5 Things to Know About Addictions
T. Cameron Wild, PhD December, 2017
Addiction. c. 1600, "tendency," of habits, pursuits, etc.; 1640s as "state of being selfaddicted," from Latin addictionem (nominative addictio) "an awarding, a devoting," noun of action from past participle stem of addicere (see addict (v.)). Earliest sense was less severe: "inclination, penchant," but this has become obsolete. In main modern sense it is first attested 1906, in reference to opium.
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Using alcohol and other drugs to alter consciousness has occurred in all places on the earth and throughout human history We are motivated to change the way we think and feel as part of our evolutionary heritage
Consciousness alteration has many desired benefits
Physical
Psychological
Social
World-wide, what are the most commonly used and abused drugs?
Caffeine – most commonly used drug in the world Alcohol (beer, wine, spirits) Tobacco (cigarettes, chewing tobacco) Cannabis (pot, hash) Tranquilizers (benzodiazepines) Cocaine (powder, crack/rock) Hallucinogens (LSD, mushrooms, others) Opioids Solvents (glues, gasoline, paint thinner, etc.)
1. Addiction has three faces: Moral, medical, and economic
Addiction – moral face
Addiction – medical face
Addiction – Economic face Item
Government of AB revenue, 2015-16
Alcohol
$856 M
Gambling
$1.2 B
Tobacco
$980 M
Total revenue for 3 legal psychoactive drugs/addictive behaviours
$3.04 B
Source: Alberta Gaming and Liquor Commission
Addiction – Economic face Item
Government of AB revenue, 2015-16
Alcohol
$856 M
Gambling
$1.2 B
Tobacco
$980 M
Total revenue for 3 legal psychoactive drugs/addictive behaviours
$3.04 B
Total revenue for non-renewable energy (all sources)
$2.8 B
Sources: Alberta Gaming and Liquor Commission; Alberta Energy
These three ‘faces’ of addiction always compete for importance and influence in human societies Each perspective informs a wide range of policies and interventions designed to deal with addictions • criminal sanctions • treatment • taxation Each perspective also sets broad social expectations and values that inform how we treat people with addictions • as social deviants • as patients • as consumers
Economic
Medical Moral
2. Addictive behaviours occur across a continuum that includes harmful and beneficial effects
Addictions generally start in adolescence…
Spady et al. (2001). Arch Ped Adolesc Med, 155, 1153-1159.
…and most people age out
Does Substance use = Abuse and addiction? No! 1.
The majority of young people experiment (illegally) with alcohol; many experiment with illicit drugs. In fact, for alcohol (and to a lesser extent, other drugs) this is normative, rather than the exception
2.
Most of those who use alcohol and illicit drugs when they are young, particularly when their use does not become a regular pattern or lead to serious adverse consequences, do not exhibit serious addiction problems in later life
Effects range across a continuum
At the individual level Acute effects depend on: • • •
•
Type of drug (e.g., stimulant, depressant, hallucinogen) used Dose taken Drug metabolism and pharmacokinetics Route of administration
At the population level Participation in addictive behaviours almost always follows a positively skewed frequency distribution This is an example for alcohol consumption • The vast majority of the drinking population consumes alcohol moderately • A smaller minority of drinkers consume high amounts of alcohol; they actually account for most of the total consumption
At the population level Dependence
Always keep in mind the size of the subgroups we’re talking about!
Problems
Users
(Population) size matters! Death rates across psychoactive drugs Alcohol-related deaths (BC)
Illicit-drug related deaths (BC)
In BC, deaths associated with… Alcohol: ~24 per 100,000 population All illicit drugs combined: ~7 per 100,000 population Opioids: ~4 per 100,000 population Fentanyl: lower still (but recently increasing)
At high levels of problem severity, addiction has a massive impact on population health In 2012, about 22% (6 million) Canadians aged 15 years or older, met criteria for lifetime experience of a substance use disorder, and 4.4% met criteria for a SUD in the past 12 months About 1 in 5 of Canadian deaths occurring under age 70 are attributable to substance misuse Everywhere, addictions are more common among socially marginalized subgroups • Substance use disorder rates among Canadian homeless and/or streetinvolved people: over 50% (2013 data)
Burden on health system and the economy In a single year, misuse of alcohol, tobacco, and illicit drugs resulted in over 4 million (10.8%) acute care hospital days. Economic impact of substance misuse: • $39.8 B in a single year (Canada) • $4.4 B in a single year (AB)
3. The neuroscience of addiction is getting better all the time, but it’s a mistake to overemphasize drug effects on the brain
Emerging neuroscientific consensus on dependence Critical role of the reward pathway…
Transition to addiction… •
• • • •
Narrowed attentional focus (preoccupation and anticipation for the drug) Decreased self-control Compulsive drug-taking, Inflexible, routinized behaviour Negative emotional states
Challenges to the view that ‘drugs (alone) hijack the brain’ - 1 Growing evidence that exposure to psychoactive drugs is not necessary to induce similar neuroadaptations! Gambling Internet gaming Sex Shopping ??
