CHAPTER 1. PSYCHOACTIVE SUBSTANCE USE: EPIDEMIOLOGY AND BURDEN OF DISEASE

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1 CHAPTER 1. PSYCHOACTIVE SUBSTANCE USE: EPIDEMIOLOGY AND BURDEN OF DISEASE 1.1 Alchl Jürgen Rehm and Jayadeep Patra Alchl is pssibly the ldest psychactive substance used by mankind (McGvern, 2009). Currently, it is als the mst prevalent psychactive substance, althugh the majrity f the wrld adult ppulatin abstains. Glbally, 46% f all men and 73% f all wmen abstain frm alchl, and mst f these persns have nt cnsumed any alchlic beverage during their entire lives. There are huge variatins in abstentin arund the wrld. The verwhelming majrity f peple in a belt stretching frm Nrthern Africa, ver the Eastern Mediterranean, Suth Central Asia and Suth-East Asia t the islands f Indnesia abstain fr reasns ften attributable t religin and culture. In ther parts f the wrld such as Eurpe, less than 2 f the ppulatin abstains n average. The level f abstentin is relatively strngly assciated with the level f verall adult per capita cnsumptin. Ttal adult per capita cnsumptin is highest in cuntries in Eastern Eurpe where ttal adult per capita cnsumptin ranges frm 15 t 21 litres per year, and is lwest in Nrthern Africa, the Eastern Mediterranean, Suth Central Asia, Suth- East Asia and the Indnesian islands where als the majrity f the ppulatin abstains. The burden f disease attributable t alchl The burden f disease attributable t alchl was based n the Cmparative Risk Assessment (CRA) methds (Rehm, Kltsche & Patra, 2007; Rehm et al., 2009b) which were als used in the WHO Reprt n Glbal Health Risks t cmpare with ther risk factrs (WHO, 2009a). In 2004, 7.6% f the glbal burden f disease and injury was attributable t alchl cnsumptin amng men and 1.4% t cnsumptin amng wmen. Neurpsychiatric disrders, including alchl use disrders, accunt fr 36.4% f all disability-adjusted life years (DALYs) 1 caused by alchl (Rehm et al., 2009b). Alchl-attributable harm is determined nt nly by the verall level f cnsumptin but als by the drinking pattern (e.g. by heavy drinking ccasins) (Rehm et al., 2010). Bth level and pattern f alchl cnsumptin are related t many disease categries, but alchl use disrders, cancers, cardivascular diseases, liver cirrhsis and injuries cnstitute the mst imprtant disease categries which are causally related t alchl cnsumptin (Rehm et al., 2009b). Glbally, the Russian Federatin and the surrunding cuntries a regin with high verall vlume and detrimental drinking patterns have the highest level f alchl-attributable harm. Almst ne ut f every five years f life lst due t premature mrtality r disability is attributable t alchl in this regin; fr the Russian Federatin this tll is even higher. Latin America is anther regin with a relatively high 1 The sum f years f ptential life lst due t premature mrtality and the years f prductive life lst due t disability. 7

2 ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders impact frm alchl. The least alchl-attributable harm can be fund in Africa, the Eastern Mediterranean and in the suthern part f Asia, especially in cuntries with predminantly Muslim ppulatins. In evaluating these numbers it shuld be recgnized, hwever, that these data are based n the CRA f the year 2000, in which the detrimental impact f alchl n infectius diseases such as tuberculsis was nt sufficiently established and the Glbal Burden f Disease study had fewer categries which resulted in exclusin f sme f the impact f alchl (e.g. n pancreatitis) (Rehm & Mathers, 2009). Inclusin f alchl-attributable infectius disease categries wuld change the picture t a great extent (Rehm et al., 2009a; Rehm & Parry, 2009). Even withut cnsidering the effect f alchl n infectius diseases, harmful use f alchl is ne f the mst imprtant cntributrs t the glbal burden f disease (WHO, 2009a) and mst recently (2004) ranked third behind childhd underweight and unsafe sex. Alchl use disrders and glbal estimates Alchl use disrders cmprise alchl dependence and the harmful use f alchl. Glbal estimates fr alchl use disrders are based n epidemilgical studies which assess these disrders thrugh diagnstic assessment instruments and define alchl use disrders thrugh internatinal disease classificatin systems such as the Internatinal Classificatin f Diseases (ICD) and the Diagnstic and Statistical Manual f Mental Disrders (DSM) (Kehe, Rehm & Chatterji, 2007; Rehm et al., 2009b). The highest prevalence rates f alchl use disrders in the ppulatin can be fund in parts f Eastern and Central Eurpe (highest prevalence rates f alchl use disrders in sme cuntries reaching up t 16%), in the Americas (prevalence rates in sme cuntries in this regin reaching up t 1), Suth-East Asia (prevalence rates reaching up t 1) and in sme cuntries in the Western Pacific (prevalence rates in sme cuntries reaching up t 13%). In India, fr example, in spite f high abstentin rates with almst all wmen abstaining frm alchl, a pattern f frequent and heavy drinking is bserved amng thse wh drink, resulting in high rates f alchl use disrders amng drinkers (Prasad, 2009; Rehm et al., 2009b). 8

