effects, quantitative approaches are essential, but important contributions can be achieved if qualitative studies are also included [ 71 , 72 ]. The mixed-methods approaches have been developed for some of the more extensively studied programs, which also will be included in doctoral dissertations [ 73 , 74 ].

The analysis starts with a quantitative description of the investment in NGOs by agencies awarding grants and an analysis of which organizations and projects that were supported. The types of organizations are analysed with regard to their main focus or mission. Then the investment in research is described including an overview of the participants in different empirical studies using a range of data collection methods. This includes a description of how the embedded units, the project in the NBHW portfolio, have been documented and presented in annual reports using a format for the written reports based on questions and answers in the case study database [ 64 ]. The two types of in-depth studies are briefly presented: effect studies and studies of process and implementation.

An analysis of the experiences of cross-project comparisons as well as using the multiple sources of evidence in the case study database follows. The different measures in the research program was developed in order to foster a trustful partnership is then presented. These measures were assessed by all project leaders in the annuals reporting to the research team, which reviewed the content of the research strategy each year in the annual report to the NBHW. The implementation of the research strategy with regard to evaluation initiatives together with the NGOs as well as in-depth studies was carefully documented over the years and used as indicator for developing a research partnership with the NGOs. In this case study the focus is on the implementation of the research and evaluation efforts and not on the outcome of the alcohol and drug prevention program. This has been reported in other publications [ 47 ]. The different types of data and perspectives included in the case study database are used for triangulation and finding key elements and mechanisms in the research strategy. In this case study a mixed-methods approach means parallel mixed data analysis, i.e. parallel analysis of qualitative and quantitative data from different sources. Moreover, integrated mixed data analysis also occurs in the analysis of the project portfolio and subsequent development of research initiatives. To grasp the complexity and inclusiveness of integrated methods the term inference has been proposed as the last and most important stage of research [ 70 ]. The inference process consists of a dynamic journey from ideas to results in an effort to make sense of data. In our case study the regular project leader meetings as well as the preparation of the annual evaluation and reporting to the NBHW are key activities in this process of drawing inferences. Key concepts in an integrative framework are inference quality, which is related to design quality, interpretative rigour, and inference transferability.

The results will be presented according to the three research questions. The calls for applications resulted in many proposals from many different organizations for a variety of projects engaging many project leaders.

Investing in the NGOs - Allocation of Grants 2003-2009

Since 2003 10-15 million SEK per year have been administered to this special venture (Table 1 ). The government's decisions have over the years differed somewhat according to which target groups are being specially addressed in the calls for grant applications. For the first period, which was a two-year period, the call was broad. For the second period, 2005, the main part of the grants went to projects from the earlier period. From 2006 to 2009 the target groups have been children, youth, young adults, and the workplace according to the national action plans. It has also been emphasized that the projects would be new or in the process of expanding existing activities.

About one in four applications were awarded a grant. The amount of funds provided to NGOs varies. The minimum amount of funding for one year was 40,000 SEK and the largest amount was 1,200,000 SEK. Many organizations have been funded for several years. Over the years 2003-2009 the NBHW has in total apportioned about 80,000,000 SEK to the NGOs. In addition a yearly grant has been awarded to an integrated Research & Development (R&D) program as well as funds for administration and information activities. The total allocation from the NBHW has been 95,000,000 SEK, covering 135 projects in 69 organizations funded during these years.

The projects differed in size. Table 2 presents these 219 project grants over the years 2003-2009. The reason for this lower number of project (135) is that 50 projects have been funded over more than one year, 26 projects over two years, 17 projects over three years, and two projects over four and five years each. The first period, which covered two years, had the highest number of large projects. Moreover, the number of funded project has increased between 2005 and 2008 and the number of large projects has remained relatively stable since 2005.

Organizations and projects

The strategy to involve a broad range of organizations has been successful. In Figure 2 the 69 organizations and the 135 projects are presented according to type of organization. The largest number of projects were run by the nine alcohol and drug organizations. More than half of these projects were run by the Swedish temperance organisation IOGT-NTO (24 of 38 projects) amounting to 15 million SEK. The majority of these were small one-year projects, except for two programs where effect studies were conducted by the research team and the organization jointly. Between 15 and 20 projects were run by organizations focusing on social work, assistance, and ethnic groups. About 10 projects were run by sports, adult education, and religious organizations respectively. Furthermore, 14 projects were set up by two umbrella organizations each consisting of a number of member organizations.

Organizations and projects in different types of organizations according to main objectives .

The projects have different primary target groups for their activities. A majority of the projects have children or adolescents as target groups. Some of these projects are focused on young girls with the aim of promoting self confidence and a positive self image. Sports organizations have been developing alcohol and drug policies including anti-doping initiatives. Projects run by ethnic groups have as their target group members of their organizations including children, adolescents, and parents. A few projects have the workplace as the arena for intervention.

During the first years, three community-based projects were funded. These aimed to reduce drugs in two parts of Stockholm and the island Gotland. The strategy included a range of activities and collaboration with different actors. A broad membership in the organizations seems to be important for the sustainability of the community-based prevention.

Only one project has reduction of availability as its focus. This project focused on following up the alcohol legislation concerning the sale of beer to minors in Sweden [ 75 ] and the effect of different strategies to influence shops to comply with the law [ 74 ].

Internet has a great potential in promotion and preventive work [ 76 ]. The majority of the organizations have their own website on the Internet and about one third have a project-specific site. The organizations used information technology as a source of health information in three projects, as an intervention medium in four, for professional development in two, and as a research instrument in one project. The use of e-screening as a tool for drug prevention is studied by researchers at Karolinska Institute. There are still very few scientific evaluations of the use of Internet in drug prevention [ 77 ].

Basic characteristics of the project leaders in the alcohol and drug prevention projects are given in Table 3 . All four years the proportion of women was larger than men; about two of three project leaders were women. Most of the project leaders belonged to the age group 41-50 years in the early periods (2003/2005) while in the later periods (2007/2009) an increased proportion of the project leaders were 50 years or older. Moreover, nearly one in ten project leaders was 30 years or younger. Many of the project leaders in volunteer work were members of the organization before being appointed project leaders (Table 3 ). In 2003 eight of ten project leaders were members compared with four of ten in 2007 and 2009. Nearly half of the project leaders were also doing volunteer or non-paid work in the organization. No gender differences were found in the prevalence of non-paid work.

Investing in Research and Development

A research and evaluation strategy was developed by the research team at the School of Health and Medical Sciences, Örebro University. This strategy rests on collaboration with the NGOs through regular meetings with all project leaders, development of systematic documentation of project objectives, activities, and results, annual reports to the NBHW, and biannual national conferences Reflections on prevention (2006, 2008, and 2010). The role of the researchers can most closely be characterized as researchers as technical advisors . In some projects the researcher had the position of an unobtrusive observer -for instance in following up some projects in which no longitudinal data collection was included. In addition, in no project did the researcher have the position of researcher as designer . Moreover, separate competence development and discussion of evaluation studies were conducted with a smaller number of organizations. The steering committee at the NBHW also decided, after consulting the research team, on a number of in-depth studies. Fourteen such studies were included in the funding from the NBHW (Table 4 ). The research team was also involved in three additional studies funded by other sources. These studies focused on policy development in the Swedish Football Confederation, evaluation of regional collaboration against illegal alcohol, and alcohol prevention in Novgorod, Russia.

This set of studies included systematic collection of data from children, parents, and actors in projects. A description of the empirical studies carried out between autumn 2003 and spring 2009 is given in Table 5 . Different methods, including questionnaires, personal interviews, telephone interviews, and focus group interviews, have been used depending on the purpose of the study. The main research questions have been related to the process or effect evaluations of these projects. The majority of the studies have been carried out with adolescents, as many of the projects receiving grants from the NBHW are targeting adolescents for the purpose of preventing alcohol and tobacco use. In three studies, data have been collected from both adolescents and parents, and two of these are longitudinal studies with adolescents and their parents. Dyads of adolescents and parents are identified and have been followed over the three years of secondary school. All youth surveys have been carried out in a school environment while the questionnaires to the parents have been sent by mail. Municipalities, schools, and organizations across Sweden have participated in the studies. There are many advantages with the partnerships that have been developed between the research team and the project leaders within the NGOs. For example, the large scale of the studies that have been carried out during the six years could not been managed without this cooperation. The project leaders have done much of the practical work locally, such as the dialogue with participating schools and organizations, distribution of questionnaires, and sometimes also feedback to participants.

What types of research and development have been included?

All projects in the project portfolio had to submit semi-annual and annual reports. These reports were analysis and synthesized into an annual report to the NBHW. This was based on a reporting format using questions for different important elements in the projects as well as key aspects of project management. The preparation of the annual reports included cross-project comparisons with regard to the case study questions, which resulted in some amendments and changes over the years in the research and development activities.

After the decision on potential projects for in-depth studies, planning meetings were convened with the project leaders and managers in the NGOs. Based on the project proposals and joint planning between the project leaders and the researchers, a plan for the in-depth studies was developed. Depending on the evaluation and research questions and available resources the focus, design, process, and outcome measures were set (Table 6 ). The overall results were positive; ten of the fourteen in-depth studies were completed. One project did not succeed in recruiting high-risk parents to a parental support program (IOGT-NTO Centro). Three projects were only partially completed: one started before the research team was organized, making the evaluation impossible (IOGT-NTO: Dare/Young and King); one was cancelled after a decision by the municipality (SMART Västernorrland); and in one it was impossible to follow up information from policy-makers due to a low response rate (Makalösa föräldrar). Eleven of the in-depth studies started during the first period (Table 4 ). There were some common research questions such as the effects of the projects. The NGOs wanted their approach to be studied in such a way that, in the event of positive results, the program could be regarded as evidence-based.