Challenges to the view that ‘drugs (alone) hijack the brain’ - 2 Oversimplifies a complex web of factors that contribute to addictions Genetic susceptibility
Life history
Comorbid mental disorders
Challenges to the view that ‘drugs (alone) hijack the brain’ - 3 Downplays evidence that settings and other environmental factors can dramatically influence consumption patterns Rat park
Price sensitivity and availability
Limitations of neuroscience Despite progress, neuroscience has not (yet) provided diagnostic tools. At present, there is no blood test or brain scan that can reliably identify people at risk for addiction, or that identifies people who are or are not currently addicted As a practical matter, addictions are always identified in practical settings through evaluation and interpretation of behavioural and social factors of a person presenting for services
4. There’s a massive service gap for people living with addictions
Interventions
People meeting dependence criteria have large unmet service needs
Dependence
Problems
Users
70
60
50
40
30
20
10
0
Information
Medication
Hospital care
Counseling
Harm reduction
Social interventions
Skills training
Diagnosed w addiction problem (GAP-MAP) Marginalized illicit drug users in Edm.
Alberta
Alberta’s service gap for people with severe addiction problems Compared to the general adult population, 7% - 60% of Albertans who have been diagnosed with an addiction and marginalized illicit drug users (Edmonton) report that they either • Didn’t receive a desired service at all • Didn’t receive enough service • These are way higher rates of unmet service need than the general AB population
Interventions Dependence
People with less severe addiction problems are largely not picked up in health or other systems
Problems
Users
Case-finding in primary care is low
Percentage of AB adults meeting past-year screening criteria for major depression and alcohol problems who also reported that they had been diagnosed by a health professional in the past year
Problem drinking (AUDIT+)
8.8
Depressed (PHQ+)
91.2
15.5
0%
84.5
20%
40%
Diagnosed by a health professional
60%
80%
100%
Not diagnosed
38
Alberta funding •
Relative to total GoA spending on health, addiction services proportionally receive much less than mental health services
•
The entire mental health and addiction sector accounts for less than 5% of the total Provincial health budget Yet worldwide estimates: addictions and mental disorders account for ~25% of total disease burden!
•
Prevention and Treatment – Current state
Access specialty services Diagnosed
Seen in health services
Low rates of casefinding
Long wait lists; continuing problems treating comorbid mental health problems Poor continuity of care between primary, acute, and specialty care
Users who meet clinical screening criteria for problematic use
‘At risk’ subpopulations Ineffective universal prevention (e.g., DARE)
Healthy population: includes substance users and non-users
Throughout the ‘system’: Underutilization of evidence-based interventions
If people do manage to access care, there are effective treatments Pharmacotherapies (drug treatments) can be effective • Agonist treatments (e.g., methadone, suboxone for dependence on opioids) • Antagonist treatments (e.g., naltrexone for opioid dependence, antabuse for alcohol dependence) • Anti-craving medications
Lack of pharmaceutical vaccine or treatment tools means that psychosocial interventions are the most common treatments used, around the world. Evidence supports: • 12-step support groups • Cognitive-behavioural therapies • Motivational enhancement
One of the most consistent factors related to favourable outcomes across all addiction treatment approaches is treatment completion Associated with abstinence, lower crime, fewer relapses, greater employment
A recent systematic review of 122 studies involving almost 200,000 people seeking addiction treatment reported that in most jurisdictions it is more common for patients to drop out of addiction treatment than it is to complete it
Does relapse mean that treatment has failed? No. Relapse rates for people with addiction are similar to relapse rates for other well-understood chronic illnesses such as diabetes, hypertension, and asthma.