3 Psychactive substance use: epidemilgy and burden f disease 1.2 Illicit drugs Luisa Degenhardt Illicit drugs are used by nly a minrity f the glbal ppulatin. The United Natins Office n Drugs and Crime (UNODC) estimated that between 172 and 250 millin peple aged years had used an illicit drug at least nce in 2007 (UNODC, 2009). Cannabis was by far the mst cmmnly used illicit drug ( % f the ppulatin aged years), with the highest prevalence in Nrth America, Western Eurpe and Oceania. Sme millin peple aged years were estimated t have used amphetamines ( %), with the highest levels in Suth-East Asia. An estimated millin peple used ccaine (0.4% 0.5%) with use cncentrated in Nrth America, fllwed by Western and Central Eurpe, and Suth America. The number f piate users was estimated at millin, with the main drug trafficking rutes ut f Afghanistan having the highest levels f use (UNODC, 2009). Thse wh use drugs nce r twice have, at mst, a very small increase in mrbidity and mrtality, with the cncentratin f harms ccurring amng thse wh use drugs regularly. The cmmnly used expressin prblematic drug use culd be defined as crrespnding t the WHO s Internatinal Classificatin f Diseases (ICD) categries harmful drug use and drug dependence (WHO, 1993). Risk factrs fr drug dependence Studies examining the level f risk fr dependent use amng lifetime drug users are limited, but studies in the USA and Australia have suggested that perhaps ne in five peple wh ever use an illicit drug might meet criteria fr dependence at sme pint (Glantz et al., 2008; Hall et al., 1999). The extent f this risk varies acrss drug types, with greater risks fr drugs with a rapid nset and shrter duratin f effect. Using drugs by smking r via injectin carries greater dependence risk (Anthny, Warner & Kessler, 1994; Vlkw et al., 2004; McKetin, Kelly & McLaren, 2006). Risk factrs fr drug dependence may differ between cuntries, althugh few studies have directly examined this (Degenhardt et al., 2010). A study f initiatin t use and prgressin t dependence in the WHO Wrld Mental Health Surveys fund a range f variables that were cmmn t the develpment f illicit drug dependence amng users (Degenhardt et al., 2010): earlier nset f drug use; using mre types f illicit drugs; and nset befre age 15 years f externalizing (e.g. cnduct disrder) and internalizing mental disrders (e.g. depressin) (Degenhardt et al., 2010). These findings are cnsistent with thse frm chrt studies in high-incme cuntries, which have fund that early nset drug use, and mental health prblems, are risk factrs fr later dependent drug use (Tumburu et al., 2007), and that mental health prblems increase the risk f develping prblem use if drug use begins. Less-studied risk factrs include structural determinants such as high unemplyment, pverty and scial and cultural factrs. Glbal estimates f prblem drug use Glbal and reginal estimates have been made f the number f prblematic drug users. A systematic review f data n the prevalence f injecting drug use estimated 9