Effect Studies

Seven projects were considered for evaluation with effect studies, which were planned for all seven projects. However, one project was unsuccessful and two only partially completed due to overly limited implementation. One project was already implemented when the research group was appointed. It was nevertheless possible to plan and successfully complete effect studies even with short-term yearly funding.

KSAN "About small things"

The aim of this project was to develop and test an early intervention targeting pregnant women to prevent alcohol injuries in unborn children. The project was developed by the KSAN, an umbrella organization for women's organizations concerned with alcohol and drug issues, and the Swedish Association of Midwives. It was implemented in a maternal health centre in Stockholm. A randomized controlled study was completed with 454 mothers randomly assigned to either receiving an information folder with the message "Pregnancy is not a time for risk-taking" sent to their home after the telephone contact for booking the first visit to the midwife, or getting the folder during their first visit to the midwife. The effects of the intervention were measured by a questionnaire that the pregnant women answered at the maternal health centre before they met with the midwife.

IOGT-NTO: Strong and Clear

Strong and Clear is a parental support program targeting parents with children aged 13-16 years. It is a universal program aiming to prevent drinking among adolescents and to maintain parents' restrictive attitudes concerning adolescents and alcohol. The program is manual based and includes thirteen activities during the three years of secondary school. The parents can sign up for the program during the whole period the program is carried out. There are both group and self-administered activities divided into four types: parent meetings, family dialogues, friend meetings, and family meetings. The program was implemented in six schools.

The research program includes the effect study, which was designed as a longitudinal quasi-experimental study, and studies of parental attitudes and behaviour with regard to adolescents and alcohol [ 78 ] as well as reasons for non-participation [ 73 ]. In the longitudinal study, 706 children and 613 parents participated in the baseline questionnaire, which was followed by repeated data collection in the two following school years.

IOGT-NTO: Parents Together

The program Parents Together consists of three parents' meetings during three years in secondary schools. The intention is to motivate the class parents to come to an agreement on the following issues: "We enforce the 18-year limit for alcohol; We will not provide each other's children alcohol; We will get in touch with each other if we see a child we know who is not sober, is behaving badly, or is out at times and places where we would not want our own children to be."This agreement is used to strengthen the cooperation among parents. The idea is that this will make a difference with respect to the children's alcohol use. A parent-teachers meeting is held each year to update the agreement.

The design of the study is a cluster randomized controlled study in Swedish secondary schools with seven intervention and six control school. The study included almost 2000 pupils and their parents. The program Parents Together was carried out over three years in the seven intervention schools with a start in both school years 7 and 8 (Figure 3 ). The six control schools have been offered the program for parents whose children are in year 7 in the spring 2009 and the program will follow in the years 2010 and 2011. To reveal effects of the program the evaluation also includes a questionnaire about the prevention work in schools and implementation reports. The non-governmental organization IOGT-NTO is responsible for the program and the implementation in the seven intervention schools. To maintain the cooperation between the thirteen schools, the NGO, and the research team, an agreement has been signed. The agreement includes information about the responsibilities of each party such as that the researchers should the results of surveys, within six months after the data collection, are published on the website.

Design of the intervention and evaluation of the program Parents Together .

IOGT-NTO Centro: Parental Support

This project was planned to include before and after questionnaires to high risk parents. However, the project did not succeed in attracting this type of parents to the program.

Hassela solidaritet: Peer Support in School

This NGO works with training and assisting school children to be peer supporters in their own school. The aims of the project are to prevent social exclusion by reducing teenage alcohol consumption, experimentation with drugs, and bullying through peer support in schools, and to promote a school that is a positive, creative, and stimulating workplace for all. The program was first implemented in one part of the school, and was planned to be extended to the whole school. Subsequent implementation in a second school was planned. However, this extended implementation was only partly carried out due to limited resources. The evaluation included focus group interviews with peer supporters and repeated cross-sectional questionnaires to schoolchildren in school years 7-9 in the two schools.

National Federation SMART: SMART Västernorrland

The main objective of this NGO is to prevent or postpone alcohol, tobacco, and other drug use among children through positive reinforcement and signing of contracts. The parents sign the contract together with their child. The content of these contracts varies between local organizations. The membership gives the child positive benefits reinforcing positive behaviours. The program was implemented in a Swedish county, Västernorrland. The evaluation plan included an effect study among schoolchildren in Kramfors, a study of parents, and an interview of stakeholders in the county. The program was cancelled by the municipality of Kramfors with negative consequences for the effect study, which had been planned as a repeated cross-sectional study of schoolchildren in years 4-9. Data was collected with questionnaires and during the three years, 2,052 children answered the questionnaire. The research team decided to implement the evaluation as planned even if there was no intervention the third year.

The Swedish Youth Temperance Movement (UNF): Folk Beer Project

The Non-governmental organization UNF is a politically and religiously independent organization. They are a sister organization to IOGT-NTO (The Swedish Temperance organization), which is a part of the International Organization of Good Templars. All members are between 13 and 25 years of age. To be a member you have to be a teetotaller. The activities are of different kinds, for example arranging theatrical performances, discos, cafés, study circles, and a large number of courses. Besides dealing with alcohol regulations and politics regarding alcohol, they also work with international exchange and democracy issues. Their vision is a democratic and socially responsible world free from drugs. Although they are politically independent, their task is to act politically in letting the politicians know which issues are important to them. UNF has an almost 40-year history of conducting underage alcohol purchase attempts.

In 2003 UNF applied for funding for a new idea. They wanted to compare two different strategies that included underage purchase attempts. The first was an elaboration of their earlier method, which meant confronting the media with the results of the purchase attempts, reporting the check-out clerks who sold them beer to the police, and informing the municipalities of which stores that sold beer to minors. The other method was based on the idea to actively seek cooperation with the retail grocery sector, the municipality's alcohol administrator or drug coordinator (the municipalities are organized differently), the police, and the labour unions. The evaluation program was designed as a quasi-experimental study and as a follow up of the alcohol legislation concerning the sale of beer to minors in Sweden [ 75 ] and of the effect of different strategies to influence the shops to comply with the law [ 74 ].

Studies of Process and Implementation

Seven of the in-depth studies focussed on the working process in the projects. Three projects were community-based and had a clear geographical area where the programs were implemented. Motgift Gotland was an alliance for preventing the use of narcotics on the island of Gotland. Söder mot Narkotika was also an alliance against narcotics in a central district (Södermalm) of the capital Stockholm. A broad range of agencies and organizations collaborated in these efforts. A third community-based project was run by Verdandi Tensta Rinkeby. The three community-based projects were studied during 2005-2006 and included interviews with stakeholders and actors in the projects. A lesson learned is that community-based prevention needs to have broad support and cannot depend heavily on individual project leaders.

Verdandi: Get safe in Tensta - Rinkeby. Meet us!

An in-depth analysis was made of the third project in order to uncover their successful strategy. Verdandi, founded in 1896, is a Swedish workers' organization striving for social justice and a society free from alcohol-related injuries. From the very beginning, Verdandi - as an independent organization within the workers' movement - has aimed to improve people's social and financial situations. Today's aim is to analyse the development of society through the experiences and voices of those who are not heard otherwise. People of all ages, in all parts of the country, may participate in Verdandi's activities, which are quite different from place to place since they are based on local needs. According to Verdandi, without a local angle, the organization would soon lose touch with reality as well as lose credibility and members.

Verdandi runs activities for youth. The project includes support for children both in school and after. The youth in the organization can use a facility in the neighbourhood in their leisure time. Youth activities have focused on "the young leading the young" and the project has demonstrated young people's ability to organize and run a rewarding activity in the evenings and on weekends. The aim of this prevention program is to empower young people in their daily lives and help them empower their friends. This, according to the organization, contributes to young people avoiding drugs, and the neighbourhood has become calmer and safer. The activity has a bottom-up nature and the youth are involved in the planning. They have the opportunity to develop activities and thereby affect their daily lives. Among the success factors, according to the in-depth study, are: confidence in the organization, equality, youth involvement and power, memberships, support from the parents, training of leaders, common norms and roles, volunteer work, easily accessible premises, and a leadership that facilitates democratic processes.

IOGT-NTO: Dare/Young and King

This program is a redesigned version of the American program DARE [ 79 ], which was implemented before the research group was appointed. However, an adult education component, Young and King, aiming to strengthen parents was implemented and a follow-up study was completed of this component of the program.

IOGT-NTO:s Juniorförbund: Junis sisters

In this project, groups of schoolgirls in years 5 and 6 are organized with the objective to strengthen their self-esteem and promote meaningful leisure activities and thereby delay the onset of alcohol consumption by the girls. The evaluation focused on the group leaders, who were interviewed in focus groups. A lesson learned is that special effort must be put into recruiting and assisting group leaders to achieve sustainable programs.

Makalösa föräldrar: Single Parent with Teenagers

The project consisted of two main parts. One part focused on improving the knowledge about how it is to be a single parent with a teenager in the family. A survey of single parents was done in a part of Stockholm and a small newsletter was produced. The other part included self-help groups for single parents and summer camps. The evaluation of the self-help groups consisted of follow-up questionnaires to participants. An unsuccessful part of the evaluation was the follow-up of the newsletter, which was well planned and properly designed. It was not possible to get feedback from policy-makers on the publication, which may be due to lack of awareness of the publication and its contents.

The Swedish Ice Hockey Association: School Ambassadors

The project aimed to train top athletes to become school ambassadors in order to influence the attitudes of schoolchildren and give them the opportunity to try out ice hockey. Moreover, the project was also an attempt to improve the collaboration between schools and top ice hockey clubs. In the second year the specialized ice hockey secondary schools were included in the program. The evaluation consisted of following up the training of the athletes and studying the work of the secondary school ice hockey players by means of a questionnaire to schoolchildren.