5. It’s time to invest in new approaches, built on evidence
Reconsider sector funding The moral perspective dominates our response, as reflected in disproportionately large allocations to enforcement and interdiction in the US and Canada National Anti-Drug Strategy Spending, Canada, 2007
Rethink how addiction-related services are funded Canadian model
Washington State, Oregon, Colorado, California
$
$
General provincial revenue
Legislated priorities
Prioritysetting
Initiatives
Initiatives
General state revenue
Before allocation to general state revenue… Washington State
Oregon
California (pending)
•
$1.25M/quarterly for administration
•
After covering costs to administer marijuana tax (licensing, etc)…
•
Up to 4% for administrative costs
•
50% to state basic health plan trust
•
Common school fund: 40%
•
$10M/yr (increasing by $10M/yr to $50M/yr) to addiction and mental health services
•
Up to 15% (minimum $25M) to addiction interventions for youth
•
Addiction and mental health services: 20%
•
$10M/yr to Universities to evaluate policy change
•
Up to 10% (minimum $9M) for public education, prevention, hotline
•
Law enforcement: 35%
•
$3M/yr to develop protocols to detect intoxicated driving
•
1% (minimum $1.2M to Universities for research on cannabis health effects and estimating impairment
Of remaining… • 60% to youth prevention, early intervention, treatment • 20% environmental damage (illegal production) • 20% driver education
Reconsider regulatory frameworks
Abstinence versus Harm Reduction
Highly contentious area in the addiction field Basic problem: evidence supports both objectives!
Abstinence Twelve-step (AA, NA, etc.) tradition ultimately views addiction as a ‘spiritual disease’ that requires lifelong abstinence To be ‘in recovery’ is to endorse abstinence as the desired outcome Anonymous social support provided to ‘work the steps’ Peer support groups (AA, NA meetings) provide assistance Mainstream addiction treatment programs in North America largely adopt this goal, or attempt to connect clients to community-based 12 step programs
Evidence Effectiveness
The approach has saved many lives worldwide Consistent scientific evidence that 12-step involvement is associated with better outcomes on substance-related, psychological and social measures But
•
Many people experiencing addiction problems are not attracted to the spiritual underpinnings of the approach nor the confessional form of social support for abstinence
•
Others (usually at lower levels of problem severity) prefer to seek moderate use rather than complete abstinence.
•
Consistent evidence that controlled use is possible for some (but not all)
Harm reduction
An approach to substance misuse that emphasizes interventions to reduce mortality and morbidity associated with the use psychoactive substances, without requiring people to stop using drugs.
Seat belts, emission controls, speed limits, and helmet laws are pragmatic interventions to reduce mortality and morbidity associated with using vehicles and bikes, without requiring people to stop driving. These can all be understood as harm reduction strategies to reduce the risks and harms of motoring
Evidence Intervention
Quantity and quality of evidence Strong
Syringe exchange
Take home naloxone Supervised injecting facilities
Street/peer outreach
Opioid substitution
Heroin assisted therapy
Promising
Types of outcomes examined • Mortality, • Hospitalization, • HIV transmission, • Uptake into specialty addiction treatment But: •
•
Disease model thinking about the problem implies no support for continued drug use Controversial among general public
Pragmatic, public health goals can accommodate both abstinence and harm reduction objectives. Systems should strive to: 1. Reduce harms related to addiction (first line response) 2. Stop or reduce addictive behaviour (facilitate access to a variety of treatments that best address problem severity) 3. Achieve productive functioning in family, work, social life (integrate with other health and social services)
5 Things to Know 1. Addiction has three faces: Moral, medical, economic 2. Addictive behaviours occur across a continuum of harmful and beneficial effects 3. The neuroscience is getting better all the time, but it’s a mistake to
overemphasize the drugs and the neurobiology
4. There’s a massive service gap for people living with addictions 5. It’s time to invest in new approaches, built on evidence
Thank you for your attention!
Support for U Alberta’s Addiction and Mental Health Lab has been provided by
Special thanks to: Elaine Hyshka, Caitlin Sinclair, Denise Adams, Gaju Karekezi, Ben Tan, Jesse Jahrig (U Alberta)