4 ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders that, glbally, millin peple injected drugs 1 in 2007 (Mathers et al., 2008). In 2007, UNODC estimated that there were between 18 and 38 millin prblem drug users (i.e. injecting drug users r prblem users f piids, ccaine r amphetamine) (UNODC, 2009). Illicit drug dependence was assessed in the WHO s Wrld Mental Health Surveys, in 27 cuntries in five WHO regins (Kessler & Üstün, 2008), with significant gegraphic variatin in rates f illicit drug use (Degenhardt et al, 2008) and drug dependence (Demyttenaere et al., 2004), and higher rates f drug dependence in develped cuntries (Kessler & Üstün, 2008). These differences may reflect a cmbinatin f actual differences, as well as cultural differences in the understanding f, and preparedness t reprt, illicit drug use and related prblems in surveys. T date, n estimates f the prevalence f specific frms f drug dependence have been made reginally and glbally, and few cuntries have made estimates fr specific drug types. This is a majr gap in knwledge that severely limits ur capacity t make evidencebased decisins abut the extent f need fr interventins t address drug dependence. Interventins shwn t be effective differ in imprtant ways acrss drug types, with piid pharmactherapy being the mainstay f treatment fr herin dependence, and psychscial interventins being mre apprpriate fr cannabis and psychstimulant dependence. There is a need t imprve ur understanding f these basic epidemilgical questins abut illicit drug use and dependence in rder t imprve ur capacity t respnd, natinally and glbally. 1 Injecting drug use: use f a drug by injectin, which may be intravenus, intramuscular r subcutaneus. 10

5 Psychactive substance use: epidemilgy and burden f disease 1.3 Epidemilgy f psychactive substance use and burden f disease (Figures ) Backgrund Estimates f the numbers f deaths and the amunts f lss f healthy life fr majr diseases, including the use f alchl and illicit drugs are prvided by the Glbal Burden f Disease prject which was initiated during the 1990s (WHO, 2004). Alchl and drug-attributable DALYs represent a measure f verall disease burden, quantifying mrtality and mrbidity due t alchl and illicit drug use in a single disease measure. The burden f disease expressed in DALYs quantifies the gap between the current health status f the ppulatin and an ideal situatin where everyne lives t ld age in full health (WHO, 2009a). Salient findings Prevalence f alchl and drug use disrders in the ppulatin (pint prevalence) Acrss cuntries, the pint prevalence f alchl use disrders (in the ppulatin aged 15 years and ver) is generally higher than the pint prevalence f drug use disrders in the same ppulatin and is generally higher amng men than amng wmen. Glbal prevalence rates f alchl use disrders were estimated t range frm t 16%, with the highest prevalence rates t be fund in Eastern Eurpe. Amng males, the pint prevalence f alchl use disrders fr males is estimated t be highest (i.e. 6.4%) in Eastern Eurpean cuntries, in parts f Asia and amng cuntries in the Americas. Amng females, the highest estimated prevalence rates f alchl disrders (i.e. 1.6%) were fund in Eastern Eurpean cuntries and in selected cuntries in the Americas and in the Western Pacific. Amng men and wmen, the estimated prevalence f alchl use disrders was fund t be lwest in the African and Eastern Mediterranean regins. Glbal prevalence rates f drug use disrders were estimated t range frm t 3%, with the highest prevalence rates fund in the Eastern Mediterranean Regin. The highest estimated prevalence rates f drug use disrders amng men ( 1.6%) and wmen ( 0.4%) were fund in parts f the Americas. Selected cuntries in Africa, Eastern Mediterranean, Eurpe and the Western Pacific were fund t have high rates f drug use disrders amng men and wmen in additin. 11

6 ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders Number f deaths and disability-adjusted life years lst Glbally, apprximately 39 deaths per ppulatin are attributable t alchl and illicit drug use, ut f which 35 deaths are attributable t alchl use, and fur deaths t illicit drug use. The highest numbers f deaths due t alchl and illicit drug use were fund in Eurpe where 70 deaths per ppulatin are attributable t alchl use and apprximately five deaths per t illicit drug use. In almst all regins, numbers f deaths attributable t alchl use are higher than thse fr illicit drug use. In the Eastern Mediterranean Regin, hwever, nine deaths per ppulatin are attributable t illicit drug use, and apprximately fur deaths per ppulatin are attributable t alchl use. Use f alchl and illicit drugs accunts fr almst 13 DALYs lst per 1000 ppulatin wrldwide. Apprximately 11 DALYs per 1000 ppulatin are lst due t alchl use, and apprximately tw DALYs are lst due t illicit drug use. DALYs lst due t alchl and illicit drug use were fund t be highest in Eurpe (apprximately 23 DALYs lst per 1000 ppulatin) and the Americas (apprximately 18 DALYs lst per 1000 ppulatin). In the Eastern Mediterranean Regin mre DALYs are lst due t illicit drug use (fur DALYs lst per 1000 ppulatin) than due t alchl use (apprximately 1.5 DALYs lst per 1000 ppulatin). The number f DALYs lst due t alchl and illicit drug use varies by cuntry incme. Higher middle-incme cuntries were fund t have the greatest number f DALYs lst due t alchl and illicit drug use (24 DALYs lst per 1000 ppulatin due t alchl use and apprximately three DALYs lst due t illicit drug use). Ntes and cmments Prevalence estimates fr alchl and drug use disrders are standardized and cmparable acrss cuntries and regins f the wrld. Prevalence data are taken frm the Glbal Burden f Disease study (WHO, 2004). Alchl use disrders included in the Glbal Burden f Disease analysis included alchl dependence and harmful use f alchl. Drug use disrders included in the Glbal Burden f Disease analysis included piid dependence and harmful use f piids, and ccaine dependence and harmful use f ccaine. The definitins f dependence and harmful use that were used were the ICD-10 definitins (WHO, 1993). As a single measure f disease burden, DALYs d nt capture all dimensins f the health burden and d nt take the suffering f patients and their relatives due t psychactive substance use int accunt. 12