In order to promote the development of a partnership a series of measures were implemented (Table 7 ). All project leaders were invited to regular meetings, which were held in Örebro as well as in Stockholm, Gothenburg, and Malmö. The agenda included presentation of project plans, information from the NBHW, and the research and development activities by the research team. Thematic lectures and discussion on issues such as the art of project management, measures to reach target groups, media advocacy, Internet as a tool for prevention, and planned communication were held at different meetings. The main objective of these meetings was to promote exchange of experiences and learning in order to strengthening the quality of the implementation of the projects as well as networking. Moreover, the systematic bi-annual and annual reports were introduced and discussed.

Depending on the needs of the different projects special project dialogues and consultations were held between individual projects, or a small group of similar projects, and the research teams. The results of these meetings ranged from refinement of project ideas to long-term collaborations. All in-depth studies started with such meetings. The competence development took different forms. In the first period an academic training program in alcohol and drug prevention was offered to the project leaders, of whom about 10 participated. Supervision in groups was implemented in three groups during the first two years, and thereafter one or two groups were run by independent supervisors annually. During 2009 the research team arranged more project leader meeting including training in project management as an alternative to supervision.

The in-depth studies were also an important measure to foster the partnership between the NGOs and the research team. Due to available resources, more extensive process and effect evaluation activities could only be implemented in a limited number of projects. Many more projects asked to be the focus of in-depth studies than the fourteen that were initiated.

The research team together with the NBHW arranged a national conference Reflections on prevention - Collaboration for better alcohol and drug prevention. Conferences were arranged in the spring of 2006, 2008, and 2010. Among the key issues discussed at the first conference were the role of parents in prevention, adolescents, community-based approaches, and supply-reducing initiatives. The second conference also discussed the role of civil society and how to promote more effective cooperation among the different stakeholders. The third conference focussed on evidence and evidence-based practice, which have received increased attention in Sweden in many sectors of society. A main emphasis has been setting the context for reflection and sharing of experiences among the participants at the conferences; therefore a series of seminars with project presentations and panel discussions have been part of the conferences. Moreover, plenary sessions as well as theatrical performances further set the stage for professional dialogues on alcohol and drug prevention. The conferences have been well received and have attracted actors from different sectors of society as well as national agencies and NGOs.

In the annual reports the project leaders also assess the implemented measures by the researchers. These have guided the future efforts of the research team. As an example, the assessments made in January 2005 are presented in Figure 4 . The financial support was very important, followed by the support from the NBHW, the project leader meetings, and the supervision. One third of the project leaders regarded the support for the documentation as very important. The academic training in alcohol and drug prevention was regarded as very important by one fifth of the project leaders, which is a high proportion given that only a small group participated in the distance education course. Only eight projects were at that time included in the in-depth studies, nevertheless one third of the project leaders reported this measure as very important. The case study data bank includes information for questionnaires, interview and other data sources for the assessment of the implementation of the research strategy.

Assessment by project leaders of measures to improve collaboration between NGO and research in 2006 .

The research strategy has been successfully implemented despite the fact that only some projects were running more than one year while new projects and project leaders are included every year. The first two years a focus in the meetings with the project leaders was on the in-depth studies which were presented by the organisations and the researchers. Then the focus changed to addressing common concerns among the project leaders such as how to reach target groups, use of Internet, different type of prevention projects and mass communication skills. The presentations from the research teams were more concentrated to the national conferences that were organized bi-annually. The networking between the projects also resulted in new applications jointly by two organisations.

An important element was the relationship between the NBHW and the research team at Örebro University. During this period the NGO portfolio was managed at the NBHW by the same senior official. However, the department director changed three times during this period. The members of the working committee also changes over the years. The chairman was the same during all years. The support to the research and development activities was nevertheless maintained and also renewed for another year. The continuity with regard to persons seems to be very important for such an endeavour as included in this case study.

Discussion - towards practice-based research for alcohol and drug prevention

The integration of the research and development component into the support from the NBHW resulted in a unique possibility to do comparative studies involving, among other things, project management and implementation as well as project results. The measures to promote a partnership for practice-based research also improved the quality and success of the different projects. A few of the in-depth studies were unsuccessful due to factors hindering the implementation, and in several cases these factors were related to a lack of resources on the part of collaborating partners in the municipalities or other organizations.

The research strategy has been based on the overall aim to contribute to the evidence base for alcohol and drug prevention, an emphasis that this field shares with health promotion, prevention in general, and social work [ 2 – 8 ]. The current development of practice-based research will give more relevant knowledge and our research program attempts to be a part of this trend. Moreover, the utilization of research results may also be improved if studies on efficacy, effectiveness, and dissemination are promoted [ 18 ]. The strategy that the NBHW developed in this program of governmental support to NGOs was an attempt to bridge this gap as described by Nutbeam [ 10 , 11 ]. This challenge for agencies to respond to the push from the funders and pull from the communities has been noted by Green and Mercier [ 23 ] and the public health researcher also needs to leave the university campus to get involved in more practice-based research. Our research program has developed along such lines.

The research strategy includes the use of qualitative, quantitative, and mixed methods. This means that data collection and data analysis are done using guidelines for these three traditions. The challenge is most apparent with regard to inference and integration. In the stages of inference in a study, quality issues such as internal and external validity in the quantitative approach and aspects of credibility, confirmability, and transferability in the qualitative approach are pertinent. Integration is the mixed-methods approach of working across strands and using meta-inferential issues related to the integration of findings and inferences from the two strands. Here design quality, interpretative rigour, and inference transferability have been proposed as indicators of quality [ 70 ]. In this research strategy case study, the set of research entities changed each year due to the funding of applications from NGOs by the NBHW. The present study covered a six-year period, and the stages of inference and integration were completed yearly in the preparation of the annual reports to the NBHW.

The research strategy also includes elements of participatory research. The organizations were involved in developing the main research questions in the in-depth studies. Sometimes the organizations also assisted in collecting questionnaires from school children; in making participatory observations, as in the studies of beer purchasing by minors; or in providing feedback to school staff and target groups, as in the parental support programs. Moreover, the organizations also played a role in discussing preliminary results as part of a validating process for the empirical studies. These discussions never changed the interpretations of the findings but often gave more insight into the noble art of implementation of preventive programs. Nevertheless, as in other research programs, a number of methodological challenges had to be dealt with. The resources were limited, which gave room for only a small number of in-depth studies. Therefore the research strategy included additional elements such as support to documentation as well as support to the project leaders in meetings and management training. The selection of these studies was mainly done by the steering committee at the NBHW. The research team developed a proper design for these studies based on the assessed potential for a successful implementation and possible options given the resources available for effect or process studies. Then the choice of methods for data collections was reviewed and target groups for the evaluation research selected. In this process the best choice from an academic point of view was often not possible due to limited staff and other resources. Nevertheless, the research program resulted in data collected from 9,568 children, 4,832 parents and 327 actors or stakeholders. Moreover, it was possible to carry out two large longitudinal studies of children and their parents in this research program. Even if the funding was granted annually, it was possible to think and plan on more long-term basis.

A broad range of organizations received project funding from the NBHW. Although the largest number of projects was run by the nine alcohol and drug organizations, the alcohol and drug prevention was successfully integrated into a range of organizations with other main objectives. Moreover, the project leaders also came from different societal sectors. This was an intended effect of the governmental initiative to strengthen the alcohol and drug prevention in Sweden. This led to another methodological challenge caused by the fact that the programs were so different. The research team developed questionnaires with common modules that could be used in different evaluations thus giving them access to data from schoolchildren and parents in different contexts and programs. This made it possible, for instance, to study the reasons for non-participation in parental support programs [ 73 ]. Another added value related to this was the possibility to organize a study of project management through a special study of the project leaders, which was integrated into the overall design of the support from the NBHW.

A challenge for the research team was that the funding for the research as well as for the alcohol and drug projects was decided annually by the NBHW. However, the research was planned with a longer time period in mind, which has actually led to a research program that has been running more than six years. A more long-term grant would have been beneficial for the development of a partnership between the NGOs and the research team. In order to overcome this barrier a multi-year agreement has been signed for the newer in-depth studies, but it was still signed on the condition of renewed funding the following year. Nevertheless, a trustful partnership was developed between all three partners: the practitioners in the NGOs, the national agencies, and the researchers. In many cases the planning and implementation were done jointly, dividing the responsibilities according to skills and keeping the roles clear and feasible to complete successfully. The validity of the results was also a major concern as well as an emphasis on a participatory approach to the research process.

Ethical concerns were very important, as stipulated by Swedish law. The effect studies were assessed by the regional research ethics boards. However, it is also important to analyse if the NGOs have vested interests in the research process. Government agencies as well as NGOs can also have a vested interest in scientific research, such as when science is misused to benefit a particular political agenda, ideology, or favoured interest group [ 80 ]. However, the problem of vested interests is more dangerous when key parts of the government sector are in conflict over their public health responsibilities; for instance health sector engagement in partnership arrangements with addictive consumption industries (particularly alcohol, tobacco, and gambling) entails too many risks [ 81 ]. In our case there have been shared visions and objectives between the government agency and the NGOs, which guided the developmental activities as well as the research work. Moreover, the division of responsibilities between the NGOs and the researcher was important. The NGOs had the responsibility for developing the proposals, conducting the interventions, and implementing the preventive programs or initiatives. The researchers had the responsibility for planning the effect evaluations after consulting with representatives of the NGOs, as well as for implementing the research components, analysis, and reporting of results, including dialogues about the outcomes, and presenting the findings for the NGOs.

The organization of the research program under the auspices of public health science at Örebro University was natural as the principal investigator holds a professorial chair in public health there. During the first two years, other members of the research group were formally employed by an NGO but worked at the university campus in Örebro. All members of the research team were subsequently offered employment at the university, giving the research team a formal independence from all NGOs.

