National narcotics agencies are a feature of law enforcement for drug crimes worldwide. They exist in most Southeast Asian nations that retain the death penalty for drug offences, including in Indonesia (Badan Narkotika Nasional); Singapore (Central Narcotics Board); Thailand (Narcotics Control Board); and Malaysia (Agensi Antidadah Kebangsaan). This chapter undertakes a comparative study of national narcotics agencies in Southeast Asia. Each of the aforementioned four agencies plays an outsize role in shaping both public opinion and government policy on the death penalty for drugs and on punitive responses to non-capital drug crimes more generally. Previous NGO reports and academic studies on Southeast Asian drug policy have failed to consider the institutional dimensions of drug control: this chapter aims to rectify this particular gap in the literature. Comparing relevant institutions across the region, this chapter accounts for organisational similarities and differences, explores the relationship between anti-drugs and other state institutions, and suggests modest policy recommendations.

Harmful substances and behaviours include alcohol, drugs, smoking, gambling, harmful technology use, and risky sexual practices, with a spectrum of harm from minimal to severe. Stigma and discrimination compound the harmful effects of these substances and behaviours. The biopsychosocial model has been historically used to understand, assess, and intervene in problems with such substances and behaviours. Harmful use of substances and behaviours is a growing problem and contributes significantly to the global burden of disease. The rise of technology-driven behaviours, such as gaming and social media use, can lead to addictive or compulsive patterns. Alcohol is a leading risk factor for disease and death, with no safe level of consumption recommended by the World Health Organization. Misuse of illicit and prescription drugs is rising globally, with opioids contributing to the most significant drug-related harm. Tobacco use remains a major modifiable risk factor for disease and mortality. Problem gambling has a high suicide rate and is often accompanied by financial problems. Definitions of problematic use of gaming and other technologies are challenging, with varying cultural and generational views on acceptable levels.

Using the new criteria for empirically supported treatments, cognitive-behavioral therapy and contingency management were both given strong recommendations for substance use disorders. Credible components of treatment include skills training, motivational enhancement, and access to nondrug alternative reinforcement. A sidebar discusses mutual support organizations such as Alcoholics Anonymous. Another sidebar describes harm reduction strategies.

The use of psychoactive substances (legal, illegal, or prescribed) continues to be a major public health problem. The prevalence of alcohol and drug use/abuse among Muslims is extremely difficult to determine as it relies upon self-reporting and is a stigmatized behavior. While alcohol and drug consumption are ostensibly forbidden in Islam, some Muslims drink alcohol and take psychoactive substances. Islam takes a strong prohibitive stance and forbids all intoxicants (alcohol, drugs, and tobacco), regardless of the quantity or kind, because any substance that harms the body is prohibited. Islam established a zero-tolerance policy towards addictions. The public health approach in the response to addiction began in the seventh century during the first Islamic caliphate and is based on an abstinence model. In contrast to the abstinence model, due to the increased use of drugs and injecting behavior (and the control of HIV), harm reduction approaches have been adopted by few in the Islamic world.

Problems relating to alcohol or drugs occur across a spectrum of levels of consumption and may be physical, psychological or social in nature. At one extreme, there is a small but significant proportion of people who develop dependence and may require both intensive and extensive support. However, on a population level, huge reductions in the harm caused by psychoactive substances could be made if everyone was encouraged to use a bit less. All health and social care professionals should be able to screen for potential alcohol use disorders, deliver brief advice and refer on to specialist services where appropriate. They should also have an awareness of the common illicit drugs and the potential problems these drugs are associated with. The evidence base for treatment of substance use disorders has developed over the past 30 years, and clinicians should be positive and optimistic that meaningful change in behaviour can be achieved. Prompt referral to the right level of support and treatment may prevent future problems. Recovery support services play a crucial part in sustaining any gains made in treatment, and many people recover without using professionally directed treatment at all. It is estimated that approximately 10 per cent of the population of the USA is in remission from a substance use disorder of any severity.