7 Psychactive substance use: epidemilgy and burden f disease FIGURE 1.1 PREVALENCE OF ALCOHOL USE DISORDERS %, ADULT MALES 15 YEARS AND ABOVE, 2004 < Data nt available Nt applicable FIGURE 1.2 PREVALENCE OF ALCOHOL USE DISORDERS %, ADULT FEMALES 15 YEARS AND ABOVE, 2004 < Data nt available Nt applicable The bundaries and names shwn and the designatins used n these maps d nt imply the expressin f any pinin whatsever n the part f the Wrld Health Organizatin cncerning the legal status f any cuntry, territry, city r area r f its authrities, r cncerning the delimitatin f its frntiers r bundaries. Dtted lines n maps represent apprximate brder lines fr which there may nt yet be full agreement. 13

8 ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders FIGURE 1.3 PREVALENCE OF DRUG USE DISORDERS %, ADULT MALES 15 YEARS AND ABOVE, 2004 < Data nt available Nt applicable FIGURE 1.4 PREVALENCE OF DRUG USE DISORDERS %, ADULT FEMALES 15 YEARS AND ABOVE, 2004 < Data nt available Nt applicable 14 The bundaries and names shwn and the designatins used n these maps d nt imply the expressin f any pinin whatsever n the part f the Wrld Health Organizatin cncerning the legal status f any cuntry, territry, city r area r f its authrities, r cncerning the delimitatin f its frntiers r bundaries. Dtted lines n maps represent apprximate brder lines fr which there may nt yet be full agreement.

9 Psychactive substance use: epidemilgy and burden f disease Illicit drug use Alchl Deaths per ppulatin FIGURE 1.5 DEATHS ATTRIBUTABLE TO ALCOHOL AND ILLICIT DRUG USE, PER , BY REGION, Wrld Western Pacifi c Suth-East Asia Eurpe Eastern Mediterranean Americas Africa DALYs per 1000 ppulatin FIGURE 1.6 DALYS LOST BY ALCOHOL AND ILLICIT DRUG USE, PER 1000, BY REGION, Wrld Western Pacifi c Suth-East Asia Eurpe Eastern Mediterranean Americas Africa 25 DALYs per 1000 ppulatin High Higher-middle Lwer-middle Lw FIGURE 1.7 DALYS LOST BY ALCOHOL AND ILLICIT DRUG USE, BY INCOME GROUP, PER 1000,