The addiction research centres have mandates that are broader than the present research program. The centre in Michigan has the mission to develop new knowledge about the cause, course, and consequences of substance use disorder and to train the next generation of researchers [ 28 ]; and the Canadian centre in British Columbia to create an internationally recognized centre distributed across BC that is dedicated to research and knowledge exchange on substance use, harm reduction, and addiction [ 27 ]. The Swiss institute is primarily involved in collecting alcohol-related information and making it available to professionals and the general public. The Swiss Institute will continue to monitor substance use, while stepping up its prevention research activities and ensuring that it is able to react promptly to emerging phenomena [ 25 ]. Our small research team is attempting to fill a gap in knowledge about the NGO alcohol and drug prevention efforts as these offer unique opportunities [ 82 ].

The research strategy was successful in establishing prevention research for alcohol and drug prevention by NGOs, which previously had been lacking in Sweden. Moreover, added value came from having meetings for project leaders, and the capacity building led to new innovative collaboration between different NGOs, which resulted in new applications for funding and successful implementation of new initiatives. The administrative support for improving the documentation of the implementation and progress of the projects was also recognized as beneficial for the practitioners and the national agency as well as the researchers. The best approach is always transparency and discussion, disclosure and debate [ 83 , 84 ].

A weakness in the research strategy was that the funding was not sufficient for more than a limited number of in-depth studies. The role of researchers-as-technical advisors was suitable for the fostering of a trustful partnership for research and development. The independence of the NGOs was regarded as important for the momentum in the project implementation. It was beneficial because it gave the research team opportunities to address other issues. From a strictly research point of view it would have been of interest to see what could be achieved by researchers-as-designer , but this would have been very costly and all funds allocated to the integrated research activities would have been consumed by just one project. In other words, the present research strategy can be regarded as cost-effective.

The overall strategy for research and development includes capacity building for both the practitioners in the NGOs and the research team, and two doctoral dissertations will be finalized during the coming year. The NBHW has also noted that, given the limited duration of funding, this organization of knowledge development - as an integral part of the support to NGOs - is beneficial, which is indicated by the annual renewal of the contract with Örebro University. Moreover, the much more extensively funded projects in municipalities, regions, and counties still lack this strategic element. At present there is a trend that some larger governmental grants are given to such parties, but a mandatory linkage to universities for research is included in the call for proposals. This could lead to similar forms of trustful partnerships as found in the present research strategy case study.

The in-depth studies in this research strategy varied in content, design, and size. A common element was that they were program-driven and not research-driven interventions [ 9 ]. This may give the studies improved external validity [ 54 ]. The research strategy aimed at improving the evidence-base for alcohol and drug prevention. In our case this has meant using qualitative, quantitative, and mixed methods, as well a variety of designs to answer questions in practice-based settings. Including feedback and dialogue with the NGOs has further contributed to sustainable AD prevention in different settings. The missions of the NGOs differ, but the AD prevention has been included as an essential part of their activities, which in many cases meant that AD prevention has received increased priority. Moreover, the integrated research program has also been seen as beneficial and important for the organizations, which often wanted their programs to be recognized as evidence-based. Therefore, the demand for research by the NGOs is larger than what we can supply at present. This is a challenge to the funding agencies as well as research bodies. The addiction research centres seem to nurture creativity but often lack the networks and priorities for preventive research. It is important to go beyond the notion that a lack of evidence for a program is necessarily a sign of a lack of effectiveness. Therefore, practice-based research and collaboration between decision-makers, national agencies, NGOs, local authorities and researchers is needed. Using a combination of different and interactive measures it was possible to over the years built a trustful partnership between these parts. This research strategy case study shows that it is possible even in such a dynamic field as alcohol and drug prevention in NGOs where the organisations are competing for grants from the NBHW. There are added values in supporting a research group assigned to a project portfolio instead of having a series of smaller independent evaluations.

This research strategy case study shows that it is possible to integrate research into alcohol and drug prevention programs run by NGOs, and thereby contribute to a more evidence-based practice. A core element is developing a trustful partnership between the researchers and the organizations. Competence development is necessary for developing evidence for policy and practice. Given research groups assignments to address the knowledge development issues is better than having minor evaluation in individual projects. Moreover, the funding agency must acknowledge the importance of knowledge development and allocating resources to research groups that is capable of cooperating with practitioners and NGOs.

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Acknowledgements

The authors are very grateful to all the NGOs that have shared their efforts and experiences with the research team. We would also like to acknowledge Åke Setréus for his support and encouragement during the whole period. The Swedish National Board of Health and Welfare supported the study.

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The four authors of the manuscript are presented in alphabetical order and their shares of the responsibility for the paper are equal. CE is the principal investigator for the research program integrated in the NBHW support to NGOs for alcohol and drug prevention. CE, ML, and CP were involved in all aspects of the program as well as this study. SG was involved in the planning, project implementation, and writing of the section on NGOs. All authors read and approved the final manuscript.

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Eriksson, C., Geidne, S., Larsson, M. et al. A Research Strategy Case Study of Alcohol and Drug Prevention by Non-Governmental Organizations in Sweden 2003-2009. Subst Abuse Treat Prev Policy 6 , 8 (2011). https://doi.org/10.1186/1747-597X-6-8

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Understanding alcohol use disorder.

Alcohol use disorder (AUD) is a medical condition characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences. It encompasses the conditions that some people refer to as alcohol abuse, alcohol dependence, alcohol addiction, and the colloquial term, alcoholism. Considered a brain disorder, AUD can be mild, moderate, or severe. Lasting changes in the brain caused by alcohol misuse perpetuate AUD and make individuals vulnerable to relapse. The good news is that no matter how severe the problem may seem, evidence-based treatment with behavioral therapies, mutual-support groups, and/or medications can help people with AUD achieve and maintain recovery. According to the 2022 National Survey on Drug Use and Health, 28.8 million adults ages 18 and older (11.2% in this age group) had AUD in 2021. 1,2 Among youth, an estimated 753,000 adolescents ages 12 to 17 (2.9% of this age group) had AUD during this time frame. 1,2

What Increases the Risk for Alcohol Use Disorder?

A person’s risk for developing AUD depends in part on how much, how often, and how quickly they consume alcohol. Alcohol misuse, which includes binge drinking  and heavy alcohol use , over time increases the risk of AUD. Other factors also increase the risk of AUD, such as:

• Drinking at an early age. A recent national survey found that among people ages 26 and older, those who began drinking before age 15 were more than three times as likely to report having AUD in the past year as those who waited until age 21 or later to begin drinking. 3 The risk for females in this group is higher than that of males.
• Genetics and family history of alcohol problems. Genetics play a role, with hereditability accounting for approximately 60%; however, like other chronic health conditions, AUD risk is influenced by the interplay between a person’s genes and their environment. Parents’ drinking patterns may also influence the likelihood that a child will one day develop AUD.
• Mental health conditions and a history of trauma. A wide range of psychiatric conditions—including depression, post-traumatic stress disorder, and attention deficit hyperactivity disorder—are comorbid with AUD and are associated with an increased risk of AUD. People with a history of childhood trauma are also vulnerable to AUD.

What Are the Symptoms of Alcohol Use Disorder?

Health care professionals use criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), to assess whether a person has AUD and to determine the severity, if the disorder is present. Severity is based on the number of criteria a person meets based on their symptoms—mild (2–3 criteria), moderate (4–5 criteria), or severe (6 or more criteria).

A health care provider might ask the following questions to assess a person’s symptoms.

In the past year, have you:

• Had times when you ended up drinking more, or longer, than you intended?
• More than once wanted to cut down or stop drinking, or tried to, but couldn’t?
• Spent a lot of time drinking, being sick from drinking, or getting over other aftereffects?
• Wanted a drink so badly you couldn’t think of anything else?
• Found that drinking—or being sick from drinking—often interfered with taking care of your home or family? Or caused job troubles? Or school problems?
• Continued to drink even though it was causing trouble with your family or friends?
• Given up or cut back on activities you found important, interesting, or pleasurable so you could drink?
• More than once gotten into situations while or after drinking that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area, or unsafe sexual behavior)?
• Continued to drink even though it was making you feel depressed or anxious or adding to another health problem? Or after having had an alcohol-related memory blackout?
• Had to drink much more than you once did to get the effect you want? Or found that your usual number of drinks had much less effect than before?
• Found that when the effects of alcohol were wearing off, you had withdrawal symptoms, such as trouble sleeping, shakiness, restlessness, nausea, sweating, a racing heart, dysphoria (feeling uneasy or unhappy), malaise (general sense of being unwell), feeling low, or a seizure? Or sensed things that were not there?

Any of these symptoms may be cause for concern. The more symptoms, the more urgent the need for change.

What Are the Types of Treatment for Alcohol Use Disorder?

Several evidence-based treatment approaches are available for AUD. One size does not fit all and a treatment approach that may work for one person may not work for another. Treatment can be outpatient and/or inpatient and be provided by specialty programs, therapists, and health care providers.

Medications

Three medications are currently approved by the U.S. Food and Drug Administration to help people stop or reduce their drinking and prevent a return to drinking: naltrexone (oral and long-acting injectable), acamprosate, and disulfiram. All these medications are nonaddictive, and they may be used alone or combined with behavioral treatments or mutual-support groups.

Behavioral Treatments

Behavioral treatments—also known as alcohol counseling, or talk therapy, and provided by licensed therapists—are aimed at changing drinking behavior. Examples of behavioral treatments are brief interventions and reinforcement approaches, treatments that build motivation and teach skills for coping and preventing a return to drinking, and mindfulness-based therapies.

Mutual-Support Groups

Mutual-support groups provide peer support for stopping or reducing drinking. Group meetings are available in most communities at low or no cost, and at convenient times and locations—including an increasing presence online. This means they can be especially helpful to individuals at risk for relapse to drinking. Combined with medications and behavioral treatment provided by health care professionals, mutual-support groups can offer a valuable added layer of support.

