Discussion
The study sheds light on young adults with experience in the use of illegal substances who had actively sought out a website that provided information about possible health risks and precautions related to substance use. The majority were students or in employment. Only 14 % stated that they needed treatment for substance use, and a minority had experienced being arrested by the police for illegal substance use (20 %).
Just over a third of this sample had refrained from telling healthcare personnel about their substance use in situations where it would have been relevant to do so. Many had experienced that an ambulance was not called in acute substance-related situations. Among those who had told healthcare personnel about substance use problems, one in four thought it had had negative consequences for them. However, there were also a good number who had disclosed their use of illegal substances but who did not believe that they needed medical assistance. The picture is thus somewhat mixed.
In relation to alcohol, the so-called prevention paradox means that the predominance of injuries is found in moderate users, who, despite the lower risk of injury, constitute a much larger group than extremely heavy users (15). A different picture emerges when considering illegal substances as a whole: the Norwegian Institute of Public Health's latest figures estimate that only around 9 000 people are involved in high-risk use of opioids in Norway (16). The concentrated health burden in this group is estimated at 300 disability-adjusted life years (DALY) per 100 000 inhabitants, while the corresponding health burden in the much larger group of cannabis users is estimated to be 8 DALY (17). The most serious substance use disorders involve ill health and considerable suffering. They are also difficult to treat and often only appear following many years of substance use. Breaking down barriers to seeking help among relatively new users can therefore be an important preventive measure. In addition, there is probably a generally unmet need for medical assistance related to illegal substance use among the many who never become heavy users.
In our study, there appear to be several reasons for postponing or avoiding calling an ambulance in acute substance-related situations. The majority stated that they had feared that the police and/or other public agencies would be notified. However, it should be noted that more than half thought that calling an ambulance had not been considered necessary. This may seem contradictory, and we discuss this matter below. We also want to emphasise that the data do not make it possible to ascertain whether the situations in question actually involved potentially life-threatening events.
A Swedish study found similar scepticism to calling for help in acute medical situations in a sample of mainly moderate users of illegal substances. Here, 32 % stated that they would hesitate, while 8 % were adamant they would not seek help in a situation where substance use constituted an acute threat to health or the risk of overdose (18). The main reasons cited were fear of the police, of being socially stigmatised, of having their home searched and of getting into trouble with the child welfare service.
Fewer people with mental illnesses seek medical assistance than those with somatic diseases (19), and those with substance use disorders are the least likely to seek help (1). There can be several reasons for this. Some people may find that the benefits of using substances and the enjoyment it gives them outweigh the potential harm it may cause, and therefore do not want to tell healthcare personnel about their substance use, or they may underestimate the actual risk (20). However, shame and concern about being socially stigmatised are also likely to be factors, especially in the case of illegal substance use (2). There is also a commonly held view that the criminalisation of the use of illegal substances plays a role (3, 4). Our findings may indicate that fear of notifying the police comes into play in acute situations, but we do not know whether the fear concerns the involvement of the police themselves or the possibility of being convicted.
Healthcare personnel may also be unsure of what treatment they should offer patients with defined substance use disorders (21). A literature review showed that they can also perceive the patient group as manipulative and not motivated to get help. This may be partly due to a lack of professional training to deal with this patient group and the absence of good support in the working environment (22). It is therefore not surprising that many with diagnosed substance use disorders believe that the help they received was inadequate (23). One possible consequence is that both the group with diagnosed substance use disorders and other users of illegal substances instead seek help in their personal networks of other users or in online forums, where there may be scepticism both to established forms of treatment and to the healthcare professions (24).
One limitation of the study is that we do not use standardised or validated instruments. Additionally, some of the questions can be perceived as leading and some had a relatively high proportion of 'No' responses. The sample is also self-selected and cannot be considered representative of a clearly defined population of 'experimental users'. The high number who did not consider it necessary to call an ambulance but believed that immediate help was needed may have several explanations. It may be due to ambiguities in questions and response alternatives, or to respondents being confused about or not recognising the seriousness of acute situations triggered by substance use. Some of those who reported this may have been under the influence of drugs themselves, in which case it is conceivable that they viewed the situation differently to others present.
Another limitation is that users who have experienced acute situations triggered by substance use or are sceptical to disclosing their own problems to a doctor or other healthcare professional may be more likely to seek out a source of information such as Rusopplysningen.no, and heavy users are probably underrepresented. Neither names nor IP addresses were logged, and the possibility of some people participating more than once cannot therefore be ruled out. It is also conceivable that the website is associated with some of the organisations that have developed the support services. This particularly applies to the Association for Safer Drug Policies, which operates the site and has another more drug policy-oriented website with a related visual design. We do not have the opportunity to shed light on such selection factors in our data.
The study also lacks a comparison group. We know that few people with alcohol problems seek help (25). Future studies should therefore include different groups of alcohol users, including those who share background characteristics with our sample. This will enable researchers to identify whether the mechanisms we allude to here are also to be found in relation to legal consumption.
We found that a significant proportion of the participants who self-reported the use of illegal substances did not disclose this to healthcare/social care personnel. As indicated by the majority of the sample, they probably have a limited need for treatment. Nevertheless, it is unfortunate that so many do not disclose their illegal substance use when it is relevant to do so, and that some have experienced an ambulance not being called in acute substance-related situations. The study also illustrates how websites visited by people who use illegal substances were a useful gateway to accessing the group we wanted to study: users of illegal substances who have typically not told healthcare personnel about their substance use and who have typically not been revealed to be users by police and the judicial system. It is thus not easy to identify this group in datasets extracted from public registers.