Addiction medicine

About: Addiction medicine is a research topic. Over the lifetime, 1070 publications have been published within this topic receiving 23685 citations.

Framing Nicotine Addiction as a “Disease of the Brain”: Social and Ethical Consequences†

Abstract: In November 2010, the Director of the National Institutes of Health (NIH), Francis Collins, announced the creation of a taskforce to help move all substance use, abuse, and addiction research programs within the NIH into a single, new institute (Collins, 2010). This transition would force a merger of the National Institute on Drug Abuse (NIDA), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and the drug-related research portfolios from other institutes such as the National Cancer Institute (NCI) (Seffrin et al., 2010). Supporters justify the new institute’s creation by highlighting an emerging body of scientific findings: recent research in neuroscience suggests that a single mechanism underlies compulsive behavior and addiction, regardless of the particular substance or drug of abuse. Similar brain reward pathways are thought to be involved in the development and maintenance of addiction, raising the possibility of common risk factors and the hope for novel prevention and treatment strategies across substances. In addition, supporters argue that many would be better served by a single institute combining all substance use, including patients with comorbid drug use, as well as the general population, which would benefit from comprehensive early prevention efforts (Scientific Management Review Board, 2010). Collins stated that this new institute “makes scientific sense and would enhance NIH’s efforts to address the substance abuse and addiction problems that take such a terrible toll on our society” (Collins, 2010). However, the merger remains contentious; others express concern that the merger will result in less funding for drug or substance-specific research portfolios focused on prevention, as well as decreased support for psychological and social research. One concern is that an overly reductionist vision of addiction is fueling the merger in ways that may narrow the research focus, minimizing approaches that situate addiction within a complex biopsychosocial context. One coalition of tobacco prevention groups complained: “We believe that the proposed reorganization could also narrow the focus of tobacco-related research to issues related to addiction when such research, however significant, is only one of several areas in which innovation research is necessary to expand the evidence base” (Seffrin et al., 2010:2–3). Similarly, Caryn Lerman, President of the Society for Research on Nicotine and Tobacco, advised NIH director Francis Collins that if “tobacco use research is to be moved from other NIH institutes to a new Institute, retain tobacco policy and product research within NCI, consistent with the relevance of this subset of the portfolio to medical consequences of drug use” (Lerman, 2010:3, emphasis in original). In other words, there is a concern that addiction’s etiology will be reduced to biology alone, to a “disease of the brain.” No decisions have been announced regarding this possible merger. Framing addiction as a disease of the brain with common mechanisms is one driving force behind the proposed merger, which is of special concern since NIDA claims that it alone “supports more than 85 percent of the world’s research on the health aspects of drug abuse and addiction” (National Institute on Drug Abuse, 2004). Although NIDA funds prevention and environmental influences on drug initiation, maintenance, and cessation, the bulk of NIDA research funding ($519.497 million) goes to “Basic and Clinical Neuroscience,” which includes work to “expand the understanding of the neurobiological, genetic/epigenetic, and behavioral factors underlying drug abuse and addiction” (National Institute on Drug Abuse, 2011). Another $116.017 million goes to “Pharmacotherapies and Medical Consequences” research, which is responsible for “medications development aimed at helping people recover from drug abuse and addiction and sustain abstinence” (National Institute on Drug Abuse, 2011). By contrast, research