Please note: People with severe AUD may need medical help to avoid alcohol withdrawal if they decide to stop drinking. Alcohol withdrawal is a potentially life-threatening process that can occur when someone who has been drinking heavily for a prolonged period of time suddenly stops drinking. Doctors can prescribe medications to address these symptoms and make the process safer and less distressing.

Can People With Alcohol Use Disorder Recover?

Many people with AUD do recover, but setbacks are common among people in treatment. Seeking professional help early can prevent a return to drinking. Behavioral therapies can help people develop skills to avoid and overcome triggers, such as stress, that might lead to drinking. Medications also can help deter drinking during times when individuals may be at greater risk of a return to drinking (e.g., divorce, death of a family member).

If you are concerned about your alcohol use and would like to explore whether you might have AUD, please visit the Rethinking Drinking website .

To learn more about alcohol treatment options and search for quality care near you, please visit the NIAAA Alcohol Treatment Navigator .

For more information about alcohol and your health, please visit: niaaa.nih.gov

1  SAMHSA, Center for Behavioral Health Statistics and Quality. 2022 National Survey on Drug Use and Health. Table 5.1A—Substance use disorder for specific substances in past year: among people aged 12 or older; by age group, numbers in thousands, 2021 and 2022 [cited 2023 Dec 29]. Available from:  https://www.samhsa.gov/data/sites/default/files/reports/rpt42728/NSDUHDetailedTabs2022/NSDUHDetailedTabs2022/NSDUHDetTabsSect5pe2022.htm#tab5.1a  

2 SAMHSA, Center for Behavioral Health Statistics and Quality. 2022 National Survey on Drug Use and Health. Table 5.1B—Substance use disorder for specific substances in past year: among people aged 12 or older; by age group, percentages, 2021 and 2022 [cited 2023 Dec 29]. Available from: https://www.samhsa.gov/data/sites/default/files/reports/rpt42728/NSDUHDetailedTabs2022/NSDUHDetailedTabs2022/NSDUHDetTabsSect5pe2022.htm#tab5.1b

3  Age at drinking onset: age when first drank a beverage containing alcohol (a can or bottle of beer, a glass of wine or a wine cooler, a shot of distilled spirits, or a mixed drink with distilled spirits in it), not counting a sip or two from a drink. AUD: having met two or more of the 11 AUD diagnostic criteria in the past-year according to the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) AUD risk across different ages at drinking onset is compared using the prevalence ratio weighted by the person-level analysis weight. Derived from the Center for Behavioral Health Statistics and Quality 2022 National Survey on Drug Use and Health (NSDUH-2022-DS0001) public-use file. [cited 2024 Jan 12]. Available from: https://www.datafiles.samhsa.gov/dataset/national-survey-drug-use-and-health-2022-nsduh-2022-ds0001

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For people with mental illness, drugs and alcohol can be a key survival strategy. I’ve learned they shouldn’t have to ‘get clean’ to get treatment

Mental Health Social Worker and PhD Candidate, Staffordshire University

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A decade ago, while working in a women’s prison, I met a young woman whose story would leave an indelible mark on me. She had endured severe abuse at the hands of men, and I was initially concerned that, as a male social worker, my presence might rekindle her trauma. Yet, through careful and considered engagement, we were able to forge a relationship of trust.

Jenny* confided in me that heroin had become her refuge – the only respite that quieted the relentless storm of her thoughts. But her dependency had brought dire consequences: the removal of her children and her subsequent imprisonment for possession with intent to supply. Even so, Jenny told me that before she was imprisoned: “Heroin was the only thing that helped me to cope.”

While inside, she experienced regular flashbacks and profound anxiety. Her treatment regime included antipsychotic medication Seroquel and heroin replacement Subutex – but Jenny didn’t use them conventionally. “The only way they help is if I grind them together and snort them,” she explained. This method provided her a fleeting, euphoric respite from her psychological torment.

Across the world, we’re seeing unprecedented levels of mental illness at all ages, from children to the very old – with huge costs to families, communities and economies. In this series , we investigate what’s causing this crisis, and report on the latest research to improve people’s mental health at all stages of life.

It wasn’t Jenny’s drug revelation that struck me most profoundly, but the reaction of some of my prison colleagues. Her unconventional use of the medication was labelled substance abuse, leading to her being ostracised by the prison’s mental health service, which refused to work with her until she “sorted out” her drug issues.

Even though I had known Jenny for a year, it was only when she was about to be released from prison that I really understood how serious her situation was. I was shocked to see her breaking the prison’s rules on purpose because she didn’t want to leave. She started smoking in places she shouldn’t, damaged her own cell and areas everyone used, attacked another prisoner, which was not like her at all, and started using spice and hooch.

Jenny preferred staying in jail over facing life outside, but she was let out all the same. A week after her release, I received news that she had died from a heroin overdose.

My search for answers

Mental health problems are experienced by the majority of drug and alcohol users in community substance use treatment. Death by suicide is also common, with a history of alcohol or drug use being recorded in 54% of all suicides in people experiencing mental health problems. ( Public Health England guide , 2017.)

Jenny’s tragic story left me with many questions – what were the underlying causes of mental illness? What spurred the spiral into addiction? Why did individuals turn to substance use? – that, even after six years as a mental health social worker working in prisons and psychiatric hospitals, I had neither the knowledge nor experience to answer. Talking to colleagues did not resolve them, so I sought answers by returning to academia alongside my day job.

A postgraduate diploma helped me better understand the theories of mental health from neuroscientific, psychiatric and pharmacological perspectives. But above all, I realised that many of the people I was now encountering in my new role, working in a crisis home treatment team (a community-based team set up to support people experiencing severe mental health issues), would never get better. Rather, they would just keep coming back with a new crisis.

And for a large majority of them (around four in five), substances ranging from highly addictive narcotics to potent, mind-altering chemicals would be a key part of their daily lives in addition to, or as an alternative for, their prescribed psychiatric medication.

This article is part of Conversation Insights The Insights team generates long-form journalism derived from interdisciplinary research. The team is working with academics from different backgrounds who have been engaged in projects aimed at tackling societal and scientific challenges.

Roger was one of many people I met who relied on Spice , a synthetic cannabinoid designed to mimic the effects of naturally occurring THC . (In addition to consumption by smoking, there are increasing reports of synthetic cannabinoids being used in e-cigarettes or vapes .)

Nonetheless, Roger told me Spice was the “only thing that would help sort my head out”. And, after listening to a lecture from me about the dangers of these substances, he responded:

I know how much to take – I know when I’ve taken too much or not enough. I use it in doses now. Why would I stop if it’s the only thing that works?

It was clear that Roger knew much more about the effects of Spice than I did. Interactions like this ignited a desire in me for deeper knowledge – not from books or universities, but directly from people with co-existing mental health and addiction problems.

Perhaps surprisingly, in the UK we don’t know how many people are living in this combined state. Estimates have tended to focus only on people with severe mental health problems and problematic substance use. For example, a 2002 Department of Health guide suggested that 8-15% of its patients had a dual diagnosis – while acknowledging that it is difficult to assess exact levels of substance use, both in the general population and among those with mental health problems.

A decade earlier, US research had identified that for people with schizophrenia , substance use (non-prescribed drugs) was a significant problem relative to the general population. More recently, a 2023 global review of evidence identified that the prevalence of co-existing mental health and substance use among children and adolescents treated for psychiatric conditions ranged between 18.3% and 54%.

But what I found particularly interesting was an analysis of the writings of Thomas De Quincey from more than 200 years ago. In his 2009 article Lessons From an English Opium Eater: Thomas De Quincey Reconsidered , leading clinical academic, John Strang, highlighted that issues raised by De Quincey in 1821 remain causes for concern some two centuries later.

De Quincey was arguably the first person to document his own use of substances, in particular opium. His writing shows that he self-medicated to manage pain, including “excruciating rheumatic pains of the head and face”:

It was not for the purpose of creating pleasure, but of mitigating pain in the severest degree, that I first began to use opium as an article of daily diet … In an hour, oh Heavens! What an upheaving, from its lowest depths, of the inner spirit!

De Quincey’s use of non-prescribed drugs mirrors that of John, Jenny, Roger and so many other people I have met as a social worker. Clearly, we’ve known about the close relationship between mental illness and substance abuse for hundreds of years, yet are still wrestling with how best to respond.

Read more: Guide to the classics: Confessions of an English Opium Eater by Thomas De Quincey – a dense, strange journey through addiction

Official guidance almost always advocates for a “no wrong door” policy , meaning that those with dual addiction and mental health issues will get help whichever service encounters them first. But from what people with lived experience were telling me, this was not the case.

I sent freedom of information requests to 54 mental health trusts across England, to try to discern any patterns of variation in the way their patients were being measured and treated. Some 90% of the trusts responded, of which a majority (58%) recognised the dual occurrence of mental illness and substance use. However, the estimated prevalence of this dual diagnosis varied widely – from only nine to around 1,200 patients per trust.

What I found most alarming was that less than 30% of the mental health trusts said they have a specialised service for addiction which accepts referrals for dual diagnosis patients. In other words, throughout England, a lot of these patients are not being appropriately supported.

‘When I say I use heroin, people change’

I started using when I was around 18. Things weren’t good in my life at the time, and I got in with a crowd who offered me heroin. It was the most amazing experience; all my worries disappeared better than the antidepressants I had been taking. But the more I used, the more I needed it. Now I use it in stages, just before I go to work and at night.

Carl had been using heroin for more than ten years when I interviewed him. When I asked if he wanted to stop, he shrugged and said no, explaining:

I’ve tried so many times – I’ve been on methadone but that was worse, especially coming off it. I know how much to take, and no one knows I use gear – so, no. But, as soon as you tell a professional you take heroin, their whole attitude changes. I’ve seen it many times. I dress quite well and I have a job, but as soon as I say I use heroin, they change. It’s almost as if they don’t see the same person any more.