Alcohol and drug misuse are no longer confined to younger people, as the baby boomer cohort of older people shows the fastest rise in rates of mortality from drugs and from alcohol. This chapter provides an overview of substance misuse in older people, starting with its terminological, epidemiological, and pharmacological aspects. It goes on to detail clinical aspects that include screening, diagnosis, and presentations such as alcohol withdrawal, self-harm, drug intoxication, overdose, drug withdrawal, and psychosis.

Particular attention is paid to age-related syndromes such as alcohol-related brain damage – amnestic syndrome and alcohol-related dementia. The chapter also considers the relevance of comorbid physical disorders that can affect a range of pathologies and dysfunctions, particularly in gastro-intestinal, respiratory, cardiovascular, and neurological systems.

The organisation of care is also discussed, in order to highlight the importance of multi-agency working to provide a range of interventions that include liaison old age psychiatry and hepatology. The chapter goes on to cover medico-legal aspects as well as substance misuse and driving. It concludes with a section on discharge planning, emphasising the role of multidisciplinary teams in harm reduction – as well that of carers, non-statutory organisations, medical, and mental health services.

Social media are changing the way people are exposed to products with addictive potential – including gambling. This chapter provides a brief overview of the way digital technologies like social media are changing the gambling landscape and their relationship with gambling harm. Traditional approaches to gambling harm reduction have largely failed to recognize and address many of the systemic factors that shape the environment in which gambling harm occurs, such as promotion of gambling. Greater regulatory attention is needed to prevent social media from contributing to harm, especially among vulnerable groups such as minors and people experiencing gambling problems.

Harm reduction refers to a set of strategies aimed to limit the negative consequences associated with drug use, but without requiring complete abstinence. Some harm-reduction strategies aim to reduce the risk of overdose, such as the use of naloxone rescue kits, fentanyl testing strips, and implementation of Good Samaritan laws. Other strategies lower the risk of overdose but also the likelihood of contracting infectious diseases such as HIV and hepatitis. Syringe services programs, also referred to as needle exchange programs, and supervised consumption facilities all fall under this category. Medications for opioid use disorder (MOUD), which include methadone, buprenorphine, and naltrexone, have been proven to lower the risk of overdose, improve the likelihood of maintaining sobriety, and therefore lower rates of disease transmission. Finally, harm reduction is utilized in criminal justice system through the use of drug decriminalization, police diversion programs, and drug treatment courts.

In this chapter, Valeria Catalani, a research student, interviews Dave Croslands, a former professional bodybuilder who is now actively involved in the harm reduction sector, providing online support and educational services to the bodybuilding community. In the course of the interview he describes in detail his journey with the use of performance-enhancing drugs (PEDs), from his initial teenage experiences, when no information about PEDs was available, to his later, more informed years. His aim is not to stop people using PEDs, but to educate them about responsible consumption and usage. He emphasizes his belief that knowledge will reduce the harm and severe side effects caused by using PEDs. He also explains why he does not think that bodybuilding or indeed other sports disciplines can ever be separated from performance-enhancing practices.

Among the image- and performance-enhancing drugs (IPEDs), anabolic-androgenic steroids (AAS) are now a global public health issue. Once confined to sporting arenas and competitive bodybuilding, they have now reached an increasingly image-conscious general population. In addition to the well-documented evidence of physical harm caused by AAS, there is emerging evidence that in sustained high doses they affect the structure and functioning of the brain. For some of the newer drugs the potential long-term impact is unknown. The risks to health are compounded by polypharmacy, high levels of injecting, and variable product content and contamination resulting from the illicit market. Responses to the issue (i.e., the level and implementation of regulations, education and preventive activities, and treatment and harm reduction) vary. However, there are few data to inform the development of effective interventions, and there is a clear need to develop the evidence base, which requires effective engagement with drug-using populations.