10 ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders 1.4 Main psychactive substances used in the treatment ppulatin (Figures ) Backgrund Nminated fcal pints in cuntries were asked t reprt the main psychactive substances accuntable fr entry int treatment. Salient findings In the majrity f cuntries (53.9%) alchl was identified as the main psychactive substance at entry int treatment. Alchl was reprted t be the main psychactive substance respnsible fr treatment demand in the majrity f cuntries in every regin, with the exceptin f the Americas. The majrity f cuntries in the Regin f the Americas (5) reprted ccaine t be the main psychactive substance at treatment entry. In the Eastern Mediterranean Regin, alchl and cannabis were identified by the majrity f cuntries as being mst frequently the main psychactive substances at treatment entry. Opiids were reprted as the main psychactive substance at treatment entry in 2 f cuntries in the Eastern Mediterranean Regin. In the African Regin, cannabis appears t be the mst frequent psychactive substance at treatment entry in apprximately 4 f cuntries. In the Suth-East Asia and Eurpean regins, piids were identified as the mst frequent psychactive substance behind the demand fr treatment in 42.9% and 26.5% f cuntries respectively. In the Western Pacific Regin, cannabis and amphetamine-type stimulants (ATS) were reprted t be the mst frequent psychactive substance accuntable fr treatment entry in 16.7% f cuntries. N cuntry in the survey identified inhalants, sedatives r prescribed piids as the main psychactive substance at treatment entry amng persns in treatment. In cntrast t high-incme and higher middle-incme cuntries, cannabis appears t be the mst frequent psychactive substance accuntable fr treatment entry in arund ne third f lw-incme and lwer middle-incme cuntries in the survey. Besides this finding, there is n distinct effect f cuntry incme level n the main psychactive substance at treatment entry acrss different incme grups f cuntries. Ntes and cmments Infrmatin n the main psychactive substance at treatment entry was cmpleted by 89 cuntries, just ver half the number f cuntries that respnded t the survey, prbably reflecting the lack f data cllectin systems fr treatment in many cuntries (see sectin 1.5). 16

11 Psychactive substance use: epidemilgy and burden f disease The questin aimed t identify the single mst cmmn psychactive substance behind substance use disrders that cause entry int treatment in cuntries. The cmbinatin f multiple psychactive substances accuntable fr treatment entry by patients such as the cmbined use f alchl and ther psychactive drugs was nt specifically examined. Other main psychactive substances in the treatment ppulatin include lcal r reginal-specific psychactive drugs. A number f African cuntries indicated that the main psychactive substance at treatment entry was khat, which is included under this categry. Treatment data may nt necessarily crrelate clsely with data n the prevalence f the respective disrder and underlying substance use in ppulatins. Treatment data may be influenced by what treatment is available, and may als reflect the patient grup with substance use disrders wh seek treatment, and the perceived value f treatment. An example is the Eastern Mediterranean Regin where 4 f cuntries identified alchl as being the mst cmmn substance at treatment entry despite the lwer rates f alchl use in these cuntries (see sectin 1.3). 17

12 ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders FIGURE 1.8 MAIN PSYCHOACTIVE SUBSTANCE ACCOUNTABLE FOR TREATMENT ENTRY IN COUNTRIES, BY REGION, 2008 Alchl Cannabis Ccaine ATS Inhalants Sedatives Hallucingens Opiids Prescribed piids Other Percentage f cuntries n= % % 1.1% 14.5% 1.1% WORLD 3.4% 48.1% 40.7% Percentage f cuntries 3.7% 7.4% Percentage f cuntries 10. n=27 AFRICA n=10 AMERICAS 61.8% % Percentage f cuntries Percentage f cuntries 2.9% 2.9% 2.9% 2.9% n=5 EASTERN MEDITERRANEAN n=34 EUROPE 66.7% 57.1% 42.9% Percentage f cuntries Percentage f cuntries 16.7% 16.7% n=7 SOUTH EAST ASIA n=6 WESTERN PACIFIC 18

13 Psychactive substance use: epidemilgy and burden f disease FIGURE 1.9 MAIN PSYCHOACTIVE SUBSTANCE ACCOUNTABLE FOR TREATMENT ENTRY IN COUNTRIES, BY INCOME GROUP, 2008 Alchl Cannabis Ccaine ATS Inhalants Sedatives Hallucingens Opiids Prescribed piids Other 45.8% 50. Percentage f cuntries 33.3% 4.2% 8.3% 8.3% Percentage f cuntries n=24 LOW n=20 LOWER MIDDLE 63.3% 56.5% 26.1% Percentage f cuntries 9.1% 22.7% 4.5% Percentage f cuntries 4.3% 4.3% 4.3% 4.3% n=22 HIGHER MIDDLE n=23 HIGH 19

