It truly is a small world. Worldwide communications have become possible through the Internet. We have a global perspective that has never before existed as it does today.

When it comes to addiction treatment and research, there is a growing global concern about alcohol and drug abuse, with a primary focus on illicit drugs and the spread of HIV/AIDS. Recently there has been a call for more drug treatment services as nations have responded to the drug crisis. Many countries with previously few specific drug treatment services have seen a rapid expansion in the 1990s. Organizations such as the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute on Drug Abuse (NIDA), and the World Health Organization (WHO), have led these efforts, providing information exchange and scientist exchange throughout the world. Technical cooperation and collaboration and joint research projects have enhanced the skills of researchers worldwide.

WHO-related activities have included joint efforts in diagnosis and classification and the search for a biological marker. NIAAA, NIDA, and the National Institute of Mental Health (NIMH) have worked in specific countries, including Finland, Hungary, India and especially Russia to promote international collaboration.

For example, the WHO and the United Nations Commission on Narcotic Drugs have tracked for many years the correlation between drug use and other diseases such as TB and HIV rates. The WHO, showing the dramatic increase in HIV and TB cases for injecting drug users, provided the following data. This data is most significant from a global epidemiological perspective so healthcare officials can follow trends in drug abuse and its correlation with other diseases.

This cooperation has resulted in excellent cross-national comparisons of drinking behavior, epidemiological research and alcohol- and drug-consumption levels. National and international alcohol control measures and drinking and driving programs have greatly benefited from this collaboration.

Since World War II, most Western nations have shifted from regarding alcoholism as a social problem to be punished, to viewing it as a health problem to be treated. This effort has had dramatic, positive impact on treatment systems, how they view alcoholism, the goals of treatment, and the deinstitutionalization and decentralization of treatment. The international diffusion of Alcoholics Anonymous is spectacular, as evidenced by the 65th AA International Convention in Minneapolis in June 2000. The relationship between AA to the global professional treatment community has also markedly improved in recent years.

However, standardized, reliable worldwide data concerning the impact of substance abuse on nations, as well as treatment approaches, is still hard to find. If we are to address the issue of addictions from a global perspective we must begin with an interdisciplinary and cross-cultural approach.

In America we have a tendency to exhibit ethnocentrism and parochialism, the belief that we have the finest technology, science and medicine and know the answers to other nation's problems. As we travel abroad we face a paradox: the more nations are different the more they are the same and no nation has a lock on solutions when it comes to addiction treatment. A spirit of understanding and collaboration is essential if we as a global community are to solve our addiction issues.

National treatment systems must respond as global actors on an international stage. For example, the use of a harm reduction approach in various European nations has been influenced by the experiences of experimental countries such as England, the Netherlands, and Switzerland. And the latter nations have offered models of care to Australia and Germany. American monitoring systems and treatment models have been diffused throughout Latin America. The European Union has had an influence in funding treatment and prevention in central European countries such as Poland (Alcohol Health and Research World, Vol. 17, Number 3, 1993).

China, Slovakia, Russia and Portugal each have different approaches to addiction. Although data is available from NIAAA, NIDA, NIMH, and the WHO concerning the nature and extent of addiction in these nations, I will offer my personal experiences and reflections in these countries over the years.

The nature and extent of alcohol and drug use and abuse in China remain unclear, due to limited data. In 1990, the National Drug Prohibition Committee published the first figures on drug addicts: 70,000 had been registered (in a country of 1 billion people). These figures have doubled every year since. This increase reflects not only the extension of drug consumption but also growing awareness of the nature of the problem and better reporting methods.

Provincial studies or city epidemiological surveys have been conducted in China since1990. Heroin and opium are the two most frequently used drugs (mainly nasally inhaled, smoked or intravenously injected), though with notable regional and cultural differences. Increased costs and reduced availability are reasons given by addicts for injecting (Wu Zunyou, et al., "Risk factors for IV drug use and sharing equipment among young male drug users in Longchuan Country, Southwest China, AIDS, 10, 1017-1024).

Cannabis and solvents are rarely used and methamphetamine is not reported although the International Narcotics Control Board (Report of the International Narcotics Control Board for 1995, 1996, New York: United Nations Publications) reported that this substance represents a major drug problem in China. What is obvious from anecdotal reports is that alcohol abuse and alcoholism is widespread throughout China, especially in the countryside. In 2000, members of the Chinese medical and psychiatric communities and representatives of the Chinese military reported significant rates of heroin use to me. However, foreigners have generally been limited in their exposure to such problems in China. Because of this, I have been fascinated by addiction in China for nearly 30 years.

I began my involvement in addiction treatment in China in 1976 when I felt called to provide education about addiction in China. As relations between the United States and China were normalized in the 1970s I began writing to China requesting visas for addiction professionals to visit China. After three years, visas were obtained, and the first historic visit of 25 leading addiction professionals from the United States, Canada, Sweden and Australia occurred in November 1979. Communication with China continued for years, until the Chinese psychiatric and medical associations stated China had no problems with substance abuse and did not foresee any in the future.