Talking to Carl underlined that many users know far more than me about the substances they take and why they take them. Yet as soon as a professional (typically a nurse, social worker or doctor) hears they are taking an illegal substance, or are misusing a legal substance such as alcohol, they are stigmatised and often ostracised from service provision.

Suzanne was homeless and also using heroin, but for different reasons to Carl. I asked why she started using it:

I’ve had a shit life – it numbs all of that. Now being homeless, it helps me to sleep and keeps me warm, but I only use it in the winter because I need to sleep.

In summer, Suzanne explained, she would switch to taking “phet” – amphetamines. I asked her why:

You need to be awake – there are lots of dickheads around. I’ve been beaten and raped in the summer when I was asleep, so you need to be awake more.

Hearing the stories of people fighting their personal battles with mental health and substance use issues was at once haunting and cathartic for me. It was deeply moving to hear them, time and again, struggling with the most difficult aspect of their condition: the simple decision to ask for help. And sadly, far too often, when they did summon the courage, their requests would go unheard, unheeded, or they would be engulfed by a sprawling system that seemed unable to help.

Dave had been using alcohol for many years and had asked for support on several occasions – only to be passed from service to service:

I was made redundant and, at 50, was finding it hard to get another job. I wasn’t drinking all of the time then. But as I started to get into more debt and the bailiffs were knocking on the door, I needed a drink to get me through it. It was not until I was charged with drunk driving that I knew I had a problem.

Dave said he wasn’t shy about asking for help – at least, for a while. But he found himself caught in a downward spiral that led to more drinking, more suffering, and less support:

So many times I’d stop drinking, but I couldn’t deal with the voices in my head. I’d ask for support, but the waiting lists were so long. The medication the doctor gave me did nothing, so I’d start drinking again, and because I’d start to drink again, mental health services wouldn’t touch me. All they kept saying was: ‘You should stop drinking first.’

The biggest barrier to getting support

To expand my understanding, I also sought the perspectives of a dozen people working on the frontline of mental healthcare – from professionals in NHS mental health and substance use teams, to people working for charitable support groups. Their insights revealed a frayed and fragmented network of services , with the holes and inefficiencies obvious and crying out for attention and repair. As one nurse explained:

The stress of trying to get services to help is unbelievable. You’ve got pressure from the person’s family because they are afraid they’ll end up dead. You’ve got pressure from managers to discharge the person. All I’d get is criticism which far outweighed encouragement or support. The stress made me so anxious that I almost gave it all up – and even considered suicide myself.

Over 80% of the professionals I spoke to called for an integration of mental health and substance use teams, in part because of the huge cuts nationwide in funding to substance use services. One social worker in a substance use service explained the current situation:

If you get someone with an alcohol addiction, it becomes quite apparent that they use drink as a way of coping with their mental health. But, because of massive waiting lists within mental health services or because they are told they need to stop drinking before [they can be treated], mental health support can’t be offered. So, the person just keeps drinking and eventually disengages from our services as there is no hope for them. We shouldn’t expect someone to stop using a substance that they perceive is helping without offering an alternative treatment.

For all the professionals I interviewed, the most significant barrier to getting support for someone’s mental health issues was that they used substances and would not receive any treatment until they addressed this. As one mental health nurse told me:

I had one chap who was using cocaine, mainly due to social anxiety. Initially, he’d use it when socialising with friends. But because it gave him confidence and he could talk to people, he started to use it all the time and got himself in debt. I wanted to address the root cause, the social anxiety, so I referred him to our Improving Access to Psychological Therapy service. But I was told he needed to be abstinent from cocaine for three months before they’d accept him. He eventually disengaged, and I haven’t seen him since.

A seismic shift is needed

In the shadows of our society, hidden behind the walls of our prisons and in the dark corners of our streets, the experiences of Jenny and countless others bear witness to the profound failings of our healthcare system to address co-existing mental health and substance use issues. For those caught in the merciless cycle of addiction and illness, these systemic inefficiencies and administrative blockades do much to intensify their torment.

Their often brutally honest accounts (and the insights of those who try to support them) draw a portrait of a split and underfunded service, collapsing under the weight of its contradictions. The loud calls for integrated mental health and substance addiction treatment become muffled amid the bureaucratic din of funding cuts, lengthy waiting lists and policy neglect.

The evidence overwhelmingly confirms the need for a model of care that is holistic and integrated – one that shifts the narrative from stigma and isolation to awareness and support.

The economic case for reshaping investment in our mental health and substance misuse services is powerful. The annual cost of mental health problems to the UK economy is a staggering £117.9 billion – equivalent to 5% of its annual GDP – with substance misuse adding a further £20 billion .

However, these figures tell only part of the tale. While we know that 70% of people in treatment for drug misuse and 86% of people in treatment for alcohol misuse have a mental health diagnosis, the full financial impact of people with these co-occurring disorders is probably far greater.

This also includes people who often plough through a punitive and bewildering series of services as they navigate their intersecting problems, encountering barriers at every turn that fail to address their acute health and social care needs. As their distress is amplified, the costs to wider society escalate too – as one social worker explained to me:

I am currently supporting a woman who is struggling with alcohol dependency, a condition that began after she endured significant domestic abuse. The cycle is devastating: her trauma cannot be effectively addressed because of her dependency on alcohol, and she cannot abandon alcohol because it’s the only solace she finds from her emotional torment. Despite several attempts at rehabilitation, none of the programmes have sufficiently tackled the mental health aspects of her trauma. Now, with cirrhosis of the liver, her health is in critical decline. It’s a heart-wrenching situation – a stark reminder of the desperate need for integrated treatment approaches that address both substance dependency and the underlying psychological trauma.

‘I might as well be dead’

In the quiet confines of a West Midlands mental health crisis centre, I’m preparing to meet someone whose story I know only from the clinical notes on my screen. The phrase “is alcohol dependent” is highlighted in bold. Behind those words is another person whose life is unravelling in the silence of a battle fought alone.

John walks into the room, a man living in the grip of two relentless forces – addiction and mental illness. “It was just to stop the noises,” he says of the whisky he uses as medication for his inner turmoil. His hands are trembling. This is the moment of truth – his story is no longer trapped within the clinical pages of a case file.

“I’ve lost everything,” he tells me. “I might as well be dead.”

Then John explains why he’s given up hope:

I’ve asked for help so many times, but all I get told is that I need to stop drinking before my mental health can be treated. However, alcohol is the only thing that works for me. I’ve gone through detox, but then I had to wait months for counselling. I just can’t cope that long without any support – antidepressants don’t do anything for me. What’s the point?

Over the past 15 years, I have met countless “Johns”, both during my day job as a mental health social worker and, latterly, in my academic research. This has led me to conclude that the health and social care system in which I work falls catastrophically short.

This is no mere professional critique. It is an impassioned plea for society to rediscover its collective heart; to explore the human stories that lie hidden in statistics such as that, between 2009 and 2019, 53% of UK suicides were among people with comorbid diagnoses of mental health and substance use.

Instead of viewing people through the limiting lens of labels, we should endeavour to see their humanity. Engaging in conversation, extending empathy and showing compassion are powerful actions. A kind word, an understanding nod or a gesture of support can affirm their dignity and spark a connection that resonates with their innate human spirit. Or as John, whose journey I’ve had the privilege to witness, puts it:

It’s not about the help offered but the meaning behind it. Knowing you’re seen as a person, not just a problem to be solved – that’s what sticks with you.

*All names in this article have been changed to protect the anonymity of the interviewees.

If you or anyone you know require expert advice about the issues raised in this article, the NHS provides this list of local helplines and support organisations .

For you: more from our Insights series :

Insomnia: how chronic sleep problems can lead to a spiralling decline in mental health

Existential crisis: how long COVID patients helped us understand what it’s like to lose your sense of identity and purpose in life

OCD is so much more than handwashing or tidying. As a historian with the disorder, here’s what I’ve learned

How music heals us, even when it’s sad – by a neuroscientist leading a new study of musical therapy

To hear about new Insights articles, join the hundreds of thousands of people who value The Conversation’s evidence-based news. Subscribe to our newsletter .

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Health Insurance

Drug, substance abuse and addiction statistics 2024

Timothy Moore

Jennifer Lobb

“Verified by an expert” means that this article has been thoroughly reviewed and evaluated for accuracy.

Heidi Gollub

Published 12:25 a.m. UTC March 28, 2024

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• 25% of Americans (70 million people) admitted they use illicit drugs, according to the most recent National Survey on Drug Use.
• 48.7 million people nationwide struggle with substance abuse according to the same survey.
• Alcohol is the most commonly used drug, followed by tobacco and marijuana.
• Health insurance policies sold on the Affordable Care Act (ACA) Marketplace or provided by Medicaid are required to cover substance abuse.

Drug and substance abuse continues to be a major problem across the United States, with 1 in 4 Americans over the age of 12 admitting that they used illicit drugs in 2022. 1  While alcohol, tobacco and marijuana represent the most popular drugs among Americans, many struggle with more illicit drugs, including cocaine, methamphetamines and heroin, according to the most recent Substance Abuse and Mental Health Services Administration (SAMHSA) survey. 3

Below, we’ve compiled comprehensive drug, substance abuse and addiction statistics that demonstrate the pervasiveness of the issue — and the importance of quality, affordable health insurance that offers substance abuse treatment.

How many people use drugs in the U.S.?

Nearly 25% of Americans ages 12 or older say they used illegal drugs in 2022. That’s 70.3 million people nationwide. 1 Approximately 50% of Americans 12 or older admit they used illegal drugs in their lifetime. 2  

The breadth of the problem is detailed in the most recent SAMHSA survey, which asked participants about their drug use habits. The survey included questions about current use (defined as using a substance within the month prior to taking the survey) as well as lifetime use. 