14 ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders 1.5 Substance use mnitring and surveillance (Figures ) Backgrund Nminated fcal pints in cuntries were asked abut the presence f natinal data cllectin systems that cllect epidemilgical data n alchl and drugs, as well as treatment data frm health systems in their respective areas. N request was made regarding the existence f infrmatin at subnatinal level. Epidemilgical data can be btained thrugh natinal surveillance systems. These can be cmpsed f natinal surveys cllecting infrmatin n alchl and drug use amng the adult r the adlescent ppulatin. Treatment data relating t alchl and drug use can be btained frm natinal service delivery data cllectin systems that cmpile admissin and discharge data, the number f utpatient cntacts and similar service infrmatin frm the health care system. Salient findings Less than 5 f cuntries reprted having natinal data cllectin systems cllecting epidemilgical data r treatment data. The regins with the highest prprtin f cuntries (apprximately 6) reprting natinal epidemilgical data cllectin systems fr alchl and drug use were the Americas and Eurpe. The lwest prprtins f cuntries reprting natinal surveys n alchl and drug use amng adlescents were in Africa (5 7%), in Eastern Mediterranean (less than 2) and in Suth-East Asia (less than 2). Treatment data n bth alchl and drug use disrders appear t be mst ften cllected in the Americas and in Eurpe, with arund 65 77% f cuntries in these regins reprting the cllectin f treatment data. Cllectin f treatment data n alchl and drug use disrders seems t be balanced acrss regins, except in the Eastern Mediterranean and Suth-East Asia regins where higher prprtins f cuntries indicated cllectin f treatment data n drug use than n alchl use. There is a strng effect f cuntry incme level n the presence f natinal data cllectin systems acrss different incme grups. Fr example, natinal epidemilgical data cllectin systems have been reprted mre frequently amng cuntries in the higher middle-incme and high-incme grups (50 76%), than in the lw-incme and lwer middle-incme grups (11 31%). 20

15 Psychactive substance use: epidemilgy and burden f disease Ntes and cmments Natinal epidemilgical data cllectin systems may fcus n alchl and drug use exclusively. Hwever, epidemilgical data cllectin systems which cver a range f health issues may nt have been detected by this survey. Infrmatin n alchl and drug use amng yuth can be cllected amng students ging t schl. A number f cuntries reprted natinal schl health surveys as a way f cllecting infrmatin n alchl and drug use amng yung peple. Natinal data cllectin systems n epidemilgy and treatment f substance use and substance use disrders appear t be lacking. This is especially evident in lw-incme and lwer middle-incme cuntries, which may hamper effrts t plan effective respnses. 21

16 ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders Alchl Drugs 76.5% 65.9% 69.7% n= % 61.9% 55.8% 35.7% 21.4% 20.9% 16.3% % 42.9% % 35.7% FIGURE 1.10 PROPORTION OF COUNTRIES WITH A NATIONAL EPIDEMIOLOGICAL DATA COLLECTION SYSTEM FOR SUBSTANCE USE, BY REGION, 2008 n= % 51.7% 31.7% 29.3% 23.8% 11.9% FIGURE 1.11 PROPORTION OF COUNTRIES WITH A NATIONAL EPIDEMIOLOGICAL DATA COLLECTION SYSTEM FOR SUBSTANCE USE, BY INCOME GROUP, 2008 n=146 Eurpe Wrld Western Pacifi c Suth-East Asia Americas Eastern Mediterranean n=146 Higher-middle High Africa Lw Lwer-middle 88.6% 85.7% 71.4% % 66.7% % 58.6% 46.7% 42.5% 42.2% n= % 7.1% 21.4% FIGURE 1.12 PROPORTION OF COUNTRIES WITH A NATIONAL SURVEY ON ALCOHOL AND DRUG USE AMONG ADOLESCENTS, BY REGION, 2008 n= % 24.4% 11.9% 7.1% FIGURE 1.13 PROPORTION OF COUNTRIES WITH A NATIONAL SURVEY ON ALCOHOL AND DRUG USE AMONG ADOLESCENTS, BY INCOME GROUP, 2008 n=147 Eurpe Wrld Western Pacifi c Suth-East Asia Americas Eastern Mediterranean n=147 Higher-middle High Africa Lw Lwer-middle 79.5% n= % 16.3% % 42.9% 71.4% % % 30. FIGURE 1.14 PROPORTION OF COUNTRIES WITH A NATIONAL SUBSTANCE ABUSE TREATMENT DATA COLLECTION SYSTEM, BY REGION, 2008 n= % % 70.6% 67.9% % FIGURE 1.15 PROPORTION OF COUNTRIES WITH A NATIONAL SUBSTANCE ABUSE TREATMENT DATA COLLECTION SYSTEM, BY INCOME GROUP, 2008 n=145 Wrld Western Pacifi c n=145 Eurpe Suth-East Asia Americas Eastern Mediterranean High Higher-middle 22 Africa Lw Lwer-middle