When I returned to China in 1999 the problems of heroin addiction and alcohol abuse were significant, especially in the countryside. Although some Chinese doctors are now willing to face these issues, little attention is given by the government and the Chinese medical community.

Twenty years ago, I met Dr. Shen, a 75-year-old pioneer in addressing alcoholism in China. In 1999 she asked if AA could be introduced into China. Working with AA World Services and AA San Francisco, four Chinese doctors attended the aforementioned 65th Worldwide AA Convention. The Big Book, formerly translated into Chinese by a Taiwanese person, has now been translated by one of these doctors in Beijing into Mandarin. And according to e-mails from China, AA has now begun in a hospital in China. It is truly a new beginning for addictions in a nation that comprises one fifth of the world's population.

There is no such thing as an alcoholism or drug abuse counselor in China. Medical personnel, particularly psychiatrists, whenever rarely they are offered, provide services. But even these few doctors are not fully accepted by the mainstream medical and psychiatric community. A National Association on Drug Dependence has been formed in Beijing to provide education and training to the Chinese public. But, with a population of 1.2 billion people, these efforts seem to be having minimal impact on the growing problem of addiction in China.

What is needed is a prolonged and patient effort by the world community to assist China in addressing their addiction issues. An All-Asian Institute on Addiction is being discussed as a starting point to launch an Asian education and training effort. Obviously social and political changes in China will continue to have a profound impact on addiction in that nation.

After emerging from the Soviet Union, Slovakia faces a significant issue with drug and alcohol abuse, as does much of Eastern Europe. Drugs of choice in Slovakia are heroin, alcohol, marijuana and Ecstasy.

With few resources available, Slovakia has established several credible addiction treatment programs based upon a modified Minnesota Model and 12-Step Programs in Bratislava and throughout the country. Anecdotal information indicates drug addiction is quickly becoming a major concern for the social and economic stability of Eastern Europe. Dr. Paul Fields, president of the International Health Resource Management (IHRM) provides education and training on addictions, HIV/AIDS, and related healthcare issues.

I visited three treatment centers dealing primarily with heroin addiction and alcoholism, where training was provided for a small but growing number of alcoholism and drug abuse professionals. Slovakia urgently needs the establishment of the addiction counselor profession, the formation of a trade association and training for counselors, and recognition of such a body by an international credentialing group such as the International Certification and Reciprocity Consortium (ICRC).

My involvement in Russia began in 1974 when I spent a month touring the former Soviet Republics of Russia, Ukraine, Uzbekistan, Georgia and Armenia. I met with Dr. Babiyan, then head and "patriarch" of Soviet addiction research and treatment. He stated they had a slight problem with alcoholism and no drug problems, as each night I witnessed many men staggering on the streets at 5 p.m. In these republics, I toured primitive addiction treatment centers that appeared to be more like prisons than hospitals. I stayed involved with Russia through the 1970s and '80s, especially through the Soviet American Conferences on Alcoholism from 1989-1990.

For alcoholism educational purposes, in 1991 I co-led a delegation of five American military personnel to the Soviet Union and a reciprocal visit of Russians to America in 1992 (after the fall of the Soviet Union). Similar visits continued throughout 1999 with increasing awareness that the problem of addictions was becoming monumental in Russia.

In May 2000 I visited several addiction treatment programs in St. Petersburg, Russia. A report from their medical staff stated that heroin addiction now affects one out of every four families in St. Petersburg. Yet, Russian society has generally been strongly opposed to spending scarce resources on the treatment of addiction. A needle exchange program proposed in 2000 was soundly defeated in St. Petersburg, after an outcry from pensioners that they were sick and going hungry while addicts were receiving treatment. The picture for addiction treatment in Russia is bleak at this time despite over a decade of assistance by many organizations from America and Europe.

The number of registered narcotic users increased from 25.7 per 100,000 population in 1985 to 60.6 per 100,000 in 1994 (Crime and delinquency (1994), Statistical Review, Moscow: Ministry of Internal Affairs, Russia). According to data from the St. Petersburg Narcological Center, Health Committee of St. Petersburg Administration, the rate of drug addiction among teens/adolescents in St. Petersburg has risen by approximately 800 percent from 1997 to 1999. Since the 1980s the use of hallucinogenic substances has increased, in both synthetic form (phencyclidine) and natural form. In the 1990s, Ecstasy made its appearance but opiates are still the most popular (Klingemann, H. and Hunt, G. Drug Treatment Systems in an International Perspective, London: Sage Publications, 1998). Overall across Russia the rate of drug addiction among women has risen from a low of 390,000 in 1994 to a high in 1999 of 13,160,000 (Report, Health Committee of St. Petersburg Administration, May, 2000).

It was reported to me that one in every four families in St. Petersburg is directly impacted by heroin addiction in some way. Rates of alcohol use and alcoholism, although always somewhat hidden and mysterious, remain astonishingly high and have been so for many years. Owing to the size of the country and of its population, and the deterioration of its health services, it has been impossible to determine accurately the nature and extent of drug and alcohol abuse and the relationship with HIV infection or AIDS. However, data does point to the growing problem of drug abuse throughout Russia. Despite many attempts to address this problem, from several efforts at prohibition to treatment and prevention strategies, the problem appears to continue to grow out of control.