in “Epidemiology, Services and Prevention Research,” which seeks to “promote integrated approaches to understand and address the interactions between individuals and environments that contribute to the continuum of drug abuse-related problems,” receives less funding ($260.465 million). Cutting-edge research that seeks to “elucidate the nature of the addictive process; to determine the potential use of new therapies for substance abuse, both pharmacological and psychosocial; and to decipher the long-term consequences of drug abuse on brain development, maturation, function, and structure, and on other organ systems,” funded through the intramural research program,” receives $90.368 million (National Institute on Drug Abuse, 2011).NIAAA similarly privileges biomedical research (Midanik, 2004). Clearly, though prevention and gene- and brain-environment interaction is important to these funding institutions, genetic and neuroscience research are prioritized, suggesting the discursive power of reductionist, biological views of addiction. Important social consequences arise from the way neuroscience and genetic research is subtly, and at times not so subtly, constructing a new understanding of addiction as a disease of the brain or as a “genetic” or biological disorder. In this article, we use nicotine addiction as a case study through which to understand the changing nature of our perceptions of addiction and to anticipate how new frameworks will be integrated into existing public health and clinical programs at the federal, state, and local levels. Indeed, the issues and concerns we raise are not limited to the study of one phenomenon, nicotine addiction, but are relevant to a range of complex behaviors that involve substance use for which researchers seek to locate genetic underpinnings. Tobacco serves as an illustrative case because the medicalization of smoking/tobacco addiction has occurred more recently than for other substances, for example, alcoholism. It is also an arena where both social programs (e.g., clean air laws and higher taxes) and pharmaceutical interventions (e.g., nicotine replacement therapies) have been successful. In this article we draw on in-depth interviews with 86 experts in tobacco control, nicotine addiction research, or smoking cessation to examine how genetic research on addiction (and addiction more broadly) shapes the meaning ascribed to smoking and thus affects the scope and structure of tobacco control policy. This article is organized around four key questions raised by critical analyses of this body of research. First, will genetic research change how we understand addiction? We argue that most stakeholders hold a medicalized view of addiction, though a cultural shift that would locate addiction solely within the body, especially with regard to initiation, has not occurred. However, biology is widely understood to be a factor in the strength and speed with which one becomes addicted after initiation. Second, will increased focus on addiction as a disease of the brain lead to unrealistic expectations for treatment? Our data suggests that this is not likely, but for teenagers, it may reinforce expectations that quitting smoking is not difficult. Third, will it change the way people understand cessation, cessation options, and their personal responsibility for or ability to quit smoking? We argue that this research will change what people understand to be the most effective cessation techniques, with increased emphasis on pharmaceuticals and decreased emphasis on “willpower” and modification of behaviors and environments. Finally, will it increase or decrease stigmatization of smoking? We predict that it is unlikely this research will either increase or decrease smoking stigma, but that individuals will utilize the research to buttress their existing view of stigmatization and smoking. Because of the complex nature of smoking and addiction, we join the voices of those from a wide variety of disciplines studying addiction who are calling for an interdisciplinary understanding of addiction as a biosocial or biocultural phenomenon (Acker, 2010; Courtwright, 2010; Keane and Hamill, 2010; Kushner, 2010; Vrecko, 2010; Windle, 2010).