Current use 3

Based on survey results and the definition of current use:

• 16.5% of those who used illicit drugs in the survey year used marijuana, making it the most common illicit drug among those surveyed. 
• 3.4% of respondents admit to using marijuana and other illicit drugs within a month of taking the survey.
• Central nervous system stimulants and prescription psychotherapeutics (misuse) were the second most common illicit drugs, each representing just under 2% of reported use. 
• LSD, PCP, ecstasy and sedatives account for the lowest percentage of use, each representing 0.1% or less of illicit drugs used.

Lifetime use 3

• 47% admitted to using marijuana at some time in their life, making it the most common illicit drug among lifetime use statistics.
• Hallucinogens were the second most widely used illicit drug, with 17% admitting they used them during their lifetime. 
• Cocaine was the third most commonly used illicit drug, with 15% of participants admitting to using it over their lifetime.

What is the most popular drug in the U.S.?

Alcohol is the most popular drug in the U.S., with nearly half of Americans ages 12 and older saying they used it in the last statistically available month, based on the SAMHSA survey. Nearly 22% admitted they engaged in binge drinking in the past month at the time of the survey. 3

Tobacco use is also prevalent in the United States, with more than 1 in 5 Americans consuming tobacco in some form in the last statistically available month — and nearly 17% specifically smoking cigarettes.

While harder drug use is still a problem, less than 2% of Americans ages 12 and older reported having used cocaine in the past year. It’s even lower for methamphetamines (1%) and heroin (0.3%).

Note: These are self-reported usage statistics. It is possible some Americans may not accurately report drug use.

How many people die from drugs?

The U.S. has experienced a rising number of drug-related deaths for more than a decade, according to the latest National Safety Council Data. There were 108,490 drug-related deaths in 2022, according to preliminary data. That’s slightly lower than those reported in 2021 (106,699 deaths) but a 141% increase over the last decade and a 494% increase since 1999, the first year for which NSC data is available. 4  

This data includes drug-related deaths by suicide, homicide and undetermined intents. Of those 108,490 deaths, 92% (100,105) were categorized as preventable drug overdoses.

Opioid overdoses are the most common cause of drug-related deaths, but even cannabis (marijuana) has resulted in preventable deaths.

Here’s how those drug-related deaths break down according to NSC’s preliminary 2022 data:

Source: Preliminary 2022 data from the National Safety Council as of March 21, 2024

How many people struggle with substance abuse?

Nationwide, 38,679,000 American adults reported having a substance abuse disorder in the last statistically available year. 5  

Montana has the highest self-reported rate (19.2% of adults) of substance abuse. Oregon , Washington , South Dakota and Kansas round out the top five.

Georgia is the state with the lowest rate of self-reported substance abuse (11.31% of adults).

Source: 2023 State of Mental Health in America Report

What percentage of Americans abuse alcohol?

Alcohol abuse can be defined in two ways: binge drinking and alcohol use disorder (AUD).

• The Centers for Disease Control and Prevention defines binge drinking as five drinks on one occasion for men and four drinks on one occasion for women. 6
• The National Institute on Alcohol Abuse and Alcoholism defines AUD as a medical condition wherein someone cannot stop or control their alcohol intake, no matter the consequences. 7

Nationwide, an average of 21.7% of people reported having engaged in binge drinking in the past statistically available month, and 10.8% said they had dealt with alcohol use disorder in the last statistically available year. 3

States with the highest alcohol abuse

North Dakota and Wisconsin are the two states with the highest rate of binge drinking, with 25.99% of people ages 12 and older reporting binge drinking in the past month. 3 Nebraska , Vermont and Iowa also have high rates of binge drinking.

North Dakota also leads the country in alcohol use disorder, with more than 15% of individuals 12 and up reporting struggling with AUD in the past year. Montana , New Mexico , Oregon and Alaska round out the top five states with the highest rate of reported alcohol use disorder.

Source: SAMHSA National Survey on Drug Use and Health

How many people die from alcohol each year?

In the United States, 178,000 people died from alcohol in the last statistically available year (2021). That’s 488 deaths every day from alcohol. 8

Of those 178,000 deaths:

• 117,000 deaths are attributed to chronic conditions related to long-term alcohol use.
• 61,000 deaths are attributed to alcohol-related car crashes, alcohol poisoning or suicide. 

What percentage of Americans use tobacco?

Across the U.S., an average of 21.2% of people ages 12 and older reported tobacco use in the last statistically available month. More specifically, 16.82% reported smoking cigarettes. 3

States with the most smokers

Kentucky is the state with the most tobacco users; more than one-third of Kentuckians ages 12 and older report using tobacco of some kind in the past month. Kentucky also leads the country in cigarette users, with 1 in 4 people self-reporting smoking cigarettes. 3

More than 1 in 5 people smoke cigarettes in West Virginia , Missouri, Wyoming , Louisiana and Arkansas . West Virginia, Missouri and Louisiana are also close behind Kentucky for overall tobacco use as well.

Only 13.01% of Californians reported having used tobacco in the last statistically available month. Cigarette usage is even lower in Utah, where just over 10% of the state’s population reported cigarette usage.

How many people use marijuana?

On average, more than 13% of Americans ages 12 and older reported using cannabis, also known as marijuana, in the previous month. 3

However, the most recent statistically significant data comes from 2021 to 2022. It’s important to note that since then, several additional states have legalized marijuana both medicinally and recreationally, which may lead to an increase in usage.

States with the highest rate of marijuana use

Vermont leads the nation with the highest rate of marijuana use; just over 22% of people 12 and up reported using marijuana in the last month. Recreational marijuana has been legal in Vermont since 2020. 3

Alaska , Colorado , Oregon and Maine round out the top five states for marijuana usage. Recreational marijuana has been legal in Alaska and Oregon since 2014, Colorado since 2012 and Maine since 2016.

Oklahoma is the state with the highest rate of marijuana usage (16.61%) where recreational use is currently not legal.

How many people die from marijuana usage?

Preliminary data for 2022 indicates that there were 1,183 linked to marijuana and its derivatives, in the U.S., which marks an increase over the years prior. 4 The National Safety Council specifies that marijuana derivatives can include THC, CBD or their synthetic derivatives.

Source: National Safety Council data

The National Safety Council has data dating back to 1999 when there were only 36 cannabis-related deaths.

What percentage of people have used cocaine?

Nationwide, an average of 1.7% of people ages 12 and older reported having used cocaine in 2022, the last statistically available year. 3

States with the highest rate of cocaine use

Vermont is the state with the highest rate of self-reported cocaine use, with 3.2% of people 12 and up saying they used the drug in the year prior. New York , Maryland , Massachusetts and Rhode Island make up the remaining top five states. 3

The state with the lowest cocaine use is Texas, with just 1 in 100 Texans self-reporting cocaine use.

What percentage of people have used methamphetamines?

Nationwide, an average of 1% of people 12 and older reported having used methamphetamines in the last statistically available year. 3

States with the highest rate of methamphetamine use

Nevada tops the list of states with the highest rate of methamphetamine usage. More than 1 in 50 people ages 12 and up reported using this drug in the last statistically available year. Self-reported meth use is also high in Tennessee , Iowa , Mississippi and Alabama . 3

Connecticut and Florida have the lowest rate of methamphetamine use; just 0.52% of residents self-reported usage in the last statistically available year.

What percentage of people abuse prescription pain pills?

Nationwide, an average of 3.12% of people 12 and older reported having abused prescription pain pills in the last statistically available year. 3

States with the highest rate of prescription pain pill abuse

Tennessee leads the country in prescription pain pill misuse. More than 4% of the state’s population, ages 12 and older, reported having abused pain relievers in the year prior. 3

Prescription pain pill abuse is also high in Arkansas , Nevada , Louisiana and Alabama .

Nebraska is the state with the lowest rate of self-reported pain pill abuse (2.39%).

What percentage of people have used heroin?

Nationwide, an average of 0.3% of people ages 12 and up reported having used heroin in the last statistically available year. 3

States with the highest rate of heroin use

Heroin use is most common in the state of Delaware , where 0.6% (that’s more than 1 in every 200 residents) of people ages 12 and up reported having used heroin in the year prior. The only other states with a rate higher than 1 in 200 are Maine , Vermont and Alaska . 3

Texas is the state with the lowest rate of self-reported heroin use: Only 0.15% of Texans 12 and up reported having used the drug in the most recent statistically available year.

What percentage of people have abused opioids?

Across the country, an average of 3.3% of Americans ages 12 and up reported having abused opioids in the year prior. 3

States with the highest rate of opioid abuse

Tennessee has the highest rate of opioid abuse in the U.S. Nearly 4.7% of people in the state reported having engaged in opioid abuse in the last statistically available year. Arkansas , Alabama , Louisiana and Nevada round out the top five. 3  

Nebraska has the lowest rate of opioid abuse in the country, with only 2.4% saying they had abused opioids in the year prior.

States with the highest number of overdose deaths

West Virginia has the highest rate of overdose death in the U.S., with 84 overdose deaths for every 100,000 people. Nebraska and South Dakota has the lowest rate of overdose deaths, with 9 deaths for every 100,000 people. 10

Overdose deaths are on the rise in West Virginia (up by 7.3%) but on the decline in South Dakota (down by 16.7%). Oregon has seen the biggest increase (41.5%) in overdose deaths over the last statistically available 12 months.

What drug causes the most overdose deaths?

Opioids are involved in more overdose deaths than any other drug. In 2022, there were 108,490 drug-related deaths — and just over 75% of them (82,234 deaths) involved an opioid. 4

Fentanyl is by far the deadliest opioid. Of the 82,234 opioid-related deaths, 70,601 of them involved fentanyl.

Health insurance and substance abuse

Substance abuse disorders represent a dangerous health condition — one that deserves the proper care and treatment. Yet 93.5% of Americans with a self-reported substance abuse problem do not seek help. 5

If you or someone you love is suffering from substance abuse, know that there are options available. Many health insurance plans include coverage for mental health and substance abuse. If you purchase health insurance from the ACA Marketplace, the insurer is required to cover substance abuse counseling and treatment. 11 Medicare will also pay for treatment of alcoholism and substance use disorders, though its coverage is not as extensive as it is for other services.