Having begun visiting Portugal in the mid-1980s, I was pleasantly surprised when I returned there in 1999 and 2000 to find a growing number of professionals addressing the issue of addiction.

The Portuguese medical and psychiatric community readily admits to having a significant drug problem, particularly with marijuana and heroin. A counselor association, formed in June 1999 under the leadership of George Faria and others, became a credible and recognized body in Portugal within a year. The next step for the Portuguese Alcoholism and Drug Abuse Association will be to seek acceptance into the ICRC or another worldwide credentialing organization. Training has been provided in Portugal and several professionals have attended training in the United States at the Navy Drug and Alcohol Programs in San Diego, Calif., and Norfolk, Va. The Portuguese Navy has developed one of the most sophisticated drug screening laboratories in the world under the leadership of Comdr. Jaoquim Carrillho. In June 1999 an historic agreement was signed by the Portuguese Navy and the Portuguese Industrial Association (PIA) to provide employee assistance program-type services to Portuguese companies (the PIA consists of more than 3,500 companies in Portugal).

The number of persons attending drug treatment has steadily risen over the 1990s, from a low in 1990 and an annual increase of 29 to 42. Self-help groups first appeared in 1985. Today there are about 1,000 NA groups, which hold 120 weekly meetings throughout the country (Klingemann, Hunt, Ibid.).

As we look into the future there are several uncharted territories ahead for international addiction treatment.

1. A world council of alcoholism and drug abuse counselors must be formed. The International Certification and Reciprocity Consortium (ICRC) needs to become truly international with the development of a cross-cultural examination written in languages other than English. ICRC should broaden its representation of national treatment systems, including Portugal, Russia, Slovakia, the Czech Republic, Poland and especially China, as these nations move forward in developing addiction treatment and counselor credentialing.
2. International networks for education and training are needed. A global curriculum for professional development, with national adaptations, must be written. Systems are essential for treatment management and clinical supervision that meet the needs of individual countries and their unique approach to delivery of care.
3. The integration of drug and alcohol treatment, which in many nations remain separate entities, must be addressed. For example, addiction treatment in countries such as Colombia, Spain, Poland and France are oriented more to alcoholism issues with low integration of services for drug treatment. Switzerland, Peru, Germany and England are more drug oriented with low integration of alcoholism treatment. The countries with the highest integration of services between alcoholism and drug treatment are Canada, Finland, Netherlands, Austria, Hungary, and the United States (Klingemann and Hunt, Ibid).
4. Approaches to polydrug user treatment must be explored between nations. There are considerable differences in terminology, such as the concepts of multihabituation, multiple drug abuse, polyvalent abuse and multiple dependence. The institutional division between alcohol and drugs in many nations may largely determine how we perceive and handle problems connected with polydrug use.
5. The International Center for Health Concerns, Inc. (ICHC) has faced a new frontier by addressing alcoholism and drug abuse issues in the militaries of nations. With working agreements from the surgeon generals of several nations, ICHC met with 16 nations in 2000 to promote dialogue and exchange of information, and is working on a worldwide gathering of the militaries of 15 nations to discuss substance abuse in the military. Currently, ICHC is working in Western and Eastern Europe to share resources and to provide education and training. Counselor and supervisory training programs are provided to professionals across Europe and in Asian nations such as Singapore. ICHC is also assisting AA World Services in establishing AA in China.

There are many opportunities and challenges in international addiction treatment. If you are a counselor reading this article, give consideration to these needs and see if you feel called to respond:

• Counselors, educators, trainers and managers are needed who are willing to share their skills and wisdom and volunteer to assist overseas. An example of such dedication is Claudia Blackburn, an American psychologist who works internationally with programs that serve families living in difficult conditions, and individuals traumatized by alcoholism, abuses and social dissolution. For a decade, she has dedicated herself to helping Poland develop their addiction treatment system. Are you willing to go at your own expense as a volunteer to assist other nations as they respond to their addiction treatment needs?
• Think globally. As the world community shrinks, each of us is able to assist one another on an international stage. Become aware of the needs of other nations as they tackle their addiction issues. Go online and communicate with others overseas who are reaching out for assistance. As AA has taught us, by keeping our eyes on others and their needs, we are enriched.
• If you are proficient in a language other than English, offer your help in translating educational materials to organizations such as ICRC and ICHC.

I will never forget the words of a Russian general as a group of American and Russian military personnel and I baked naked in a steaming hot tub in Moscow in 1991. He said, "When we take our uniforms off, we are all the same. We are children of one God, with the same desire, to see our children grow up in a world that is safe and free from pain." May it be so.

David J. Powell, PhD, is president, International Center for Health Concerns, Inc. Dr. Powell has 35 years in the addiction field. He is a licensed alcohol and drug abuse counselor, a licensed marriage and family therapist, a certified clinical supervisor and diplomat in the International Academy of Behavioral Medicine and Psychotherapy.

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