Day hospital and residential addiction treatment: Randomized and nonrandomized managed care clients.

Abstract: Male and female managed care clients randomized to day hospital (n=154) or community residential treatment (n=139) were compared on substance use outcomes at 6 and 12 months. To address possible bias in naturalistic studies, outcomes were also examined for clients who self-selected day hospital (n=321) and for clients excluded from randomization and directed to residential treatment because of high environmental risk (n=82). American Society of Addiction Medicine criteria defined study and randomization eligibility. More than 50% of followed clients reported past-30-day abstinence at follow-ups (unadjusted rates, not significant between groups). Despite differing baseline severities, randomized, self-selecting, and directed clients displayed similar abstinence outcomes in multivariate longitudinal models. Index treatment days and 12-step attendance were associated with abstinence (p<.001). Other prognostic effects (including gender and ethnicity) were not significant predictors of differences in outcomes for clients in the treatment modalities. Although 12-step attendance continued to be important for the full 12 months, treatment beyond the index stay was not, suggesting an advantage for engaging clients in treatment initially and promoting 12-step attendance for at least a year.

Addiction Neuroethics: The Promises and Perils of Neuroscience Research on Addiction

Abstract: Drug addiction is a significant problem facing most societies It is associated with increased violence, crime and mental illness, and is one of the leading causes of preventable mortality and disability in most developed societies, accounting for over 12% of the total burden of disease (Begg et al, 2007) Neuroscience promises to significantly reduce the incidence and severity of addictive drug use, and the harm that it causes, by providing more effective and better targeted treatment of addiction (Volkow and Li, 2005) Proponents argue that an increased understanding of the neurobiological basis of drug addiction will also lend support for more humane social policies These policies will recognise that addiction is a neuropsychiatric condition that should be treated therapeutically, leading to increased investment in addiction research and treatment (Dackis and O'Brien, 2005; McLellan et al, 2000) Optimism about the benefits of an understanding of the neurobiological basis of addiction needs to be tempered by more critical considerations Overly simplistic interpretations of what this kind of approach reveals about addiction could result in less welcome consequences, especially if inappropriate use is made of emerging neurotechnologies, such as coerced use of naltrexone implants, population-wide vaccination programs against addiction, or the promotion of heroic ‘cures’ for addiction, such as neurosurgery and deep brain stimulation This thesis examines both the potentially welcome and unwelcome uses of neurobiological research of addiction with the aims of maximising the benefits, while minimizing any unanticipated harms I refer to this as Addiction Neuroethics The primary aims are to examine: (1) the impact that neuroscience research may have upon our understanding of autonomy and self-control in addicted individuals, (2) the implications this understanding may have for how we treat individuals with an addiction; and (3) the conditions under which it would be ethically acceptable to use various technologies emerging from this research This thesis falls into three parts First, a concise and accessible summary of the key findings of recent genetic and neuroscience research of addiction is provided This includes the neuroanatomy of addiction (eg the mesolimbic reward pathway), the molecular and cellular biology of addiction, neurocognitive changes, and the role of genetic and environmental vulnerabilities The second part of this thesis explores how neuroscience research may influence the way that modern societies think about drug use and addiction, and deal with those that suffer from it This section addresses the central question: do addicted persons have the capacity to make autonomous decisions regarding their own drug use? This raises a number of additional questions How much responsibility and blame should we attribute to addicted individual’s for their actions? How should society deal with addicted persons, or respond to the harm that they cause? Should society coerce addicted individuals into treatment, and if so, under what conditions? The third part of this thesis examines the ethical issues raised by the use of powerful new technologies that are emerging from neurobiological research on addiction, such as novel psychopharmacologies, depot implants, drug vaccines, neurosurgery and brain stimulation, neuroimaging and genetic testing The report also considers the more speculative possibility that addiction neurobiology may improve our ability to prevent the development of addiction, for example, by using genetic screening to identify individuals at high risk of addiction and ‘drug vaccines’ to prevent these individuals from becoming addicted This thesis demonstrates that the chronic use of addictive drugs has significant impacts upon key decision-making regions of the brain (eg motivation, memory, impulse inhibition) that affect addicted individuals ability to choose not to use drugs While the autonomy of addicted individuals is impaired in certain situations, and to varying degrees, it is not extinguished Rather than deny autonomy, we should aim to engage addicted individuals in ways that increase their autonomy For example, coerced treatment of addiction may be a valid approach to getting addicted individuals in treatment However we should avoid overriding the autonomy of addicted individuals by offering treatment as an alternative to punishment for some crimes (eg theft to fund drug habit) Such treatment should aim to treat a medical condition, and not be a form of extrajudicial punishment Addiction is a highly stigmatised condition This can significantly impact upon the way in which neuroscience research is understood and applied Scientists, clinicians and policy makers must be mindful of over-enthusiastic applications of novel technologies that may be prematurely embraced and promoted to a desperate and vulnerable population without proper evaluation of the risks, or without considering how these technologies may be used once approved The treatment of addiction should be judged by its efficacy and safety, as for any other medical treatment Addicted individuals should be treated as any other individual suffering from a medical condition The thesis concludes with some general suggestions about the directions in which this debate is likely to develop and identifies areas that will require further analysis and empirical investigation

Effectiveness and Organization of Addiction Medicine Training Across the Globe

Abstract: Background: Over the past decade, addiction medicine training curricula have been developed to prepare physicians to work with substance use disorder patients. This review paper aimed at (1) summarizing scientific publications that outline the content of addiction medicine curricula and (2) evaluating the evidence for efficacy for training in addiction medicine. Methods: We carried out a literature search on articles about addiction medicine training initiatives across the world, using PubMed, PsychINFO and EMBASE with the following search terms ‘substance abuse, addiction medicine, education and training.' Results: We found 29 articles on addiction medicine curricula at various academic levels. Nine studies reported on the need for addiction medicine training, 9 described addiction medicine curricula at various academic levels, and 11 described efficacy on addiction medicine curricula. Conclusions: Several key competences in addiction medicine were identified. Efficacy studies show that even short addiction medicine training programs can be effective in improving knowledge, skills and attitudes related to addiction medicine. A more uniform approach to addiction medicine training in terms of content and accreditation is discussed.