If you’re not sure if your current health plan covers mental health surveys or substance abuse counseling and treatment, contact your insurer to discuss your benefits. 

Looking for better health insurance that includes coverage for substance abuse disorders? Browse our roundup of the best health insurance companies to get started.

Worried about the cost? How to save money on health insurance

For free, confidential help with substance abuse, contact the SAMHSA's National Helpline at 1-800-662-HELP(4357). The service is available 24/7, 365 days a year to help individuals and families facing mental and/or substance use disorders find treatment referrals and information services.

Article sources

• United States Department of Health and Human Services
• National Center for Drug Abuse Statistics
• Substance Abuse and Mental Health Services Administration - National Survey on Drug Use and Health
• National Safety Council
• State of Mental Health in America Report
• Centers for Disease Control and Prevention - Binge Drinking
• National Institute on Alcohol Abuse and Alcoholism
• Centers for Disease Control and Prevention - Excessive Alcohol Deaths
• National Institute on Drug Abuse - Drug Overdose Death Rates
• Centers for Disease Control - Provisional Drug Overdose Death Counts
• Substance Abuse and Affordable Care Act

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Blueprint has an advertiser disclosure policy . The opinions, analyses, reviews or recommendations expressed in this article are those of the Blueprint editorial staff alone. Blueprint adheres to strict editorial integrity standards. The information is accurate as of the publish date, but always check the provider’s website for the most current information.

Timothy Moore is a writer and editor covering personal finance, travel, autos, and home renovation. He's written financial advice for sites like LendEDU, LendingTree, Forbes Home and The Penny Hoarder; edited complex ROI analyses for B2B tech companies like Microsoft and Google; served as managing editor at a print magazine; led content creation for a digital marketing agency; and written for brands like Chime, Angi and SoFi.

Jennifer Lobb is deputy editor at USA TODAY Blueprint and is an experienced insurance and personal finance writer. Jennifer served as an insurance staff writer and editor at U.S. News and World Report and deputy editor of insurance at Forbes Advisor. She also spent several years covering finance and insurance for various financial media sites, including LendingTree and Investopedia. For nearly a decade, she’s helped consumers make educated decisions about the products that protect their finances, families and homes.

Heidi Gollub is the USA TODAY Blueprint managing editor of insurance. She was previously lead editor of insurance at Forbes Advisor and led the insurance team at U.S. News & World Report as assistant managing editor of 360 Reviews. Heidi has an MBA from Emporia State University and is a licensed property and casualty insurance expert.

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Exercise may help battle alcohol, drug abuse

Exercise might help people who are battling addiction stay on the straight and narrow, a new research review finds.

Investigators who analyzed 43 studies from around the world found a link between physical activity and reduced substance use among people in treatment for alcohol and drug abuse.

The idea for the study review "came to me when I was working as a kinesiologist in a therapy house for people with substance use disorders, and realized that physical health was not considered at all in these treatments, although the need was enormous," explained study lead author Florence Piché . She is a doctoral candidate in sciences and physical activity at the University of Quebec in Trois-Rivières and the University of Montreal, in Canada.

"We can assume that the mechanisms are multiple and multifactorial," Piché said of the findings.

The amount of exercise involved wasn't overwhelming. Most of the studies focused on the potential benefit of "moderately intense" activity, conducted for about an hour three times a week over the course of approximately three months.

Would more exercise confer greater benefits? Piché noted that none of the studies assessed that.

Collectively, the studies included just over 3,100 participants. They looked at the relationship between exercise and the risk of using heroin, opioids, cocaine and crack cocaine, methadone, marijuana, alcohol or methamphetamines. None involved cigarette smoking.

Half of the investigations evaluated exercise's relationship to total abstinence or reduction in substance misuse. Among these, 75% found that substance use fell in connection with physical activity.

Fourteen studies looked at aerobic activities, and 71% of these concluded aerobic exercise appears to help patients maintain their resolve to cut back or quit.

Twelve studies additionally reported a link between exercise and a reduction in depression-related symptoms.

Connie Diekman is a food and nutrition consultant and former president of the Academy of Nutrition & Dietetics.

"Participating in physical activity does increase people's goals to be healthy. It can also generate a 'euphoric'-type feeling. And it provides some structure to our daily lives. All things that can help us feel more in control of emotions and any need for substances to manage daily life issues," Diekman said.

"The overall conclusion was that exercise does appear to have a significant protective effect when it comes to reducing substance use among patients struggling with substance use disorders," according to Diekman, who was not involved in the review.

"The caveat," she added, "is that more studies are needed," given that smoking wasn't considered and many of the investigations had design flaws "making a clear cause-and-effect outcome hard to declare."

Also, aside from the one-third of the studies that focused on aerobic activity, Diekman noted that the team did not break down how different types of exercise might variously impact addiction.

Forty percent of the studies included in the analysis were done in the United States. About one-quarter were launched in China, and about 8% in northern Europe.

The findings were published online Wednesday in PLOS ONE .

More information

There's more on a possible connection between exercise and addiction at Harvard Medical School .

Copyright © 2023 HealthDay. All rights reserved.

Ontario's top doctor calls for decriminalization, limits on legal substances

Dr. kieran moore also wants province to explore value of raising legal drinking age from 19 to 21.

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Ontario's top doctor is calling on the province to decriminalize possession of unregulated drugs for personal use and make available safer supply, as well explore raising the legal drinking age from 19 to 21.

Dr. Kieran Moore, the province's chief medical officer of health, is also calling on the province to immediately enact policy that will limit access to alcohol, vapes and cannabis as the number of people who have died or visited a hospital due to using multiple substances has spiked in recent years.

Moore said more than 2,500 people have died in Ontario each year in the past few years due to a toxic drug supply. And the number of opioid-related deaths among teens and young adults in Ontario tripled between 2014 and 2021. Research has found a safer drug supply is the solution to immediately prevent thousands more from dying in the coming years, he said.

"The system must first take urgent steps to keep people alive, such as creating safe spaces where people can use unregulated drugs and providing regulated pharmaceutical alternatives," the medical officer wrote in an annual report released this week.

"With these harm reduction responses in place, people who are using opioids may be in a position to benefit from offers of education and treatment, and to make choices that enable them to reduce or even stop their opioid use," he wrote in the report. 

"When we see preventable threats, like substance use, that harm too many people too young, devastate families, destroy communities, and reduce life expectancy, we must act."

Moore's research suggests his "multi-pronged" recommendations can help officials prevent fatal overdoses and stop people, especially youth, from dangerously and increasingly using multiple legal substances.

Hannah Jensen, a spokeswoman for Ontario's minister of health, said in an email on Thursday the government appreciates Moore's "recommendations to restrict legal substances while decriminalizing hard drugs."

• Toronto wants to expand drug decriminalization to cover all ages and substances

But Jensen said they "ignore the unintended consequences and significant public safety concerns experienced by other jurisdictions that have implemented similar proposals," though she did not provide examples.

As for decriminalization, Moore said it "allows the justice and enforcement systems to focus their resources on stopping the organizations and individuals profiting from unregulated drug sales rather than on people who use substances whose needs would be better met in the health system."

'Disturbing trend' of binge drinking, vaping

He noted Ontarians, especially youth, have also been a part of a "disturbing trend" in recent years of binge drinking and vaping.

The report, citing recently released data from the Canadian Institute for Health Information, found 33 per cent of adults said they used cannabis in 2020, an eight per cent increase from 2019. And when it released its cannabis survey in 2022, Health Canada reported the number of Ontarians who died of alcohol toxicity rose 16 per cent between 2018 and 2021.

"We have also seen concerning changes in substance use patterns and harms more broadly, including higher rates of vaping among non-smokers, increased unintentional poisonings in children from cannabis ingestion, and an ongoing high burden of hospitalizations and cancers caused by alcohol," Moore said in the report.

He said that's why efforts need to be made to "shift social norms by making Ontarians more aware of new evidence on alcohol-related harms."

He suggested in the report, for example, that more restrictions on how legal substances are marketed can be implemented to educate people on the harms of substance use.

"The province does prohibit advertising of alcohol to minors on traditional media outlets like television, radio or print, but neither the federal nor the provincial government limits advertising on social media platforms, which is where youth get most of their information," Moore said.

Make sure people know the risks: Moore

He also recommended Ontario "explore the value of increasing the legal minimum drinking age from 19 to 21" and 'work with the federal government to require that all alcohol products have warning labels and signage that describe the risks and harms of drinking booze.

He said it's common knowledge that Ontarians will continue to use the legal substances.

"The challenge is to help people understand the risks, and moderate or stop their use," he said.

• Prescribed fentanyl helps this man manage his addiction. Experts want more access to safe supply
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"In 2020, the harms associated with substance use cost Ontario about $18 billion – or $1,234 per person – in health care, social and legal/policing costs," the report reads.

Moore argued his recommendations need to be implemented with the understanding that societal burdens, such as the affordability crisis, are driving more Canadians to use substances. 

That's why he said Ontario needs to implement his recommendations while working with all levels of government in developing affordable housing policies, programs for families that reduce the risk of adverse childhood experiences and domestic violence, and initiatives to improve social circumstances.

"This report calls for an all-of-society approach to improve health and reduce substance use harms: one that recognizes the complexity of human experience with substances, the factors that drive substance use, and the policy environment where public health policies may conflict with economic policies, and with public attitudes and perspectives," he wrote.

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A new study from Kaiser Permanente of Northern California is showing a link between alcohol use and heart disease in women. The research found that women who drink more than one drink a day are up to 50% more likely to develop heart disease. NBC News’ Medical Fellow, Dr. Akshay Syal, explains the results of the new study. March 29, 2024

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